Article

What do UK osteopaths view as the safest lifting posture, and how are these views influenced by their back beliefs?

Authors:
  • University College of Osteopathy
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Abstract

Background Lower back pain is a leading cause of disability and a common condition seen by osteopaths. Evidence and advice for the safest lifting posture vary, as do healthcare practitioners' attitudes and beliefs towards back pain. Objectives The aim of this study was to understand osteopaths' beliefs about safe lifting postures in relation to their attitudes towards back pain, and to compare these findings with published data from physiotherapists and manual handling advisors. Design Cross-sectional study. Method Between October and November 2018 a cross-sectional electronic survey was used to invite a sample of UK osteopaths to select images that best represent their perception of safe lifting posture (straight or rounded back), and to complete the Back Pain Attitudes Questionnaire (Back-PAQ). Data was analysed to assess lifting posture selection and relationship to back pain attitudes. Results 46 (85.2%) out of 54 osteopaths selected straight back posture as safest, these participants had significantly more negative attitudes to back pain injury (i.e. higher Back-PAQ scores), than the 8 osteopaths who selected a rounded back posture (p = 0.007). Data from 266 physiotherapists and 132 manual handling advisors revealed an overall agreement about straight back lifting posture, and differences in Back-PAQ attitude between the professions. Conclusion Despite a lack of evidence and inconsistent recommendations, osteopaths in this study believed that straight back lifting posture is the safest. Practitioners' attitudes vary and are known to influence their patients' attitudes and recovery behaviour. Further research is recommended to identify reasons for different beliefs, and their impact on advice-giving and patient outcomes.

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... Les questions sont formulées de manière à ce que l'instrument puisse convenir aux personnes souffrant de rachialgie, aux personnes sans rachialgie et aux professionnels de la santé. Ce questionnaire a notamment été utilisé dans plusieurs études récentes évaluant les croyances de différents types de professionnels : kinésithérapeutes (26)(27)(28) , étudiants en kinésithérapie (29) , étudiants en ostéopathie (30) et ostéopathes (31,32) . ...
... Dans une autre étude explorant les croyances de la population générale suisse (42) , un score au Back PAQ de 113,2 a été retrouvé, ce qui est comparable au score de nos étudiants de première année qui commencent tout juste leur formation. Enfin, une étude a étudié les croyances des ostéopathes britanniques (31) et le score obtenu dans cette étude a été de 87,3 ± 17,09 soit un score comparable aux étudiants de quatrième année de cette étude (85,4 ± 16,6). ...
... Avoir plus d'expérience professionnelle et/ou être impliqué dans l'enseignement de l'ostéopathie n'a pas conduit à de meilleures attitudes et des croyances plus adaptées concernant la prise en charge des patients souffrant de lombalgie. Bien que la moyenne de leurs résultats ait été très proche des autres types de professionnels étudiés dans la littérature (26,31) , la variabilité importante des résultats au Back-PAQ a montré des disparités significatives entre les professionnels. Une explication pourrait être que les enseignants actuels n'ont pas eu le même programme de formation que les étudiants d'aujourd'hui. ...
Article
Full-text available
Les facteurs psychosociaux jouent un rôle essentiel dans le pronostic et la prise en charge des patients présentant une lombalgie non-spécifique (LNS). Les données scientifiques indiquent que les croyances d'un individu concernant la douleur sont associées aux attitudes et aux croyances du clinicien consulté. Cette étude a exploré les attitudes, croyances et orientations cliniques des étudiants, des nouveaux diplômés, des enseignants et praticiens non-enseignants issus de deux instituts français d'enseignement de l'ostéopathie en ce qui concerne la prise en charge de la LNS. Cette population a été étudiée au moyen d'une enquête transversale réalisée en ligne entre août et octobre 2021 comprenant un recueil des caractéristiques socio-démographiques, un questionnaire (Back-PAQ) et une vignette clinique. 798 participants ont répondu à l'enquête (556 étudiants, 47 nouveaux diplômés, 88 enseignants, 107 praticiens). Les résultats des étudiants au Back-PAQ ont montré une diminution progressive des scores (croyances plus adaptées) de la première année (113 ± 10,2) à la cinquième année (81,4 ± 12,1) (p < 0,001) avec une diminution plus importante entre les étudiants de 5ème année (81,4 ± 12,1) et les nouveaux diplômés (48,4 ± 7,5) (p < 0,001). Les orientations cliniques basées sur les questions de la vignette (score moyen : 1,7/3) étaient modérément corrélées au score du Back-PAQ (r =-0,489, p < 0,001). Ainsi, les participants ayant plus de croyances délétères étaient plus susceptibles d'encourager la limitation de l'activité physique ou professionnelle. Pour que les futurs cliniciens puissent aborder de manière adéquate les facteurs psychosociaux associés à la LNS, il semble crucial d'évaluer leurs attitudes pendant leur formation afin de mieux appréhender les croyances qui les sous-tendent.
... [29][30][31][32] Es interesante resaltar que investigaciones previas han demostrado que aquellos que creen que levantar con la espalda recta es más seguro, puntuaron más alto en el Back-PAQ que aquellos que eligen una espalda redondeada. 15,17 Las creencias protectoras alrededor de la espalda fueron altamente prevalentes. Más del 90% cree que "es importante tener músculos fuertes para proteger la espalda" y que "podrías lastimarte la espalda si no tienes cuidado", coincidiendo con hallazgos previos en poblaciones generales. ...
... 7,23 Hasta el momento, las poblaciones que han mostrado creencias diferentes y más positivas son los kinesiólogos, osteópatas y terapistas manuales, todos relacionados con la asistencia sanitaria. 15,17 Los puntajes totales de cada grupo fueron de 67, 87 y 101, respectivamente. El mayor conocimiento de la evidencia reciente sobre el dolor lumbar de estas profesiones puede explicar las diferencias con la población atlética. ...
Article
Full-text available
Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, proponemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profesionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como “positivas”, “neutras” o “negativas”. Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5 - 113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108 - 121) versus 113 (rango intercuartílico 105 - 120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, independientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor lumbar.
... [29][30][31][32] Es interesante resaltar que investigaciones previas han demostrado que aquellos que creen que levantar con la espalda recta es más seguro, puntuaron más alto en el Back-PAQ que aquellos que eligen una espalda redondeada. 15,17 Las creencias protectoras alrededor de la espalda fueron altamente prevalentes. Más del 90% cree que "es importante tener músculos fuertes para proteger la espalda" y que "podrías lastimarte la espalda si no tienes cuidado", coincidiendo con hallazgos previos en poblaciones generales. ...
... 7,23 Hasta el momento, las poblaciones que han mostrado creencias diferentes y más positivas son los kinesiólogos, osteópatas y terapistas manuales, todos relacionados con la asistencia sanitaria. 15,17 Los puntajes totales de cada grupo fueron de 67, 87 y 101, respectivamente. El mayor conocimiento de la evidencia reciente sobre el dolor lumbar de estas profesiones puede explicar las diferencias con la población atlética. ...
Article
Full-text available
Resumen Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, propo-nemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profe-sionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como "positivas", "neutras" o "negativas". Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5-113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108-121) versus 113 (rango intercuartílico 105-120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, inde-pendientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor Fuentes de financiamiento: Los autores declaran no tener ninguna afiliación financiera ni participación en ninguna organización comercial que tenga un interés financiero directo en cualquier asunto incluido en este manuscrito. Conflicto de intereses: Los autores declaran no tener ningún conflicto de intereses.
... Participants appeared to believe their LBP was due to incorrectly engaging their world, which implies there is a 'right' and 'wrong' way to move. Such beliefs align with prior research findings regarding beliefs of patients, clinicians, and 'pain-free' populations (Caneiro et al., 2018b(Caneiro et al., , 2019Nolan et al., 2019;Smith and Thomson, 2020;Korakakis et al., 2019). However, to date we lack supportive evidence linking biomechanics as an important modifiable risk factor for LBP (Parreira et al., 2018;Saraceni et al., 2020). ...
... Collectively, these data demonstrate a widespread problem across cultures and societies, with inaccurate beliefs about LBP that are primarily attributed to HCPs. This is problematic given that many HCPs commonly hold inaccurate beliefs about the etiology, management, and prognosis of LBP (Alvin et al., 2018;Caneiro et al., 2019;Nolan et al., 2019;Smith and Thomson, 2020;Korakakis et al., 2019;Synnott et al., 2015). These erroneous beliefs often lead to negative effects on patients, resulting in low-value care involving unnecessary investigations, interventions, and healthcare costs (Rajasekaran et al., 2021;Darlow et al., 2013;Downie et al., 2020;Lemmers et al., 2019;Foster et al., 2018;Buchbinder et al., 2020;Stevans et al., 2021). ...
Article
Background Prior research has demonstrated that people across different populations hold beliefs about low back pain (LBP) that are inconsistent with current evidence. Qualitative research is needed to explore current LBP beliefs in Northern America (NA). Objectives We conducted a primarily qualitative cross-sectional online survey to assess LBP beliefs in a NA population (USA and Canada). Methods Participants were recruited online using social media advertisements targeting individuals in NA over the age of 18 with English speaking and reading comprehension. Participants answered questions regarding the cause of LBP, reasons for reoccurrence or persistence of LBP, and sources of these beliefs. Responses were analyzed using conventional (inductive) content analysis. Results/findings 62 participants were included with a mean age of 47.6 years. Most participants reported multiple causes for LBP as well as its persistence and reoccurrence, however, these were biomedically focused with minimal to no regard for psychological or environmental influences. The primary cited source of participants’ beliefs was healthcare professionals. Conclusions Our findings align with prior research from other regions, demonstrating a need for updating clinical education and public messaging about the biopsychosocial nature of LBP.
... Participants appeared to believe their LBP was due to incorrectly engaging their world, which implies there is a 'right' and 'wrong' way to move. Such beliefs align with prior research findings regarding beliefs of patients, clinicians, and 'pain-free' populations (Caneiro et al., 2018b(Caneiro et al., , 2019Nolan et al., 2019;Smith and Thomson, 2020;Korakakis et al., 2019). However, to date we lack supportive evidence linking biomechanics as an important modifiable risk factor for LBP (Parreira et al., 2018;Saraceni et al., 2020). ...
... Collectively, these data demonstrate a widespread problem across cultures and societies, with inaccurate beliefs about LBP that are primarily attributed to HCPs. This is problematic given that many HCPs commonly hold inaccurate beliefs about the etiology, management, and prognosis of LBP (Alvin et al., 2018;Caneiro et al., 2019;Nolan et al., 2019;Smith and Thomson, 2020;Korakakis et al., 2019;Synnott et al., 2015). These erroneous beliefs often lead to negative effects on patients, resulting in low-value care involving unnecessary investigations, interventions, and healthcare costs (Rajasekaran et al., 2021;Darlow et al., 2013;Downie et al., 2020;Lemmers et al., 2019;Foster et al., 2018;Buchbinder et al., 2020;Stevans et al., 2021). ...
Presentation
Globally, low back pain (LBP) is the leading cause of years lived with disability. LBP is usually benign yet is often interpreted as an ominous sign of disease. Prior research has demonstrated many populations have misinformed beliefs about the nature, etiology, and prognosis of LBP, with the primary source being healthcare professionals (HCP). There is a gap in knowledge about LBP beliefs in the North American (NA) population. Current beliefs must be identified to inform future educational interventions. We conducted a cross-sectional online qualitative survey to assess NA population beliefs about LBP. Participants were recruited via social media advertisements targeting individuals over age 18 with English speaking and reading comprehension. We used an inductive content analysis approach to develop categories based on participants’ responses to 3 open-ended questions about the presumed cause of their low back pain, its persistence, and the source of these beliefs. 62 participants (51 women, 7 men) were included, mean age of 47.6 years, 33 located in U.S.A. and 29 in Canada. Participants presumed causes of LBP fell into three categories: physical (biology, biomechanics, prior injury), psychological, unknown. Similar themes were generated regarding reported reasons for the recurrence or persistence of LBP, with the addition of a single category, environmental. Participants' primary source of beliefs was HCP (n = 34, 55%) with secondary sources of family (n = 12, 19%) and internet (n = 12, 19%). Many participants reported multiple causes for LBP, however, these were mostly focused on the physical body, with minimal consideration of psychological and sociological influences.[PASD1] Our study findings align with prior research from other regions in the world, further demonstrating a need for updating clinical education and public messaging about LBP. Funding provided by Faculty Research Fund at Bridgewater College.
... [29][30][31][32] Es interesante resaltar que investigaciones previas han demostrado que aquellos que creen que levantar con la espalda recta es más seguro, puntuaron más alto en el Back-PAQ que aquellos que eligen una espalda redondeada. 15,17 Las creencias protectoras alrededor de la espalda fueron altamente prevalentes. Más del 90% cree que "es importante tener músculos fuertes para proteger la espalda" y que "podrías lastimarte la espalda si no tienes cuidado", coincidiendo con hallazgos previos en poblaciones generales. ...
... 7,23 Hasta el momento, las poblaciones que han mostrado creencias diferentes y más positivas son los kinesiólogos, osteópatas y terapistas manuales, todos relacionados con la asistencia sanitaria. 15,17 Los puntajes totales de cada grupo fueron de 67, 87 y 101, respectivamente. El mayor conocimiento de la evidencia reciente sobre el dolor lumbar de estas profesiones puede explicar las diferencias con la población atlética. ...
Article
Full-text available
Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, proponemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profesionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como "positivas", "neutras" o "negativas". Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5-113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108-121) versus 113 (rango intercuartílico 105-120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, independientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor Fuentes de financiamiento: Los autores declaran no tener ninguna afiliación financiera ni participación en ninguna organización comercial que tenga un interés financiero directo en cualquier asunto incluido en este manuscrito. Conflicto de intereses: Los autores declaran no tener ningún conflicto de intereses.
... The Back-PAQ has been also used in research to compare the beliefs of different of HCP groups (physiotherapists, physiotherapy students, manual handling advisors, osteopaths, and medical doctors) and explore whether these influence their advice to patients and/or their lifting/bending techniques (Christe et al., 2021b;Davis et al., 2022;Nolan et al., 2018Nolan et al., , 2019Rialet-Micoulau et al., 2022;Smith & Thomson, 2020). Moran et al. found that the beliefs of osteopaths were significantly more negative than those of physiotherapists (Moran et al., 2017). ...
... This need is also inevitably demanded by people with disabilities, desiring to improve mobility and freedom on a day-to-day basis [5]. This desire for mobility to be independent also allows people with disabilities to demand a specific tool for daily assistance, such as getting into the car easily with the help of only 1 person to operate [6]- [8]. Ordinarily, people with disabilities who require these tools are the teenagers, desiring the potential to drive their own car [9]- [11]. ...
Conference Paper
Persons with disabilities describe the prolonged condition of a person who experiences physical, intellectual, mental, and sensory limitations, experiencing particular difficulties in participating fully and effectively with other people based on equal rights. Mobility has been currently higher, enabling the higher desire to explore certain places. This necessity is also suffered by people with disabilities, expecting a specific device for daily assistance such as getting into the car easily and without needing much help from others. Thus, it is necessary to design a specific tool to help people with disabilities, acknowledged as the Disability Lifter, installed on cars that have an L-type hinge. The design of this Disability Lifter employs a hydraulic lifter with a Tiandi TDDL-20 type motor. Based on the design result, the motor power is 0.109 kW with a pressure of 15.69 Bar. The safety factor value of 2.25 indicates that this Disability Lifter has strong resistance and is safe to use.
... Additionally, measures of healthcare practitioners' fear-avoidance beliefs (Waddell et al. 1993) and back pain beliefs (Darlow et al. 2014) have been developed. There are also examples within the literature that use the aforementioned measures to explore osteopaths' attitudes and beliefs towards back pain and lifting (Smith and Thomson 2020) and back pain more generally (Bar-Zaccay and Bailey 2018; Macdonald et al. 2018;Van Biesen and Alvarez 2020) in addition to other measures evaluating osteopaths' attitudes and beliefs about pain (Fitzgerald et al. 2020;Draper-Rodi, Vogel, and Bishop 2021) and empathy within a patient-centred care context (Licciardone and Aryal 2021) using the Consultation and Relational Empathy (CARE) instrument (Mercer et al. 2004). ...
Article
Background Osteopathy requires reliable and valid research tools to generate evidence on the different aspects of practice including how practitioners approach the clinical care of patients. Such research will help the osteopathy profession understand its contribution to healthcare provision and communicate this to stakeholders. However, current quantitative tools to measure the different aspects of osteopathic practice are either focused on single pain conditions or developed from other health professional contexts. Aim The Osteopaths' Therapeutic Approaches Questionnaire (Osteo-TAQ) is a novel tool developed from qualitative research and aims to measure and describe multiple dimensions of osteopaths’ therapeutic approach to patient care. The aim of this study was to further develop the Osteo-TAQ to assess the content validity of the tool. Method A modified nominal group technique (NGT) was employed to establish whether the Osteo-TAQ items were consistent with the underlying construct and to ascertain the prevalence and strength of agreement amongst the expert group panel members (N = 11). A content validity index (CVI) was performed to obtain the evidence for the content validity for a revised version of the Osteo-TAQ. Results Two rounds of review and feedback by an expert panel as part of the NGT resulted in the revision of 13 of the 37 candidate items and refinement of the previously published Osteo-TAQ. Item CVI scores after phase 1 ranged from 0.44-1.0 and agreement was reached after two rounds. Data from the expert panel supports the content validity of the revised Osteo-TAQ items based on high levels of agreement with respect to coverage of the construct being measured. Conclusion This preliminary work to revise and refine the Osteo-TAQ resulted in a measure that is suitable for further testing as part of a validation research program.
... Despite the similarities, osteopathy and physical therapy are completely distinct and function as a separate profession. Nevertheless, considering that osteopaths do not have a more biopsychosocial orientation towards the management of low back pain than other health professionals [41][42][43], the MBBQ might be useful as an assessment tool to identify incorrect beliefs and to guide the development of educational content for undergraduate training. The strengths of our study include the use of appropriate sample size (n = 100) for the analysis conducted which followed the recommended guidelines for assessing the measurement properties of health questionnaire [26]. ...
Article
Background The Modified Back Beliefs Questionnaire (MBBQ) evaluates and screen for incorrect beliefs about low back pain (LBP). Although the MBBQ has been used to assess measurement properties remain unknown therefore, a rigorous cross-cultural validation is necessary. Objective To translate and cross-culturally adapt the MBBQ into Brazilian Portuguese and investigate its measurement properties. Methods The MBBQ was translated and cross-culturally adapted into Brazilian Portuguese. In the final stage of the cross-cultural adaptation process, the translated version was tested in 30 physical therapists to check the understanding of each item. Then, we evaluated the measurement properties in a sample of 100 physical therapists. We calculated test-retest reliability, internal consistency, standard error of the measurement (SEM) and minimal detectable change (MDC). The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) was used in the construct validity analysis. Results The reliability analysis showed high internal consistency, good to excellent test-retest reproducibility. Cronbach alpha coefficient for the MBBQ inevitability score was 0.80 and for the composite score 0.89. Intraclass correlation coefficient (ICC) for the Inevitability score was 0.67 (95%CI: 0.55 to 0.77) and 0.79 (95%CI: 0.70 to 0.86) for the composite score. The MBBQ inevitability and composite scores showed SEM of 1.9 and 2.4 points and minimal detectable change (MDC) of 5.1 and 6.7 points, respectively. Construct validity analyses showed moderate to excellent correlation of the MBBQ scores and the biomedical subscale of the PABS.PT. Conclusions MBBQ showed acceptable measurement properties and may be considered a reliable and valid tool to assess physical therapists' beliefs about low back pain.
... Smith and Thomson's study describes beliefs about lifting amongst UK osteopath using a cross sectional survey [6]. They also relate lifting beliefs with attitudes towards back pain. ...
Article
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Background Health professionals develop their own approach to patient care based on education, experience and philosophical stance. Literature suggests that this practice approach informs patient care, and clinical outcomes. The Osteopaths’ Therapeutic Approaches Questionnaire (Osteo-TAQ) is a novel 36-item instrument developed from qualitative grounded theory research with osteopaths in the United Kingdom. The aim of the study was to develop evidence for the structural and construct validity of the Osteo-TAQ in the Australian osteopathic profession and provide initial descriptive data about the therapeutic approaches of osteopaths in Australia. Methods A cross-sectional study design was used to collect data from registered osteopaths in Australia using the Osteo-TAQ and analysed with Exploratory Factor Analysis (EFA). The EFA utilised parallel analysis to determine the number of factors to extract and McDonald’s omega calculated as the reliability estimation statistic. Results 691 Australian osteopaths provided data for the study, representing 25% of the Australian osteopathic profession. Empirically the number of factors to extract based on the parallel analysis was seven. Two- and three-factor solutions were evaluated given the underpinning theory identifying two conceptions of practice and three interrelated therapeutic approaches. Both the two- and three-factor solutions were consistent with the underpinning theory with acceptable reliability estimations for each factor. Descriptive data suggested the most common element of the therapeutic approach of Australian osteopaths was establishing rapport, while the least common was ‘only talking’ with their patients. Conclusions This study provides evidence for the structural, content and construct validity of the Osteo-TAQ in an Australian osteopathic practitioner population. The results support both a two- and three-factor structure for the Osteo-TAQ in an Australian osteopathic population, with each factor demonstrating acceptable reliability estimations supporting the items comprising each factor as measuring a single construct. From a theoretical and empirical perspective, it can be inferred that the Osteo-TAQ tool encapsulates an osteopaths’ conception of practice (professional artistry and technical rational) and three main therapeutic approaches to patient care: Educator, Communicator and Treater. Further research is required to explore each of these therapeutic approaches to better understand how they relate to an individual osteopath’s conception of practice, and their associations with other measures of practice including clinical outcomes.
Article
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Lifting something off the ground is an essential task and lifting is a documented risk factor for low back pain (LBP). The standard lifting techniques are stoop (lifting with your back), squat (lifting with your legs), and semi-squat (midway between stoop and squat). Most clinicians believe the squat technique is optimal; however, training on squat lifting does not prevent LBP and utilizing greater lumbar flexion (i.e. stoop) when lifting is not a risk factor for LBP. The disconnect between what occurs in clinical practice and what the evidence suggests has resulted in ongoing debate. Clinicians must ask the right questions in order to apply the evidence appropriately. A proposed clinical framework of calm tissue down, build tissue up, improve work capacity can be used to determine which lifting technique is optimal for a patient at any given time. When applying this clinical framework, clinicians should consider metabolic, biomechanical, physical stress tolerance, and pain factors in order to address the movement system. For example, stoop lifting is more metabolically efficient and less challenging to the cardiopulmonary system. There may be few biomechanical differences in spinal postures and gross loads on the lumbar spine between stoop, squat, and semi-squat lifting; however, each lift has distinct kinematic patterns that affects muscle activation patterns, and ultimately the movement system. Clinicians must find the optimal dosage of physical stress to address all aspects of the movement system to minimize the risk of injury. There is no universal consensus on the optimal lifting technique which will satisfy every situation; however, there may be a lifting technique that optimizes movement to achieve a specific outcome. The calm tissue down, build tissue up, improve work capacity framework offers an approach to determine the best lifting technique for an individual patient at any give time. Level of evidence: 5.
Article
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Objectives This study investigated the beliefs and attitudes of UK registered osteopaths towards chronic pain and the management of chronic pain sufferers. Methods A cross-sectional questionnaire based survey of UK registered osteopaths was performed to test the hypothesis that osteopaths have a more biopsychosocial approach to treating and managing chronic pain patients than other healthcare professionals. Sociodemographic determinants of the participants were explored and the original HC-PAIRS and the PABS-PT used as measurement tools. They assess practitioners' attitudes and beliefs towards perceived harmfulness of physical activities for patients with cLBP and participants' knowledge of pain. International meta-analyses were performed with both measurement tools to allow comparison with other healthcare professionals. Results UK registered osteopaths (n = 216) had mean PABS-PT subscale scores of 31.37 ± 6.26 [CI95% 30.53–32.21] (biomedical) and 32.72 ± 4.29 [CI95% 32.14–33.29] (biopsychosocial). The mean HC-PAIRS total score was 45.45 ± 10.05 [CI95% 44.11–46.8]. These indicate a wide spread of beliefs and knowledge towards chronic pain with a tendency to agree that physical activity is not necessarily harmful for patients with cLBP. Post-graduate education had a significant positive effect on questionnaire results. Meta-analyses revealed that UK registered osteopaths have significantly better HC-PAIRS scores than most physiotherapy students, nurses and pharmacists, and had similar PABS-PT scores to most other healthcare professionals. Conclusions The hypothesis of UK registered osteopaths having a more biopsychosocial approach to treating and managing chronic pain patients in comparison to other healthcare providers has been rejected. This seems in contrast to the typically claimed unique concepts of osteopathy. Nevertheless, this study supports their ability to engage with psychosocial factors of the patients' pain experience, but shows that it can be improved. This paper suggests that training is needed to increase osteopaths' expertise in knowledge of chronic pain, and their attitudes towards the management of chronic pain sufferers.
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Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in one primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was carried out on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-years follow-up plus at least 3 (of 6) subsequent monthly questionnaires. Baseline factors were measured using validated tools. Pain intensity scores from the 5-year follow-up and monthly questionnaires were used to assign participants into 4 previously derived pain trajectories (no or occasional mild, persistent mild, fluctuating, persistent severe), using latent class analysis. Posterior probabilities of belonging to each cluster were estimated for each participant. The posterior probabilities for the assigned clusters were very high (>0.90) for each cluster except for the smallest 'fluctuating' cluster (0.74). Lower social class and higher pain intensity were significantly associated with a more severe trajectory 5-years later, as were patients' perceptions of the greater consequences and longer duration of pain, and greater passive behavioural coping. LBP trajectories identified previously appear generalizable. These allow better understanding of the long-term course of LBP and effective management tailored to individual trajectories needs to be identified.
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Question: What influence do physiotherapists' beliefs and attitudes about chronic low back pain have on their clinical management of people with chronic low back pain? Design: Systematic review with data from quantitative and qualitative studies. Quantitative and qualitative studies were included if they investigated an association between physiotherapists' attitudes and beliefs about chronic low back pain and their clinical management of people with chronic low back pain. Results: Five quantitative and five qualitative studies were included. Quantitative studies used measures of treatment orientation and fear avoidance to indicate physiotherapists' beliefs and attitudes about chronic low back pain. Quantitative studies showed that a higher biomedical orientation score (indicating a belief that pain and disability result from a specific structural impairment, and treatment is selected to address that impairment) was associated with: advice to delay return to work, advice to delay return to activity, and a belief that return to work or activity is a threat to the patient. Physiotherapists' fear avoidance scores were positively correlated with: increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. Qualitative studies revealed two main themes attributed to beliefs and attitudes of physiotherapists who have a relationship to their management of chronic low back pain: treatment orientation and patient factors. Conclusion: Both quantitative and qualitative studies showed a relationship between treatment orientation and clinical practice. The inclusion of qualitative studies captured the influence of patient factors in clinical practice in chronic low back pain. There is a need to recognise that both beliefs and attitudes regarding treatment orientation of physiotherapists, and therapist-patient factors need to be considered when introducing new clinical practice models, so that the adoption of new clinical practice is maximised. [Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S (2017) Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy XX: XX-XX].
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
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Background Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one. Methods We used a grounded theory-based qualitative approach to conduct our study. We conducted 30-min in-person interviews with 15 primary care physicians at the Cleveland VA Medical Center and its clinics. We used a semi-structured interview guide to standardize the interviews. ResultsOur two findings include (1) practice change disturbs the status quo equilibrium. Establishing a new equilibrium that incorporates the change may be a struggle; and (2) part of the struggle to establish a new equilibrium incorporating a practice change involves both the “evidence” itself and tensions between evidence and context. Conclusions Our findings provide evidence-based support for many of the empirical unlearning models that have been adapted to healthcare. Our findings differ from these empirical models in that they refute the static and unidirectional nature of change that previous models imply. Rather, our findings suggest that clinical practice is in a constant flux of change; each instance of unlearning and learning is merely a punctuation mark in this spectrum of change. We suggest that physician unlearning models be modified to reflect the constantly changing nature of clinical practice and demonstrate that change is a multi-directional process.
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Background: Non-fatal outcomes of disease and injury increasingly detract from the ability of the world's population to live in full health, a trend largely attributable to an epidemiological transition in many countries from causes affecting children, to non-communicable diseases (NCDs) more common in adults. For the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015), we estimated the incidence, prevalence, and years lived with disability for diseases and injuries at the global, regional, and national scale over the period of 1990 to 2015. Methods: We estimated incidence and prevalence by age, sex, cause, year, and geography with a wide range of updated and standardised analytical procedures. Improvements from GBD 2013 included the addition of new data sources, updates to literature reviews for 85 causes, and the identification and inclusion of additional studies published up to November, 2015, to expand the database used for estimation of non-fatal outcomes to 60 900 unique data sources. Prevalence and incidence by cause and sequelae were determined with DisMod-MR 2.1, an improved version of the DisMod-MR Bayesian meta-regression tool first developed for GBD 2010 and GBD 2013. For some causes, we used alternative modelling strategies where the complexity of the disease was not suited to DisMod-MR 2.1 or where incidence and prevalence needed to be determined from other data. For GBD 2015 we created a summary indicator that combines measures of income per capita, educational attainment, and fertility (the Socio-demographic Index [SDI]) and used it to compare observed patterns of health loss to the expected pattern for countries or locations with similar SDI scores. Findings: We generated 9·3 billion estimates from the various combinations of prevalence, incidence, and YLDs for causes, sequelae, and impairments by age, sex, geography, and year. In 2015, two causes had acute incidences in excess of 1 billion: upper respiratory infections (17·2 billion, 95% uncertainty interval [UI] 15·4–19·2 billion) and diarrhoeal diseases (2·39 billion, 2·30–2·50 billion). Eight causes of chronic disease and injury each affected more than 10% of the world's population in 2015: permanent caries, tension-type headache, iron-deficiency anaemia, age-related and other hearing loss, migraine, genital herpes, refraction and accommodation disorders, and ascariasis. The impairment that affected the greatest number of people in 2015 was anaemia, with 2·36 billion (2·35–2·37 billion) individuals affected. The second and third leading impairments by number of individuals affected were hearing loss and vision loss, respectively. Between 2005 and 2015, there was little change in the leading causes of years lived with disability (YLDs) on a global basis. NCDs accounted for 18 of the leading 20 causes of age-standardised YLDs on a global scale. Where rates were decreasing, the rate of decrease for YLDs was slower than that of years of life lost (YLLs) for nearly every cause included in our analysis. For low SDI geographies, Group 1 causes typically accounted for 20–30% of total disability, largely attributable to nutritional deficiencies, malaria, neglected tropical diseases, HIV/AIDS, and tuberculosis. Lower back and neck pain was the leading global cause of disability in 2015 in most countries. The leading cause was sense organ disorders in 22 countries in Asia and Africa and one in central Latin America; diabetes in four countries in Oceania; HIV/AIDS in three southern sub-Saharan African countries; collective violence and legal intervention in two north African and Middle Eastern countries; iron-deficiency anaemia in Somalia and Venezuela; depression in Uganda; onchoceriasis in Liberia; and other neglected tropical diseases in the Democratic Republic of the Congo. Interpretation: Ageing of the world's population is increasing the number of people living with sequelae of diseases and injuries. Shifts in the epidemiological profile driven by socioeconomic change also contribute to the continued increase in years lived with disability (YLDs) as well as the rate of increase in YLDs. Despite limitations imposed by gaps in data availability and the variable quality of the data available, the standardised and comprehensive approach of the GBD study provides opportunities to examine broad trends, compare those trends between countries or subnational geographies, benchmark against locations at similar stages of development, and gauge the strength or weakness of the estimates available.
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Patient beliefs play an important role in the development of back pain and disability, as well as subsequent recovery. Community beliefs about the back and back pain which are inconsistent with current research evidence have been found in a number of developed countries. These beliefs negatively influence people's back-related behaviour in general, and these effects may be amplified when someone experiences an episode of back pain.In-depth qualitative research has helped to shed light on why people hold the beliefs which they do about the back, and how these have been influenced. Clinicians appear to have a strong influence on patients' beliefs. These data may be used by clinicians to inform exploration of unhelpful beliefs which patients hold, mitigate potential negative influences as a result of receiving health care, and subsequently influence beliefs in a positive manner.
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Study design: Cross-sectional survey. Objective: To compare patients' and physiotherapists' views on triggers for LBP, and to identify any novel factors not previously reported. Summary of background data: Most research on risk factors for low back pain (LBP) is guided by the views of clinicians and researchers, not patients. Consequently, potentially valuable information about risk factors for LBP is not available from those suffering the condition.This study aimed to compare patients' and physiotherapists' views on triggers for LBP, and to identify any novel factors not previously reported. Methods: 102physiotherapists and 999 patients with a sudden, acute episode of LBP participated in this study. Participating physiotherapistswere asked to nominate the most likely short-term risk factors to trigger a LBP episode. Similarly, patients were asked what they thought had triggered their onset of LBP. Responses were coded into risk factor categories and sub-categories by two independent researchers.Endorsement of each category was compared using the Pearson chi-squared statistic. Results: Both patients and physiotherapists endorsed biomechanical risk factors as the most important risk factor category (87.7% and 89.4% respectively) andhad similar levels of endorsement for three of the top five sub-categories (lifting, bending and prolonged sitting). There were significant differences in endorsement of awkward postures (13.4% vs 1.2%; p < 0.001) sports injuries (15.9% vs 4.7%; p < 0.001), physical trauma (3.4% vs 9.2%; p < 0.001) and unaccustomed activity (2.3%vs7.3%; p < 0.001) by patients and physiotherapists respectively. Conclusions: Overall, patients' and physiotherapists'views were remarkably similar. Both patients and physiotherapistsendorsed lifting as the most important trigger for LBP and agreed on three of the top five (lifting, bending and prolonged sitting).No new risk factors were suggested by patients. Level of evidence: 2.
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Introduction: Low back pain remains major public health problem in the Western industrialized world. The known prevalence of low back pain in Ireland is approximately 13 %. It is one of the leading causes of sickness compensation and disability pension in our justification. We hypothesized that there is a widespread misconception about the perception of low back pain among the Irish population. The aim of this study was to investigate whether the "Myths" of low back pain existed among the Irish population. Materials and methods: We carried out a cross-sectional study in the Republic of Ireland from April 2013 to August 2013. The Irish population who visited Galway University Hospital, Galway, Ireland, was contacted randomly at point of entry to the hospital. During the survey, the authors obtained verbal consent before handing the questionnaire, which contained the Deyo's seven myths. The responders were asked to mark their response in a three-point scale (agree, unsure, disagree) to the seven statements. Results: Out of 500 responders, 59 (11.8 %) people answered none of the questions correctly. Fifty-six (11.2 %) answered one question correctly, 106 (21.2 %) answered two questions correctly, 85 (17 %) people disagreed with three myths, 88 (17.6 %) disagreed with four myths, 55 (11 %) people answered five questions correctly, and 34 (6.8 %) answered six questions correctly. Therefore, only 17 (3.4 %) people disagreed with all the seven myths. Conclusion: In conclusion, this cross-sectional study showed that myths of low back pain widely exist among Irish population studied . The level of education played an important role. The findings from this study suggest that public health information regarding low back pain is inadequate and has not affected attitudes to low back pain in an Irish population.
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We developed an evidence-based practice guideline to support occupational safety and health (OSH) professionals in assessing the risk due to lifting and in selecting effective preventive measures for low back pain (LBP) in the Netherlands. The guideline was developed at the request of the Dutch government by a project team of experts and OSH professionals in lifting and work-related LBP. The recommendations for risk assessment were based on the quality of instruments to assess the risk on LBP due to lifting. Recommendations for interventions were based on a systematic review of the effects of worker- and work directed interventions to reduce back load due to lifting. The quality of the evidence was rated as strong (A), moderate (B), limited (C) or based on consensus (D). Finally, eight experts and twenty-four OSH professionals commented on and evaluated the content and the feasibility of the preliminary guideline. For risk assessment we recommend loads heavier than 25 kg always to be considered a risk for LBP while loads less than 3 kg do not pose a risk. For loads between 3-25 kg, risk assessment shall be performed using the Manual handling Assessment Charts (MAC)-Tool or National Institute for Occupational Safety and Health (NIOSH) lifting equation. Effective work oriented interventions are patient lifting devices (Level A) and lifting devices for goods (Level C), optimizing working height (Level A) and reducing load mass (Level C). Ineffective work oriented preventive measures are regulations to ban lifting without proper alternatives (Level D). We do not recommend worker-oriented interventions but consider personal lift assist devices as promising (Level C). Ineffective worker-oriented preventive measures are training in lifting technique (Level A), use of back-belts (Level A) and pre-employment medical examinations (Level A). This multidisciplinary evidence-based practice guideline gives clear criteria whether an employee is at risk for LBP while lifting and provides an easy-reference for (in)effective risk reduction measures based on scientific evidence, experience, and consensus among OSH experts and practitioners.
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Objectives To develop an instrument to assess attitudes and underlying beliefs about back pain, and subsequently investigate its internal consistency and underlying structures. Design The instrument was developed by a multidisciplinary team of clinicians and researchers based on analysis of qualitative interviews with people experiencing acute and chronic back pain. Exploratory analysis was conducted using data from a population-based cross-sectional survey. Setting Qualitative interviews with community-based participants and subsequent postal survey. Participants Instrument development informed by interviews with 12 participants with acute back pain and 11 participants with chronic back pain. Data for exploratory analysis collected from New Zealand residents and citizens aged 18 years and above. 1000 participants were randomly selected from the New Zealand Electoral Roll. 602 valid responses were received. Measures The 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed. Internal consistency was evaluated by the Cronbach α coefficient. Exploratory analysis investigated the structure of the data using Principal Component Analysis. Results The 34-item long form of the scale had acceptable internal consistency (α=0.70; 95% CI 0.66 to 0.73). Exploratory analysis identified five two-item principal components which accounted for 74% of the variance in the reduced data set: ‘vulnerability of the back’; ‘relationship between back pain and injury’; ‘activity participation while experiencing back pain’; ‘prognosis of back pain’ and ‘psychological influences on recovery’. Internal consistency was acceptable for the reduced 10-item scale (α=0.61; 95% CI 0.56 to 0.66) and the identified components (α between 0.50 and 0.78). Conclusions The 34-item long form of the scale may be appropriate for use in future cross-sectional studies. The 10-item short form may be appropriate for use as a screening tool, or an outcome assessment instrument. Further testing of the 10-item Back-PAQ's construct validity, reliability, responsiveness to change and predictive ability needs to be conducted.
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Objectives To explore the prevalence of attitudes and beliefs about back pain in New Zealand and compare certain beliefs based on back pain history or health professional exposure. Design Population-based cross-sectional survey. Setting Postal survey. Participants New Zealand residents and citizens aged 18 years and above. 1000 participants were randomly selected from the New Zealand Electoral Roll. Participants listed on the Electoral Roll with an overseas postal address were excluded. 602 valid responses were received. Measures Attitudes and beliefs about back pain were measured with the Back Pain Attitudes Questionnaire (Back-PAQ). The interaction between attitudes and beliefs and (1) back pain experience and (2) health professional exposure was investigated. Results The lifetime prevalence of back pain was reported as 87% (95% CI 84% to 90%), and the point prevalence as 27% (95% CI 24% to 31%). Negative views about the back and back pain were prevalent, in particular the need to protect the back to prevent injury. People with current back pain had more negative overall scores, particularly related to back pain prognosis. There was uncertainty about links between pain and injury and appropriate physical activity levels during an episode of back pain. Respondents had more positive views about activity if they had consulted a health professional about back pain. The beliefs of New Zealanders appeared to be broadly similar to those of other Western populations. Conclusions A large proportion of respondents believed that they needed to protect their back to prevent injury; we theorise that this belief may result in reduced confidence to use the back and contribute to fear avoidance. Uncertainty regarding what is a safe level of activity during an episode of back pain may limit participation. People experiencing back pain may benefit from more targeted information about the positive prognosis. The provision of clear guidance about levels of activity may enable confident participation in an active recovery.
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Purpose: The purpose of this study was to explore the formation and impact of attitudes and beliefs among people experiencing acute and chronic low back pain. Methods: Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks' duration) and 11 participants with chronic low back pain (more than 3 months' duration) from 1 geographical region within New Zealand. Data were analyzed using an Interpretive Description framework. Results: Participants' underlying beliefs about low back pain were influenced by a range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding. Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs. Clinicians influenced their patients' understanding of the source and meaning of symptoms, as well as their prognostic expectations. Such information and advice could continue to influence the beliefs of patients for many years. Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed. Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity. Conclusions: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.
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Objectives In this study we examined which factors best predict return to work for workers away from work due to acute low back pain. Based on the International Classification of Functioning, Disability and Health, we distinguish between factors related to LBP, to the worker, to the job and to the psychosocial environment that influence duration of an episode of being off work. We updated a previous review because of advances in the field. Methods PubMed, EMBASE, and PsycINFO were searched up to March 2011. Quality of the studies was assessed on 19 methodological items. Levels of evidence will be determined and results will be pooled if possible. Results 4947 titles and abstracts were retrieved and after screening of title abstract and papers for inclusion and exclusion criteria, 28 relevant publications from 25 studies were identified. Two studies that were selected in the previous review were excluded after contact with the authors and due to stricter criteria. Studies were from: Belgium: 2, The Netherlands: 7, USA: 10, Canada: 3, Norway: 2, and Greece: 1. After initial disagreement (overall ICC=0.63) consensus was reached on quality. The average quality of studies was 12.21 with a minimum score of 6 and a maximum score of 16. Approximately 220 factors were considered in these studies. Preliminary analysis shows that recovery expectations, radiating pain, disability and pain might be important factors. Conclusions The review raises the issue of more theory based/biological plausible studies. At the conference we will present pooled results and feedback from stakeholders on relevance.
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G*Power is a free power analysis program for a variety of statistical tests. We present extensions and improvements of the version introduced by Faul, Erdfelder, Lang, and Buchner (2007) in the domain of correlation and regression analyses. In the new version, we have added procedures to analyze the power of tests based on (1) single-sample tetrachoric correlations, (2) comparisons of dependent correlations, (3) bivariate linear regression, (4) multiple linear regression based on the random predictor model, (5) logistic regression, and (6) Poisson regression. We describe these new features and provide a brief introduction to their scope and handling.
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Patients with low back pain and asymptomatic individuals were evaluated while performing controlled and free-dynamic lifting tasks in a laboratory setting. To evaluate how low back pain influences spine loading during lifting tasks. An important, yet unresolved, issue associated with low back pain is whether patients with low back pain experience spine loading that differs from that of individuals who are asymptomatic for low back pain. This is important to understand because excessive spine loading is suspected of accelerating disc degeneration in those whose spines are damaged already. In this study, 22 patients with low back pain and 22 asymptomatic individuals performed controlled and free-dynamic exertions. Trunk muscle activity, trunk kinematics, and trunk kinetics were used to evaluate three- dimensional spine loading using an electromyography- assisted model in conjunction with a new electromyographic calibration procedure. Patients with low back pain experienced 26% greater spine compression and 75% greater lateral shear (normalized to moment) than the asymptomatic group during the controlled exertions. The increased spine loading resulted from muscle coactivation. When permitted to move freely, the patients with low back pain compensated kinematically in an attempt to minimize external moment exposure. Increased muscle coactivation and greater body mass resulted in significantly increased absolute spine loading for the patients with low back pain, especially when lifting from low vertical heights. The findings suggest a significant mechanical spine loading cost is associated with low back pain resulting from trunk muscle coactivation. This loading is further exacerbated by the increases in body weight that often accompany low back pain. Patient weight control and proper workplace design can minimize the additional spine loading associated with low back pain.
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This study evaluated spinal loads associated with lifting and hanging heavy mining cable in a variety of postures. This electrical cable can weigh up to 10 kg per metre and is often lifted in restricted spaces in underground coal mines. Seven male subjects performed eight cable lifting and hanging tasks, while trunk kinematic data and trunk muscle electromyograms (EMGs) were obtained. The eight tasks were combinations of four postures (standing, stooping, kneeling on one knee, or kneeling on both knees) and two levels of cable load (0 N or 100 N load added to the existing cable weight). An EMG-assisted model was used to calculate forces and moments acting on the lumbar spine. A two-way split-plot ANOVA showed that increased load (p < 0.05) and changes in lifting posture (p < 0.05) independently affected trunk muscle recruitment and spinal loading. The increase in cable load resulted in higher EMG activity of all trunk muscles and increased axial and lateral bending moments on the spine (p < 0.05). Changes in posture caused more selective adjustments in muscle recruitment and affected the sagittal plane moment (p < 0.05). Despite the more selective nature of trunk EMG changes due to posture, the magnitude of changes in spinal loading was often quite dramatic. However, average compression values exceeded 3400 N for all cable lifting tasks.
Article
Background: low back pain (LBP) is the main cause of years lived with disability worldwide. Psychosocial factors have been shown to be good predictors of persistent LBP. Within these, unhelpful beliefs about the back seem to be important in the development and chronicity of the symptoms. The Back Pain Attitudes Questionnaire (Back-PAQ) is an instrument that explores beliefs about the back that has been validated for people with and without back pain and healthcare professionals. However, until now, it has not been translated and validated for the Argentine population. Objective: translate into Spanish, cross-cultural adapt and validate the Back-PAQ for the Argentine population with and without back pain. Study design: study of diagnostic accuracy/assessment scale. Methods: the study was carried out in three consecutive phases: translation, cross-cultural adaptation and validation. We included Argentinians aged 18 years or more. We used the Back-PAQ, modified Fear Avoidance Beliefs Questionnaire (mFABQ) and the Global Rating of Change (GROC) scale to assess the psychometric properties. Results: three hundred and seventy-two participants were included for the analysis. The time taken to answer and score the questionnaire was 5.6 and 1.6 min, respectively. Neither a ceiling nor a floor effect was observed. Internal consistency was 0.76. One hundred and eighty-six participants were considered stable. Test-retest reliability was 0.90. A weak correlation (0.33) was found between the Back-PAQ and the mFABQ. Conclusion: the Argentine version of the Back-PAQ is a viable, reliable and valid tool for the assessment of the back beliefs of the Argentine population.
Article
Study design: Prognosis systematic review with meta-analysis. Objective: To evaluate whether lumbar spine flexion during lifting is a risk factor for low back pain (LBP) onset/persistence, or a differentiator of people with and without LBP. Literature search: Database search of Proquest, CINAHL, Medline and EMBASE until August 2018. Study selection criteria: We included peer-reviewed articles, investigating lumbar spine position during lifting as a risk factor for LBP onset or persistence, or as a differentiator of people with and without LBP. Data synthesis: Lifting task comparison data were tabulated and summarised. For meta-analysis, we calculated an n-weighted pooled mean (SD) of the results for each of the LBP and no LBP groups. Where a study contained multiple comparisons (i.e. different lifting tasks that used various weights or directions), only one result for each study was included in the meta-analysis. Results: Four studies (one longitudinal study and three cross-sectional studies) measured lumbar flexion with intra-lumbar angles and found no differences in peak lumbar spine flexion when lifting (longitudinal 1.5 degree (95%CI -0.7 to 3.7), p=0.19 and cross-sectional -0.9 (95%CI -2.5 to 0.7), p=0.29). Seven cross-sectional studies measured lumbar flexion with thoraco-pelvic angles and found people with LBP lifted with 6.0 degrees less lumbar flexion than people without LBP (95%CI -11.2 to -.89, p<0.01). Most (9 of 11) studies reported no between-group differences in lumbar flexion during lifting. The included studies were low quality. Conclusion: There was low quality evidence that greater lumbar spine flexion during lifting was not a risk factor for LBP onset/persistence, nor a differentiator of people with and without LBP. J Orthop Sports Phys Ther, Epub 28 Nov 2019. doi:10.2519/jospt.2020.9218.
Article
Background and aims To systemically review the literature to compare freestyle lifting technique, by muscle activity and kinematics, between people with and without low back pain (LBP). Methods Five databases were searched along with manual searches of retrieved articles by a single reviewer. Studies were included if they compared a freestyle lifting activity between participants with and without LBP. Data were extracted by two reviewers, and studies were appraised using the CASP tool for case-control studies. Results Nine studies were eligible. Heterogeneity did not allow for meta-analysis. Most studies (n = 8 studies) reported that people with LBP lift differently to pain-free controls. Specifically, people with LBP lift more slowly (n = 6 studies), use their legs more than their back especially when initiating lifting (n = 3 studies), and jerk less during lifting (n = 1 studies). Furthermore, the four larger studies involving people with more severe LBP also showed that people with LBP lift with less spinal range of motion and greater trunk muscle activity for a longer period. Conclusions People with LBP move slower, stiffer, and with a deeper knee bend than pain-free people during freestyle lifting tasks. Interestingly, such a lifting style mirrors how people, with and without LBP, are often told how to lift during manual handling training. The cross-sectional nature of the comparisons does not allow for causation to be determined. Implications The changes described may show embodiment of cautious movement, and the drive to protect the back. There may be value in exploring whether adopting a lifting style closer to that of pain-free people could help reduce LBP.
Article
Objectives This randomized controlled trial investigated the efficacy of cognitive functional therapy (CFT) compared with manual therapy and exercise (MT‐EX) for people with non‐specific chronic low back pain (NSCLBP) at 3‐year follow‐up. Methods 121 patients were randomized to CFT (n=62) or MT‐EX (n=59). 3‐year data were available for 30 (48.4%) participants in the CFT group, and 33 (55.9%) participants in the MT‐EX group. The primary outcomes were disability (Oswestry disability Index (ODI)) and pain intensity (numerical rating scale (NRS)) and secondary outcomes were anxiety/depression (Hopkins Symptoms Checklist) and pain related fear (Fear Avoidance Belief Questionnaire). A full intention to treat analysis was conducted using linear mixed models. Results Significantly greater reductions in disability were observed for the CFT group, with ODI scores at 3‐years 6.6 points lower in the CFT than the MT‐EX group (95%CI:‐10.1 to ‐3.1, p<.001, standardized effect size =0.70). There was no significant difference in pain intensity between the groups at 3 years (0.6 points 95%CI:‐1.4 to 0.3, p=.195). Significantly greater reductions were also observed for the CFT group for Hopkins Symptoms Checklist and Fear Avoidance Belief Questionnaire (Work). Conclusions CFT is more effective at reducing disability, depression/anxiety and pain related fear, but not pain, at 3‐year follow‐up than MT‐EX. This article is protected by copyright. All rights reserved.
Article
Background Beliefs can be assessed using explicit measures (e.g. questionnaires) that rely on information of which the person is ‘aware’ and willing to disclose. Conversely, implicit measures evaluate beliefs using computer-based tasks that allow reduced time for introspection thus reflecting ‘automatic’ associations. Thus far, physiotherapists' beliefs about back posture and safety have not been evaluated with implicit measures. Objectives (1) Evaluate implicit associations between bending lifting back posture (straight-back vs round-back) and safety (safe vs danger); (2) Explore correlations between implicit and explicit measures of beliefs towards vulnerability of the back. Design Exploratory cross-sectional quantitative study. Methods 47 musculoskeletal physiotherapists completed explicit measures of fear of movement (TSK-HC), back beliefs (BackPAQDanger) and beliefs related to bending and lifting back posture and safety (BSB). An Implicit Association Test (IAT) was used to assess implicit associations between (i) images of people bending/lifting with a ‘round-back’ or with a ‘straight-back’ posture, and (ii) words representing ‘safety’ and ‘danger’. A one-sample t-test assessed the degree and direction of the sample's IAT score. Cohen's d provided an effect size of the estimated bias. Correlation between IAT and each explicit measure was assessed using Pearson's coefficient. Results The sample displayed an implicit association between ‘round-back’ and ‘danger’ (μ = 0.213, 95% CI [0.075-0.350], p = .003), with an effect size magnitude of 0.45. There were fair to moderate correlations between IAT and BSB (r = 0.320, 95% CI [0.036-0.556], p = .029) and, IAT and BackPAQDanger (r = 0.413, 95%CI [0.143-0.626], p = .004). Conclusions Physiotherapists displayed an implicit bias towards bending and lifting with a round-back as dangerous.
Article
Background: The Back-Pain Attitudes (Back-PAQ) questionnaire measures back beliefs across 6 domains. Our previous study showed that manual handling advisors (MHAs) have more negative beliefs than physiotherapists (PTs), and those who think straight back lifting is safer than a rounder back have more negative beliefs. However, exactly which domains of the Back-PAQ are most negative is unknown. Objectives: Gain deeper understanding of how MHAs and PTs construct their back beliefs, and relate this safe lifting posture beliefs. Design: Data was collected via an electronic survey. Method: Participants’ back beliefs were collected via the Back-PAQ. They were also asked to select the safest lifting posture from four options: two with a straight back; two with a rounder back. Back beliefs were analysed in the 6 domains that construct the Back-PAQ. Relationships were investigated using multiple linear and regression models. Results: 400 PTs and MHAs completed the survey. MHAs scored higher (more negative beliefs) than PTs across all 6 domains, and those who perceive straight back lifting as safest scored higher across five of the 6 domains. The belief to keep active with back pain was common among all groups, but MHAs and those who prefer straight back lifting believe the back is vulnerable and more in need of protection. Conclusion: While all believe staying active is beneficial for back pain, residual negative beliefs regarding the vulnerability of the spine persist. Education campaigns may need to emphasise a ‘trust your back’ message rather than a ‘protect your back’ message while encouraging activity.
Article
Background and aims Despite lack of support from recent in vivo studies, bending and lifting (especially with a round-back posture) are perceived as dangerous to the back. In light of this view, it has been proposed that pain-free people may hold a common implicit belief that is congruent with the idea that bending and lifting with a round-back represents danger to a person’s back, however this has not been evaluated. The aims of this study were: (1) to evaluate implicit associations between back posture and safety related to bending and lifting in pain-free people; (2) to explore correlations between the implicit measure and explicit measures of back beliefs, fear of movement and safety of bending; (3) to investigate self-reported qualitative appraisal of safe lifting. Methods Exploratory cross-sectional study including 67 pain-free participants (no pain, or average pain ≤3/10 for less than one week over the previous 12 months) (52% male), who completed an online survey containing demographic data and self-reported measures of: fear of movement (Tampa Scale for Kinesiophobia for General population – TSK-G), back beliefs (Back Pain Attitudes Questionnaire BackPAQ), and bending beliefs (Bending Safety Belief – BSB – a pictorial scale with images of a person bending/lifting with round and straight back postures). Implicit associations between back posture and safety related to bending and lifting were evaluated with the Implicit Association Test (IAT). A qualitative assessment of descriptions of safe lifting was performed. Results An implicit association between “danger” and “round-back” bending/lifting was evident in all participants (IAT D-score =0.65 (SD=0.45; 95% CI [0.54, 0.76]). Participants’ profile indicated high fear of movement, unhelpful back beliefs, and perceived danger to round-back bending and lifting (BSB Thermometer : 5.2 (SD=3.8; 95% CI [4.26, 6.13] range −10 to 10; t (67) =11.09, p <0.001). There was a moderate correlation between IAT and BSB Thermometer (r=0.38, 95% CI [0.16, 0.62]). There were weaker and non-statistically significant correlations between IAT and TSK-G (r=0.28, 95% CI [−0.02, 0.47]), and between IAT and BackPAQ Danger (r=0.21, 95% CI [−0.03, 0.45]). Qualitative assessment of safe lifting descriptions indicated that keeping a “straight back” and “squatting” when lifting were the most common themes. Conclusions Pain-free people displayed an implicit bias towards bending and lifting with a “round-back” as dangerous. Our findings support the idea that pain-free people may have a pre-existing belief about lifting, that the back is in danger when rounded. Research to evaluate the relationship between this implicit bias and lifting behaviour is indicated. Implications The findings of this study may have implications for ergonomic guidelines and public health information related to bending and lifting back postures. Additionally, clinicians may need to be aware of this common belief, as this may be reflected in how a person responds when they experience pain.
Article
Objectives: To assess the biomedical (BM) and biopsychosocial (BM) attitudes and beliefs of osteopaths towards the management of low back pain (LBP) and whether this is associated with certain demographic variables. Methods: A cross-sectional survey of UK osteopaths was undertaken utilising the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT), which assesses practitioners' treatment orientation (BPS or BM) in LBP management. A demographic questionnaire was used to assess the relationship with certain demographic variables. Results: Responses were analysed from 107 osteopaths. The mean PABS.PT score for the BM scale was 32.41 (SD 6.32) and 31.99 (SD 4.09) for the BPS scale. There was a statistically significant, negative correlation between the scales. Most osteopaths recognised stress as a contributing factor to LBP and believed in the benefits of exercise for LBP but had diverse views regarding the relationships between pain and tissue damage. None of the demographic variables were associated with the PABS.PT scales. Conclusion: Osteopaths' beliefs may indicate an acceptance of the BPS approach, but some still hold strong BM beliefs about pain, which may influence their clinical decision making. Future studies should investigate the impact of osteopaths’ beliefs on their clinical management of LBP.
Article
Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.1Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,2,3is a call for action on this global problem of low back pain.
Article
Objectives Chronic pain is a complex and challenging problem for manual therapists, such as osteopaths, especially in identifying and managing the multiplicity of psychosocial factors associated with the chronic musculoskeletal pain experience. This study explored Italian osteopaths' attitudes and beliefs towards chronic pain, particularly their understanding of the biomedical and biopsychosocial (BPS) dimensions of chronic pain, and the role they play in their clinical practice. Methods A qualitative study was conducted using in-depth semi-structured interviews. A purposive sample of 11 osteopaths practising in Italy was recruited from a poster advert sent to 8 Italian osteopathic schools. Interview data were transcribed verbatim and interpreted using a constructivist approach to grounded theory as a framework for data analysis. Results Three themes were constructed from the data: 1) process of patient evaluation; 2) professional view; 3) developing professional knowledge. Conclusions Osteopaths displayed a greater orientation towards the biomedical dimension of chronic pain than the BPS one. Although the importance of the BPS model has been recognised as part of the osteopathic philosophy of clinical practice and the role of psychosocial factors (PS) as considered important in pain experience, the osteopaths included in this study highlighted lack of knowledge and skills to assess and address psychosocial risk factors in the management of long term pain sufferers. These findings indicate the need for osteopaths to acquire such skills and knowledge in professional training programs to develop a more operational holistic view in managing chronic pain sufferers.
Article
Background: It is commonly believed lifting is dangerous and the back should be straight during lifting. These beliefs may arise from healthcare professionals, yet no study has evaluated the lifting and back beliefs of manual handling advisors (MHAs) and physiotherapists (PTs). Objectives: To evaluate (i) what lifting technique MHAs and PTs perceive as safest, and why, and (ii) the back pain beliefs of MHAs and PTs. Design: Data was collected via an electronic survey. Method: Participants selected the safest lifting posture from four options: two with a straight back and two with a more rounded back, with justification. Back beliefs were collected via the Back-Pain Attitudes Questionnaire (Back-PAQ). Relationships were investigated using multiple linear and logistic regression models. Results: 400 PTs and MHAs completed the survey. 75% of PTs and 91% of MHAs chose a straight lifting posture as safest, mostly on the basis that it avoided rounding of the back. MHAs scored significantly higher than PTs on the Back-PAQ instrument (mean difference = 33.9), indicating more negative back beliefs. Those who chose the straight back position had significantly more negative back beliefs (mean 81.9, SD 22.7) than those who chose a round back lift (mean 61.7, SD 21.1). Conclusion: Avoiding rounding the back while lifting is a common belief in PTs and MHAs, despite the lack of evidence that any specific spinal posture is a risk factor for low back pain. MHAs, and those who perceived a straight back position as safest, had significantly more negative back beliefs.
Article
Background: Healthcare practitioner beliefs influence advice and management provided to patients with back pain. Several instruments measuring practitioner beliefs have been developed but psychometric properties for some have not been investigated. Aims: To investigate internal consistency, test-retest reliability and convergent validity of the Fear Avoidance Beliefs Tool (FABT), the Tampa Scale of Kinesiophobia for Health Care Providers (TSK-HC), the Back Pain Attitudes Questionnaire (Back-PAQ), and the Health Care Pain and Impairment Relationship Scale (HC-PAIRS). A secondary aim was to explore beliefs of New Zealand osteopaths and physiotherapists regarding low back pain. Method: FABT, TSK-HC, Back-PAQ, and HC-PAIRS were administered twice, 14 days apart. Results: Data from 91 osteopaths and 35 physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated excellent internal consistency, (Cronbach's α = 0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). Correlations between instruments (Pearson's r = 0.51 to 0.77, p < 0.001) demonstrated good convergent validity. There was a medium to large effect (Cohen's d > 0.47) for mean differences in scores, for all instruments, between professions. Conclusions: This study found excellent internal consistency, test-retest reliability and good convergent validity for the FABT, TSK-HC, and Back-PAQ. Previously reported internal consistency, test-retest and convergent validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. There were significant scoring differences on each instrument between professions, and while both groups demonstrated fear avoidant beliefs, physiotherapist respondent scores indicated that as a group, they held fewer fear-avoidant beliefs than osteopath respondents.
Article
Synopsis Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain-related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear-avoidance model. However, there is evidence that pain-related fear can also be seen as a common-sense response to deal with low back pain, for example, when one is told that one's back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common-sense response to protect a “damaged” back. While the fear-avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear-avoidance cycle is less clear. Understanding pain-related fear from a common-sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain-related fear in people with low back pain, this clinical commentary illustrates how Leventhal's common-sense model may assist physical therapists to understand the broader sense-making processes involved in the fear-avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature. J Orthop Sports Phys Ther 2017;47(9):628–636. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7434
Article
Background: A growing body of research evidence has identified psychosocial factors to be important in the management of low back pain (LBP). Evidence suggests that healthcare professionals have a considerable influence on patients’ attitudes and beliefs. Few studies have investigated how patients experiencing LBPinterpret the language used by their osteopath during their consultation and the impact of language on their attitudes and beliefs of their LBP. Objectives: To explore and describe how patients with acute or chronic LBP interpret the language used by student osteopaths when explaining their diagnosis, and the impact their interpretation has on their attitudes and beliefs of their LBP. Method: Semi-structured qualitative interviews were conducted with a purposive sample of nine patients experiencing LBP who had recently attended an osteopathic teaching clinic in the UK. Interviews were transcribed verbatim and elements of grounded theory were used as a framework for data analysis. Results: Participants expressed a range of interpretations in response to the language used when discussing their LBP. The use of medical words, metaphors, reassurance and the patient-practitioner relationship were identified as factors influencing the level to which participants engaged, taking an active role in their care. Conclusions: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.
Article
Guidelines recommend the biopsychosocial (BPS) model for managing non-specific low back pain (NSLBP) but the best method for teaching the BPS model is unclear. Printed material and face-to-face learning have limited effects on practitioners’ attitudes to back pain. An alternative way is needed and e-learning is a promising option. E-learning is becoming an important part of teaching but little guidance is available to the osteopathic profession.
Article
The aim of this case-crossover study was to investigate the extent to which patients can accurately nominate what triggered their new episode of sudden onset, acute low back pain (LBP). We interviewed 999 primary care patients to record exposure to 12 standard triggers and also asked the patient to nominate what they believed triggered their LBP. Exposure to the patient-nominated trigger during the case window was compared to exposure in the control window. Conditional logistic regression models were constructed to quantify the risk of LBP onset associated with the patient-nominated trigger. Sensitivity analyses were conducted varying the duration and timing of case/control windows. We compared the extent to which patient-nominated triggers matched standard triggers.The odds ratios for exposure to patient-nominated triggers ranged from 8.60 to 30.00 suggesting that exposure increase the risk of LBP. Patients' understanding of triggers however seem incomplete as we found evidence that while some of the standard triggers were well recognised (such as lifting heavy loads); others (such as being distracted during manual tasks) were under-recognised as possible triggers of an episode of LBP. This study provides some evidence that patients can accurately nominate the activity that triggered their new episode of sudden onset, acute LBP.
Article
As torso flexion and repetitive lifting are known risk factors for low back pain and injury, it is important to investigate lifting techniques that might reduce injury during repetitive lifting. By normalizing lumbar posture to a subject's range of motion (ROM), as a function of torso flexion, this research examined when subjects approached their range of motion limits during dynamic lifting tasks. For this study, it was hypothesized that experienced lifters would maintain a more neutral lumbar angle relative to their range of motion, while novice lifters would approach the limits of their lumbar ROM during the extension phase of a straight-leg lift. The results show a statistically significant difference in lifting patterns for these two groups supporting this hypothesis. The novice group maintained a much more kyphotic lumbar angle for both the flexion (74% of the lumbar angle ROM) and extension phases (86% of the lumbar angle ROM) of the lifting cycle, while the experienced group retained a more neutral curvature throughout the entire lifting cycle (37% of lumbar angle ROM in flexion and 48% of lumbar angle ROM in extension). By approaching the limits of their range of motion, the novice lifters could be at greater risk of injury by placing greater loads on the supporting soft tissues of the spine. Future research should examine whether training subjects to assume more neutral postures during lifting could indeed lower injury risks. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover 3 main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors, to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Eighteen items are common to all 3 study designs and 4 are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available at www.annals.org and on the Web sites of PLoS Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
Article
G*Power (Erdfelder, Faul, & Buchner, 1996) was designed as a general stand-alone power analysis program for statistical tests commonly used in social and behavioral research. G*Power 3 is a major extension of, and improvement over, the previous versions. It runs on widely used computer platforms (i.e., Windows XP, Windows Vista, and Mac OS X 10.4) and covers many different statistical tests of the t, F, and chi2 test families. In addition, it includes power analyses for z tests and some exact tests. G*Power 3 provides improved effect size calculators and graphic options, supports both distribution-based and design-based input modes, and offers all types of power analyses in which users might be interested. Like its predecessors, G*Power 3 is free.
Article
Increasing interest is being shown in osteopathy on a national and international basis. Since little prospective data had been available concerning the day-to-day practice of the profession, a standardised data collection tool was developed to try and address this issue. The tool development process has been described in an earlier paper. The standardised data collection (SDC) tool underwent national piloting between April and July 2009 in United Kingdom private practices. Osteopaths volunteered to participate and collected data on consecutive new patients or patients presenting with a new symptom episode for a period of one month; follow-up data were collected for a further two months. A total of 1630 completed datasets from the SDC pilot were analysed by the project team. Data generated from the national pilot showed that lumbar symptoms were the most commonly presented in patients (36%), followed by cervical spine (15%), sacroiliac/pelvic/groin (7.9%), head/facial area (7%), shoulder (6.8%), and thoracic spine (6%). A total of 48.8% of patients reported comorbidities, the most common being hypertension (11.7%), followed by asthma (6.6%), and arthritis (5.7%). Outcome data were collected looking at the patients' response to treatment, and any form of treatment reactions. The profiling information collected using the SDC tool provides a contemporary picture of osteopathic practice in the United Kingdom.
Article
Objectives In this study we examined which factors best predict return to work for workers away from work due to acute low back pain. Based on the International Classification of Functioning, Disability and Health, we distinguish between factors related to LBP, to the worker, to the job and to the psychosocial environment that influence duration of an episode of being off work. We updated a previous review because of advances in the field. Methods PubMed, EMBASE, and PsycINFO were searched up to March 2011. Quality of the studies was assessed on 19 methodological items. Levels of evidence will be determined and results will be pooled if possible. Results 4947 titles and abstracts were retrieved and after screening of title abstract and papers for inclusion and exclusion criteria, 28 relevant publications from 25 studies were identified. Two studies that were selected in the previous review were excluded after contact with the authors and due to stricter criteria. Studies were from: Belgium: 2, The Netherlands: 7, USA: 10, Canada: 3, Norway: 2, and Greece: 1. After initial disagreement (overall ICC=0.63) consensus was reached on quality. The average quality of studies was 12.21 with a minimum score of 6 and a maximum score of 16. Approximately 220 factors were considered in these studies. Preliminary analysis shows that recovery expectations, radiating pain, disability and pain might be important factors. Conclusions The review raises the issue of more theory based/biological plausible studies. At the conference we will present pooled results and feedback from stakeholders on relevance.
Article
In the context of uncertainty about aetiology and prognosis, good clinical practice commonly recommends both affective (creating rapport, showing empathy) and cognitive reassurance (providing explanations and education) to increase self-management in groups with non-specific pain conditions. The specific impact of each of these components in reference to patients' outcomes has not been studied. This review aimed to systematically evaluate the evidence from prospective cohorts in primary care that measured patient-practitioner interactions with reference to patient outcomes. We carried out a systematic literature search and appraisal of study methodology. We extracted measures of affective and cognitive reassurance in consultations and their associations with consultation-exit and follow up measures of patients' outcomes. We identified 16 studies from 16,059 abstracts. Eight studies were judged to be high in methodological quality. Pooling could not be achieved due to heterogeneity of samples and measures. Affective reassurance showed inconsistent findings with consultation exit outcomes. In three high-methodology studies, an association was found between affective reassurance and higher symptom burden and less improvement at follow up. Cognitive reassurance was associated with higher satisfaction and enablement and reduced concerns directly after the consultations in eight studies; with improvement in symptoms at follow up in seven studies; and with reduced health care utilization in three studies. Despite limitations, there is support for the notion that cognitive reassurance is more beneficial than affective reassurance. We present a tentative model based on these findings and propose priorities for future research.
Article
Objectives: Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. The aim of this metasynthesis of qualitative studies was to provide clinicians with a richer understanding of their patients' CLBP experience to highlight the importance of moving away from biomedical paradigms in the clinical management of CLBP. Methods: Qualitative studies exploring the CLBP experience from the perspective of the individual were included. Twenty-five articles representing 18 studies involving 713 participants were subjected to the 3-stage analytic process of extraction/coding, grouping, and abstraction. Results: Three main themes emerged: the social construction of CLBP; the psychosocial impact of the nature of CLBP; and coping with CLBP. Discussion: The authors conceptualize the experience of CLBP as biographical suspension in which 3 aspects of suspension are described: suspended "wellness," suspended "self," and suspended "future". The implications of improved clinician understanding of the CLBP experience and directions for future research are discussed.
Article
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
Squat lifting is widely regarded as the ‘correct’ technique for lifting low-lying objects. However what evidence is there to support this technique? Further, is the evidence sufficient to justify teaching the technique? Until the last decade there was very little evidence to support the use of squat lifting of low-lying objects. Semi-squat lifting has been the centre of renewed interest in recent years. However there is less evidence for semi-squat, either for or against, than for stoop and squat techniques. Whilst it may provide a reasonable compromise between stoop and squat, it may be a mixture of the disadvantages of stoop and squat or even create new problems. Stoop lifting is commonly understood to be ‘incorrect’. The vast majority of advice literature on lifting technique recommends against using stoop lifting. However some research results actually support the use of stoop lifting. This paper summarises the available evidence in support of using squat, semi-squat and stoop techniques to lift low-lying objects. Evidence is presented under headings of psychophysical, physiological, biomechanical, subjective, performance and clinical. No previous publication summarising this evidence could be found, and the results may be surprising to many.Relevance to industrySquat lifting technique training is one of the most common interventions made by industry in an attempt to reduce the musculoskeletal disorders associated with manual tasks. However the research literature has questioned this perception for many years. This article provides a concise summary to help industry understand the evidence.
Article
The widespread use of the biopsychosocial model amongst various health professions, all of which claim to take a patient-centred approach to their practice, challenges what has been considered a unique and defining feature of osteopathy. This paper discusses the complexity of what is meant by patient-centeredness, and how it is practiced and researched by other health professions. The assumption that osteopathy has always taken a patient-centred approach is questioned, and directions for further research are highlighted so that the profession can have a comprehensive working knowledge of its practice, thereby helping to define itself within the broad and competitive healthcare environment.
Article
Unlabelled: The objective of this study was to measure the effect size of three important factors in manual material handling, namely expertise, lifting height and weight lifted. The effect of expertise was evaluated by contrasting 15 expert and 15 novice handlers, the effect of the weight lifted with a 15-kg box and a 23-kg box and the effect of lifting height with two different box heights: ground level and a 32 cm height. The task consisted of transferring a series of boxes from a conveyor to a hand trolley. Lifting height and weight lifted had more effect size than expertise on external back loading variables (moments) while expertise had low impact. On the other hand, expertise showed a significant effect of posture variables on the lumbar spine and knees. All three factors are important, but for a reduction of external back loading, the focus should be on the lifting height and weight lifted. Practitioner summary: The objective was to measure the effect size of three important factors in a transfer of boxes from a conveyor to a hand trolley. Lifting height and weight lifted had more effect size than expertise on external back loading variables but expertise was a major determinant in back posture.
Article
It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population. Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined. Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP. HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.
Article
Low back pain (LBP) is a disorder that commonly affects the working population, resulting in disability, health-care utilization, and a heavy socioeconomic burden. Although the etiology of LBP remains uncertain, occupational activities have been implicated. Evaluating these potentially causal relationships requires a methodologically rigorous approach. Occupational repetitive and/or heavy lifting is widely thought to be a risk factor for the development of LBP. To conduct a systematic review of the scientific literature to evaluate the causal relationship between occupational lifting and LBP. Systematic review of the literature. Studies reporting an association between occupational lifting and LBP. Numerical association between different levels of exposure to occupational lifting and the presence or severity of LBP. A search was conducted using Medline, EMBASE, CINAHL, Cochrane Library, OSH-ROM, gray literature (eg, reports not published in scientific journals), hand-searching occupational health journals, reference lists of included studies, and content experts. Evaluation of study quality was performed using a modified version of the Newcastle-Ottawa Scale. Levels of evidence were evaluated for specific Bradford-Hill criteria (association, dose-response, temporality, experiment, and biological plausibility). This search yielded 2,766 citations, of which 35 studies met eligibility criteria and 9 were considered high methodological quality studies, including four case-controls and five prospective cohorts. Among the high-quality studies, there was conflicting evidence for association with four studies reporting significant associations and five studies reporting nonsignificant results. Two of the three studies that assessed dose-response demonstrated a nonsignificant trend. There were no significant risk estimates that demonstrated temporality. No studies were identified that satisfied the experiment criterion. Subgroup analyses identified certain types of lifting and LBP that had statistically significant results, but there were none that satisfied more than two of the Bradford-Hill criteria. This review uncovered several high-quality studies examining a relationship between occupational lifting and LBP, but these studies did not consistently support any of the Bradford-Hill criteria for causality. There was moderate evidence of an association for specific types of lifting and LBP. Based on these results, it is unlikely that occupational lifting is independently causative of LBP in the populations of workers studied. Further research in specific subcategories of lifting would further clarify the presence or absence of a causal relationship.
Article
A survey was done on 1221 men between the ages of eighteen and fifty-five years who had been seen in a family-practice facility between 1975 and 1978. Each patient completed a questionnaire concerning any history of low-back pain, associated symptoms in the lower limbs, resultant disability, types of health care utilized, certain occupational characteristics, exposure to vehicular vibration and sports activities. We found that 368 patients (30.1 per cent) had never experienced low-back pain, 565 (46.3 per cent) had or were having moderate low-back pain, and 288 (23.6 per cent) had or were having severe low-back pain. Patients with severe low-back pain had significantly more complaints in the lower limbs, sought more medical care and treatment for the low-back pain, and had lost more time from work for this reason. Risk factors associated with severe low-back pain included jobs requiring repetitive heavy lifting, the use of jackhammers or machine tools, and the operation of motor vehicles. Patients with severe pain were more likely to be cigarette-smokers and had a greater tobacco consumption as measured by both the number of cigarettes smoked per day and the number of years of exposure. Patients with moderate low-back pain were more often joggers and cross-country skiers when compared with the asymptomatic men and the men with severe low-back pain. Otherwise, there were no identifiable differences related to sports activity.
Article
To assess the biomechanical evidence in support of advocating the squat lifting technique as an administrative control to prevent low back pain. Instruction with respect to lifting technique is commonly employed to prevent low back pain. The squat technique is the most widely advised lifting technique. Intervention studies failed to show health effects of this approach and consequently the rationale behind the advised lifting techniques has been questioned. Biomechanical studies comparing the stoop and squat technique were systematically reviewed. The dependent variables used in these studies and the methods by which these were measured or estimated were ranked for validity as indicators of low back load. Spinal compression as indicated by intra-discal pressure and spinal shrinkage appeared not significantly different between both lifting techniques. Net moments and compression forces based on model estimates were found to be equal or somewhat higher in squat than in stoop lifting. Only when the load could be lifted from a position in between the feet did squat lifting cause lower net moments, although the studies reporting this finding had a marginal validity. Shear force and bending moments acting on the spine appeared lower in squat lifting. Net moments and compression forces during lifting reach magnitudes, that can probably cause injury, whereas shear forces and bending moments remained below injury threshold in both techniques. The biomechanical literature does not provide support for advocating the squat technique as a means of preventing low back pain. Training in lifting technique is widely used in primary and secondary prevention of low back pain, though health effects have not been proven. The present review assesses the biomechanical evidence supporting the most widely advocated lifting technique.