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Abstract

Multiple dimensions across the biopsychosocial spectrum are relevant in the management of non-specific chronic low back pain (NSCLBP). Cognitive functional therapy is a behaviourally targeted intervention which combines normalisation of movement and abolition of pain behaviours with cognitive reconceptualisation of the NSCLBP problem, while also targeting psychosocial and lifestyle barriers to recovery. To examine the effectiveness of cognitive functional therapy for people with disabling NSCLBP who are awaiting an appointment with a specialist medical consultant. A multiple case (n=26) cohort study consisting of 3 phases (A1-B-A2). Measurement phase A1 was a baseline phase during which pain and functional disability were collected on three occasions over three months for all participants. During phase B, participants entered a cognitive functional therapy intervention program, involving approximately eight treatments over an average of 12 weeks. Finally, phase A2 was a 12 month no-treatment follow-up period. Outcomes were analysed using repeated measures ANOVA or Friedman's test (with post-hoc Bonferroni) across seven time intervals, depending on normality of data distribution. Statistically significant improvements in both functional disability (p<0.001) and pain (p<0.001) were observed immediately post-intervention, and maintained over the 12 months follow-up period. These reductions reached clinical significance for both disability and pain. Secondary psychosocial outcomes were significantly (p<0.01) improved after the intervention, including depression, anxiety, back beliefs, fear of physical activity, catastrophising and self-efficacy. Not a randomised controlled trial. While primary outcome data was self-reported, the assessor was not blinded. These promising results suggest that cognitive functional therapy should be compared to other conservative interventions for the management of disabling NSCLBP in secondary care settings in large randomised clinical trials. © 2015 American Physical Therapy Association.
... nine (42.9%), and 11 studies (52.4%) were scored negatively respectively (see Table 3 summary). Of 11 studies with a zero rating for statistical power (item 27), five were underpowered [36,40,42,46,48], whilst it was unclear/undetermined for the remaining six [35,41,[50][51][52][53]. By implication, the between-group results may be understated, since four of 15 comparative studies (3 RCTs and 1 CCT) [35,41,42,48] reporting non-significant differences between groups were Studies included in synthesis (n = 21) Global estimates for LBP were extrapolated to create a rudimentary set of criteria to assess external validity (item 11) and uniformly applied to each study's sample. ...
... LBP is typically more common in females, but these differences appear to diminish once chronicity is accounted for [56] whilst age-related LBP prevalence is generally negatively skewed and reported to be highest between 40 to 69 years [4] whilst global LBP prevalence reportedly peaks around 80 years old [57]. Accordingly, nine studies [36,38,41,44,46,47,50,52,54] scored '1' for satisfying both conditions: (i) the proportion of females is higher but less than 60% overall; and (ii) the mean/ median age falls within the range of 40.00 to 63.5 years (but 10 and 17 studies satisfied one condition respectively -see Additional file 1: Item 11 scoring grid Results S1). Since comorbid and/or confounding conditions (e.g., age restrictions, pregnancy, neurological, rheumatological, cancer, fractures, recent surgery) were generally excluded, these samples are fairly homogenous since their inclusion-exclusion criteria were comparable, but older patients were typically excluded. ...
... Twenty-one studies (N = 3075 participants) with a wide range of research designs were included in the review; specifically, 12 randomised clinical trials (RCTs; n = 1064 [35][36][37][38][39][40][42][43][44][45][46]; n = 255 cluster-randomised [41]), three non-randomised, controlled clinical trials (CCTs; n = 460) [47][48][49], four observational cohort studies (n = 1220) [52][53][54][55], one case series (n = 50) [51], and one interrupted time series (n = 26) [50]. RCT sample sizes ranged from 38 (pilot [42]) to 222 (3-armed trial [44]) patients. ...
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Background and objective Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning. Databases and data treatment Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach. Results Twenty-one primary studies ( N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance. Conclusion This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.
... Lately, plenty of studies were published that strongly suggested the beneficial effect that cognitive-behavioral treatment (CBT) approaches have on managing CLBP. [8][9][10][11] Meticulously enough, mere wording itself has the ability to affect clinical outcomes either negatively or positively in musculoskeletal rehabilitation. 12 Still, no clear CBT pattern exists for LBP patients. ...
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Low back pain (LBP) is a common clinical problem imposing a prominent socio-economic burden. The purpose of this systematic review was to investigate the biopsychosocial effects of the Mulligan Concept (MC) of manual therapy (MT) when applied to patient's with LBP. Three researchers independently evaluated the literature quality, and completed a review on five online databases (Medline, Cochrane Library, Science Direct, ProQuest and Google Scholar) for articles published from January 1st 2010 to November 20th 2021, using a combination of free words, Wildcards and Medical Subject Headings (MESH) terms: " Mulligan mobilization " AND " back pain " OR " SNAGs." In total, 62 studies were selected for full-text reading, from which finally 6 studies were included in the present review. The results revealed that the studies where the MC of MT was applied to treat LBP mainly lacked concern regarding the effect that the intervention has on the cognitive and behavioural parameters. The ones that introduced measure outcomes for at least some parts of the cognitive behavioural components, showed that the MC has a positive effect, even though without a long-term follow-up assessment. This review summarized that the evidence of the MC on cognitive behavioural (CB) aspects of patients with LBP is controversial and scarce.
... ANE, hastalara yalnızca ağrının nörobilimi hakkında bilgi vermekle kalmamakta, aynı zamanda daha önceki baskın biyomedikal modellerden arındırılmasını (de-edükasyon) da sağlamaktadır (A. Louw et al., 2017;O'Sullivan et al., 2015). Dolayısıyla, hastalarla bel fıtığını ya da omuz yaralanmalarını gösteren anatomik modellerini paylaşmak, hastalara yarardan çok zarar verdiği belirtilmiştir . ...
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The Pandemic leads to different changes in the daily life such as eating, smoking behavior. The study mainly focused to comparatively analyze the change of eating and smoking behavior during lockdown among the people of Gujranwala, Mumbai and New York and also highlight what significant changes come in life due to pandemic. The study is cross national study and quantitative in nature. The survey method was used for data collection. The data was collected through Google survey from. The population of this study was people who belong to Gujranwala, Mumbai and New York and sample sized of 450 people were selected by using convenience sampling technique. The study results showed that participants of these three cities recorded changes in their eating and smoking behavior during pandemic. Most of the respondent’s weight were observed increased. They started eating extra food against their normal routine. The study results also noted that people have also changed their smoking behavior. They increased the frequency of smoking per day in confinement. The study also found that people spent more time with their family after the pandemic, because government of these three countries imposed a lockdown. The study concluded that Covid-19 effect on smoking and eating behavior negatively.
... Die rein biomedizinisch ausgerichteten Ansätze sind durch pathoanatomische, pathologische und biomechanische Inhalte geprägt [2,24,37]. Die bio-psychosozialenEdukationsansätzeberücksichtigen darüber hinaus Informationen zu psychosozialen Faktoren, wie beispielsweise zur Bedeutung von Stress, Emotionen, Überzeugungen und Angst oder auch zum Einfluss der Beziehungsebene zwischen den Therapierenden und den Patient*innen [11,18,20,32]. ...
Article
Objective: The objective of the review is to map the content of intervention education in people with acute nonspecific lumbar low back pain (LBP) to make it available in a synopsis. Background: In the care of people with acute non-specific LBP, education is recommended as an elementary treatment component. However, the proposed content is proving to be heterogenic and the question arises as to how education should be designed in the future. Method: A systematic literature search and content analysis of studies with content on pain education was conducted as part of a scoping review. Inclusion criteria were: provision of relevant information on the content of pain education, patients with acute nonspecific low back pain, 18 years or older, publication in English or German. The search was conducted in the Medline, CINAHL, Cochrane Library, and PEDro databases and supplemented by a hand search. The search was completed in February 2021. Results: A total of 4239 hits were identified, of which 90 studies were included. A wide range of content was found and clustered into ten categories. The most frequent statements were in the categories "recommendations for dealing with LRS," "education, reassuring aspects, and relieving basic messages," and "information and recommendations about medications." Conclusion: The teaching of pathoanatomical information can potentially trigger or increase anxiety and worry, whereas information on neurophysiological mechanisms of pain development and processing is more likely to have an anxiety-reducing effect. The results can contribute to the design of the intervention in different settings.
... Die rein biomedizinisch ausgerichteten Ansätze sind durch pathoanatomische, pathologische und biomechanische Inhalte geprägt [2,24,37]. Die bio-psychosozialenEdukationsansätzeberücksichtigen darüber hinaus Informationen zu psychosozialen Faktoren, wie beispielsweise zur Bedeutung von Stress, Emotionen, Überzeugungen und Angst oder auch zum Einfluss der Beziehungsebene zwischen den Therapierenden und den Patient*innen [11,18,20,32]. ...
Article
Zielsetzung: Das Ziel des Reviews ist es, die Inhalte der therapeutischen Maßnahme Edukation bei Menschen mit akuten unspezifischen lumbalen Rückenschmerzen (LRS) zu kartieren und diese in einer Zusammenschau verfügbar zu machen. Hintergrund: In der Versorgung von Menschen mit akuten unspezifischen LRS wird Schmerzedukation als eine elementare Behandlungskomponente empfohlen. Die vermittelten Inhalte sind jedoch heterogen und damit stellt sich die Frage nach einer optimalen Ausgestaltung. Methode: Im Rahmen eines Scoping-Reviews wurde eine systematische Literatur- recherche und inhaltliche Analyse von Studien mit Inhalten zu Schmerzedukation durchgeführt. Einschlusskriterien waren: Bereitstellen relevanter Informationen zu den Inhalten der Schmerzedukation, Patient*innen mit akuten unspezifischen Rückenschmerzen, 18 Jahre oder älter, Veröffentlichung in englischer oder deutscher Sprache. Die Recherche wurde in den Datenbanken Medline, CINAHL, Cochrane Library und PEDro durchgeführt und durch eine Handsuche ergänzt. Die Suche wurde im Februar 2021 abgeschlossen. Ergebnisse: Insgesamt konnten 4239 Treffer identifiziert werden, davon wurden 90 Studien eingeschlossen. Es zeigte sich eine große Bandbreite an Inhalten, die in zehn Kategorien geclustert wurden. Die häufigsten Angaben wurden in den Kategorien „Empfehlungen zum Umgang mit LRS“, „Aufklärung, beruhigende Aspekte und entlastende Grundbotschaften“ und „Informationen und Empfehlungen zu Medikamenten“ gemacht. Schlussfolgerung: Die Vermittlung von pathoanatomischen Informationen kann Ängste und Sorgen potenziell auslösen oder verstärken, wohingegen Informationen zu neurophysiologischen Mechanismen der Schmerzentstehung und -verarbeitung eher eine angstmindernde Wirkung zugeschrieben wird. Die Ergebnisse können einen Beitrag zur Ausgestaltung der Schmerzedukation in unterschiedlichen Settings leisten. Schlüsselwörter Schmerzwahrnehmung · Ängste · Biopsychosoziales Modell · Neurophysiologische Aspekte · Physiotherapie
... The emergence of integrated treatment approaches, such as Cognitive Functional Therapy (CFT), that target both the restoration of functional movement/postures and underlying cognitive and emotional factors may offer an opportunity to better manage LBP. 86 Recent works have shown CFT is effective at reducing disability 87 and psychological outcomes, 88 and preliminary evidence suggests it also restores changes in spinal mobility and flexion-relaxation. 83 Although promising, further work is required to determine the relative effectiveness of an integrated approach, such as CFT, compared with more traditional psychological or movement-based interventions. ...
Article
Objective Although pain-related fear and catastrophizing are predictors of disability in low back pain (LBP), their relationship with guarded motor behavior is unclear. The aim of this meta-analysis was to determine the relationship between pain-related threat (via pain-related fear and catastrophizing) and motor behavior during functional tasks in adults with LBP. Methods This review followed PRISMA guidelines. MEDLINE, Embase, PsychINFO and CINAHL databases were searched to April 2021. Included studies measured the association between pain-related fear or pain catastrophizing and motor behavior (spinal range of motion, trunk coordination and variability, muscle activity) during movement in adults with nonspecific LBP. Studies were excluded if participants were postsurgery or diagnosed with specific LBP. Two independent reviewers extracted all data. The Newcastle-Ottawa Scale was used to assess for risk of bias. Correlation coefficients were pooled using the random-effects model. Results Reduced spinal range of motion during flexion-tasks was weakly related to pain-related fear (15 studies, r = −0.21, 95% CI = −0.31 to −0.11) and pain catastrophizing (7 studies, r = −0.24, 95% CI = −0.38 to −0.087). Pain-related fear was unrelated to spinal extension (3 studies, r = −0.16, 95% CI = −0.33 to 0.026). Greater trunk extensor muscle activity during bending was moderately related to pain-related fear (2 studies, r = −0.40, 95% CI = −0.55 to −0.23). Pain catastrophizing, but not fear, was related to higher trunk activity during gait (2 studies, r = 0.25, 95% CI = 0.063 to 0.42). Methodological differences and missing data limited robust syntheses of studies examining muscle activity, so these findings should be interpreted carefully. Conclusion This study found a weak to moderate relationship between pain-related threat and guarded motor behavior during flexion-based tasks, but not consistently during other movements. Impact These findings provide a jumping-off point for future clinical research to explore the advantages of integrated treatment strategies that target both psychological and motor behavior processes, compared to traditional approaches.
... Considerada a principal causa de incapacidade em países industrializados, a DLC representa uma condição de difícil resolução, uma vez que estratégias efetivas para o seu tratamento permanecem indefinidas, com intervenções fisioterapêuticas como a cinesioterapia e terapia manual apresentando eficácia somente a curto prazo 5,6 . Esse fato é justificado pela ausência de uma abordagem de tratamento mais complexa, que consiga suprir os diferentes fatores envolvidos no ciclo vicioso da DLC, tanto fatores físicos e de estilo de vida, incluindo posturas provocativas, descondicionamento físico, desequilíbrios musculares, diminuição da flexibilidade do tronco e quadril, padrões de movimento alterados e sedentarismo, mas principalmente os fatores psicossociais, como estratégias de enfrentamento mal adaptativas, catastrofização e crenças negativas diante da dor, dentre elas a cinesiofobia 7,8,9 . ...
Article
Objetivo: Analisar a prevalência de cinesiofobia e comportamentos associados às maiores médias de cinesiofobia em indivíduos com dor lombar. Métodos: Estudo transversal, envolvendo indivíduos com diagnóstico de dor lombar que procuram atendimento fisioterapêutico vinculado ao Sistema Único de Saúde. Sendo aplicado um questionário para caracterizar a amostra. A Escala Visual Analógica para avaliar a intensidade da dor lombar e os questionários Internacional de Atividade Física e Roland Morris-Brasil para analisar o nível de atividade física e grau de incapacidade funcional. Por último, a Escala Tampa para cinesiofobia-Brasil foi aplicada para avaliar a presença e grau de cinesiofobia. Resultados: A amostra foi composta por 110 indivíduos com média de idade de 52,2 ± 12,2 anos, a maioria mulheres (74,5%). A média da intensidade da dor foi de 6,42 ± 2,26 e não houve correlação significativa entre o grau de cinesiofobia e a intensidade da dor (p=0,828 – r= -0,030). A prevalência de cinesiofobia foi de 78,2%, sendo que a maioria da amostra foi classificada com grau moderado. O escore médio de cinesiofobia foi de 45,4 ± 8,7, indivíduos sedentários (p = 0,026), com sobrepeso / obesidade (p = 0,039) e incapacidade funcional (p = 0,021) apresentaram as maiores médias de cinesiofobia. Considerações Finais: A prevalência de cinesiofobia é alta em indivíduos com dor lombar que procuram atendimento fisioterapêutico, estando associada ao nível de atividade física, incapacidade funcional e índice de massa corporal. Nível de Evidência II – Estudo Retrospectivo.
... NSCLBP is no longer considered a purely structural, anatomical, or biomechanical disorder of the lumbar spine. Instead, there is strong evidence that NSCLBP is associated with a complex interaction of factors involve structural or biomechanical, cognitive (e.g., unhelpful beliefs, catastrophizing, maladaptive coping strategies, low self-efficacy), psychological (e.g., fear, anxiety, depression), lifestyle (e.g., immobility, sleep problems), and social (e.g., work and family issues) factors [1,8,[10][11][12][13]. Consequently, NSCLBP treatment guidelines generally acknowledge a shift from biomedical models to the biopsychosocial model. ...
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Background Non-specific chronic low back pain (NSCLBP) is a major public health and global socioeconomic burden associated with a complex interplay of biopsychosocial factors. Despite scientific signs of progress, treatment of NSCLBP often tends to stick to a biomechanical model, without targeting psychological and social factors. To enhance the clinical efficacy of usual physiotherapy for NSCLBP, the development of clinical strategies is to be pursued. This study aims to assess the effectiveness of multidimensional physiotherapy based on a biopsychosocial approach compared to usual care physiotherapy, on clinical findings and electroencephalography spectrum in non-specific chronic low back pain. Methods This study is a triple-blind, two-arm (1:1) randomized controlled trial with a 4 months follow-up. Seventy NSCLBP patients will be randomly allocated to either the experimental (multidimensional physiotherapy) or the active control group (usual physiotherapy); each group will receive 6 weeks of physiotherapy. The main outcome is pain and secondary outcomes are brain function, quality of life, disability, lumbar flexion range of motion, and psychosocial correlates. Assessment will be performed at baseline, post-treatment, and at 1 and 4 months follow-up. Discussion Findings may provide evidence on the effectiveness of multidimensional physiotherapy on clinical findings and brain characteristics and might provide evidence towards showing the role of brain and biopsychosocial factors on chronic pain. Trial registration ClinicalTrials.gov NCT04270422 , Registered on 17 February 2020, IRCT Identifier: IRCT20140810018754N11
... One example of psychologically informed physiotherapy is Cognitive Functional Therapy (CFT). CFT training aims, among other objectives, to equip physiotherapists with skills in communication and clinical reasoning within a biopsychosocial framework to explore, identify and manage modifiable biopsychosocial barriers to recovery [14,15]. In qualitative studies, physiotherapists who have participated in CFT training have reported developing enhanced communication skills for dealing with their complex patients with MSP [9,16,17]. ...
Article
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Objective The aim of this study was to investigate physiotherapists’ validating and invalidating communication, before and after brief Cognitive Functional Therapy (CFT) training that included a session on validation skills. Associations between validation/invalidation and the characteristics of the interviews and physiotherapists were also explored. Methods Eighteen physiotherapists treating patients with low back pain participated in the study. The study had a within-group design in which validation and invalidation for physiotherapists were rated before and after training using a reliable observational scale. We also collected data on interview length and physiotherapists’ and patients’ speech percentages. Results The physiotherapists’ validating responses increased and invalidating responses decreased from pre- to post-training. The within-group effect size was large for validating responses and medium for invalidating responses. The interview length increased from pre- to post-training (large effect size). However, the reason for this was related to factors other than validation and invalidation. The results indicate that increased validation is associated with an increase in physiotherapists’ speech percentage. Conclusions The results of this study show changes invalidating and invalidating communication among physiotherapists from pre- to post-CFT training. The study also found associations between specific interview characteristics and validating communication. Future studies with larger samples and control groups are needed.
Article
Menschen mit chronischen Schmerzen haben oft Angst vor bestimmten Bewegungen. Sie vermeiden entsprechende Aktivitäten, bauen körperlich ab und leiden schlimmstenfalls unter noch stärkeren Schmerzen und Depressionen. Die Expositionstherapie sowie das Graded-Activity-Konzept helfen, den Teufelskreis des Angst-Vermeidungs-Modells zu durchbrechen.
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Background: Current research practice employs wide-ranging accelerometer wear time criteria to identify a valid day of physical activity (PA) measurement. Objective: To evaluate the effects of varying amounts of daily accelerometer wear time on PA data. Methods: A total of 1000 days of accelerometer data from 1000 participants (age=38.7±14.3 years; body mass index=28.2±6.7 kg/m2) were selected from the 2005–2006 National Health and Nutrition Examination Study data set. A reference data set was created using 200 random days with 14 h/day of wear time. Four additional samples of 200 days were randomly selected with a wear time of 10, 11, 12 and 13 h/day1. These data sets were used in day-to-day comparison to create four semisimulation data sets (10, 11, 12, 13 h/day) from the reference data set. Differences in step count and time spent in inactivity (<100 cts/min), light (100–1951 cts/min), moderate (1952–5724 cts/min) and vigorous (≥5725 cts/min) intensity PA were assessed using repeated-measures analysis of variance and absolute percent error (APE). Results: There were significant differences for moderate intensity PA between the reference data set and semisimulation data sets of 10 and 11 h/day. Differences were observed in 10–13 h/day1 for inactivity and light intensity PA, and 10–12 h/day for steps (all p values <0.05). APE increased with shorter wear time (13 h/day=3.9–14.1%; 12 h/day=9.9–15.2%, 11 h/day=17.1–35.5%; 10 h/day=24.6–40.3%) Discussion: These data suggest that using accelerometer wear time criteria of 12 h/day or less may underestimate step count and time spent in various PA levels.
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Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
Article
Background: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. Purpose: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. Data Sources: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. Study Selection: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. Data Extraction: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). Data Synthesis: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Conclusions: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
Article
Study Design. A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain. Objective. To test the impact of a novel educational booklet on patients’ beliefs about back pain and functional outcome. Summary of Background Data. The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines. Methods. One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%. Results. Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain. Conclusion. This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients’ beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain.
Article
Design. Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. Objectives. To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. Summary of Background Data. In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new “belief” questionnaires and “sophisticated” performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. Methods. One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. Results. Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. Conclusion. A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy programm—in addition to improving physical function—appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.
Article
Purpose A novel, minimally invasive posture monitor which can monitor lumbar postures outside the laboratory has demonstrated excellent reliability, as well as concurrent validity compared to a surface marker-based motion analysis system. However, it is unclear if this device reflects underlying vertebral motion. Methods Twelve participants performed full range sagittal plane lumbo-pelvic movements during sitting and standing. Their posture was measured simultaneously using both this device (BodyGuard™) and digital videofluoroscopy. Results Strong correlations were observed between the two methods (all r s > 0.88). Similarly, the coefficients of determination were high (all r 2 > 0.78). The maximum mean difference between the measures was located in the mid-range of motion and was approximately 3.4° in sitting and 3.9° in standing. Conclusion The BodyGuard™ appears to be a valid method for analysing vertebral motion in the sagittal plane and is a promising tool for long-term monitoring of spinal postures in laboratory and clinical settings in people with low back pain.
Article
ObjectivesTo examine whether patients with chronic low back pain exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT), delivered by physiotherapists; and to examine the association between pre- to post-treatment changes in cognitive factors (cognitive processes) and pre- to post-treatment changes in pain, disability and depression.DesignObservational before–after study.SettingOutpatient physiotherapy department.ParticipantsOne hundred and thirty-seven patients with chronic low back pain.InterventionsIBMT: ‘Work Back to Life’ rehabilitation programme.Main outcome measuresPre- to post-treatment changes in pain, disability and a range of cognitive factors.ResultsPatients demonstrated significant favourable changes for a range of cognitive factors. Furthermore, pre- to post-treatment changes in these cognitive factors explained an additional 22%, 17% and 15% of the variance in changes in pain, disability and depression, respectively, after controlling for other important factors.ConclusionsChanges that emerge in cognitive factors are strongly related to treatment outcome within a physiotherapy treatment context. Specifically, reductions in fear of movement and catastrophising, and increases in functional self-efficacy appear to be particularly important. Modifying these cognitive factors should be seen as a priority when treating patients with chronic low back pain.
Article
The aim of this study was to examine lower lumbar kinematics in cyclists with and without non-specific chronic low back pain (NS-CLBP) during a cross-sectional cycling field study. Although LBP is a common problem among cyclists, studies investigating the causes of LBP during cycling are scarce and are mainly focussed on geometric bike-related variables. Until now no cycling field studies have investigated the relationship between maladaptive lumbar kinematics and LBP during cycling. Eight cyclists with NS-CLBP classified as having a 'Flexion Pattern' (FP) disorder and nine age- and gender-matched asymptomatic cyclists were tested. Subjects performed a 2 h outdoor cycling task on their personal race bike. Lower lumbar kinematics was measured with the BodyGuard™ monitoring system. Pain intensity during and after cycling was measured using a numerical pain rating scale. The NS-CLBP (FP) subjects were significantly more flexed at the lower lumbar spine during cycling compared to healthy controls (p = 0.018), and reported a significant increase in pain over the 2 h of cycling (p < 0.001). One-way repeated measures ANOVA revealed a significant main effect for group (p = 0.035, F = 5.546) which remained just significant when adding saddle angle as a covariate (p = 0.05, F = 4.747). The difference in posture between groups did not change over time. These findings suggest that a subgroup of cyclists with NS-CLBP (FP) demonstrate an underlying maladaptive motor control pattern resulting in greater lower lumbar flexion during cycling which is related to a significant increase in pain.