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It's time for change with the management of non-specific chronic low back pain

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Abstract

Low back pain (LBP) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies, opiod medications, spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach, and evidence that only 8–15% of patients with LBP have an identified patho-anatomical diagnosis, resulting in the majority being diagnosed as having non-specific LBP.3 Of this population, a small but significant group becomes chronic and disabled, labelled non-specific chronic low back pain (NSCLBP), consuming a disproportionate amount of healthcare resources.4 1. Over the past decade, the traditional biomedical view of LBP has been greatly challenged. This is a result of: the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8; 2. the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9; 3. the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments, conflicting diagnoses, lost hope and ongoing suffering10; 4. the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder, where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12; 5. positive outcomes in randomised controlled trials (RCTs) are best predicted by changes in psychological distress, fear avoidance beliefs, self-efficacy in …
Editorial
O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638 1 of 4
Editorial
Low back pain (LBP) is the second great-
est cause of disability in the USA.
1
USA
data supports that in spite of an enormous
increase in the health resources spent on
LBP disorders, the disability relating to
them continues to increase.
2
The man-
agement of LBP is underpinned by the
exponential increase in the use of physi-
cal therapies, opiod medications, spinal
injections as well as disc replacement
and fusion surgery.
2
This is maintained
by the underlying belief that LBP is fun-
damentally a patho-anatomical disorder
and should be treated within a biomedical
model.
1
This is in spite of calls over a num-
ber of years to adopt a bio-psycho-social
approach, and evidence that only 8–15%
of patients with LBP have an identifi ed
patho-anatomical diagnosis, resulting in
the majority being diagnosed as having
non-specifi c LBP.
3
Of this population,
a small but signifi cant group becomes
chronic and disabled, labelled non-specifi c
chronic low back pain (NSCLBP), consum-
ing a disproportionate amount of health-
care resources.
4
1. Over the past decade, the traditional
biomedical view of LBP has been
greatly challenged. This is a result
of: the failure of simplistic single-
dimensional therapies to show large
effects in patients with NSCLBP
5
8
;
2. the results of clinical trials testing
commonly prescribed interventions
demonstrating that no management
approaches are clearly superior
5
7
9
;
3. the stories of NSCLBP patients relat-
ing their own ongoing pain experi-
ences of multiple failed treatments,
confl icting diagnoses, lost hope and
ongoing suffering
10
;
4. the indisputable evidence support-
ing the multidimensional nature of
NSCLBP as a disorder, where dis-
ability levels are more closely associ-
ated with cognitive and behavioural
aspects of pain rather than sensory
and biomedical ones
11
12
;
5. positive outcomes in randomised
controlled trials (RCTs) are best pre-
dicted by changes in psychological
distress, fear avoidance beliefs, self-
effi cacy in controlling pain and cop-
ing strategies
13
14
;
6. the evidence supporting the broad
subgrouping of NSCLBP disorders on
the basis of neuro-physiological,
15
16
cognitive,
17
physical factors
18
and
lifestyle behaviours.
19
20
Underlying primary healthcare clinical
practice has been simplistic biomechani-
cal and structural models of LBP and pelvic
girdle pain (PGP), which focus on struc-
tural diagnoses such as spinal and pelvic
‘instability’.
21
22
These have been based
on a belief that LBP and PGP is a result of
structural (ie, degenerative), biomechani-
cal and motor control defi cits resulting in
segmental or regional ‘instability’ of the
lumbo-pelvic region.
21
24
It is now clear
that there is little evidence (basic sci-
ence and outcome studies) to support the
view that ‘instability’ underpins the basis
of disabling NSCLBP. There are no stud-
ies that demonstrate a clear relationship
between spinal or pelvic mobility, degen-
erative processes, pain and disability.
25
26
Similarly, common patho-anatomical
ndings such as degenerative disc disease,
annular tears, fi ssures, facet joint arthrosis
and disc bulges have been found not to be
predictive of future LBP.
26
This highlights
the limitation of radiological imaging and
spinal structure to provide clear meaning
to people’s experience of pain. Rather, fac-
tors such as depression,
26
27
stress, cogni-
tive and physical behaviours and lifestyle
factors are more predictive of future LBP
episodes.
11
20
Yet in spite of this evidence, patients
with disabling NSCLBP disorders continue
to be provided with biomedical diagnoses
and on the basis of these beliefs, people
are prescribed with stabilising exercises,
pelvic belts, supportive vests, spinal injec-
tions or even stabilisation surgery.
1
2
23
28
These ‘magic bullet’ approaches, for some,
may in fact have the potential to drive
fear, abnormal body focus and reinforce
pain-related movement and avoidance
behaviours, hypervigilance, catastrophis-
ing, pain and disability fuelling the vicious
cycle of pain.
29
Diagnostic labels such as ‘instability’
should be reserved solely for ‘unstable frac-
tures’ and ‘unstable spondylolisthesis’.
30
The application of this diagnostic label to
NSCLBP and PGP disorders is both inac-
curate and potentially detrimental.
21
29
31
This ‘belief system’, which I once advo-
cated, has resulted in the development of
an educational and management industry
aimed at enhancing spinal stability for the
prevention and treatment of NSCLBP, infl u-
encing the practice of physiotherapy, allied
health as well as sports rehabilitation and
training industries across the world.
28
32
This approach commonly instructs
patients to contract their ‘stabilising’ mus-
cles (pelvic fl oor and transverse abdominal
wall and lumbar multifi dus) prior to spinal
loading and during movement.
6
9
23
33
In
sports and gym rehabilitation settings,
patients are frequently instructed to brace
their abdominal wall and back muscles,
to create more spinal ‘stability’ with the
belief that ‘more stability is better’.
Yet these management approaches
have not arrested the growing disabil-
ity associated with NSCLBP.
2
Although
there is evidence for the effi cacy of sta-
bilising exercise for NSCLBP,
34
a number
of high-quality RCTs have demonstrated
that specifi c spinal stabilising exercises for
NSCLBP are not superior to other conser-
vative approaches
6
9
35
36
, they have small
effect sizes
37
and they are only marginally
better than placebo treatment consisting
of detuned shortwave and ultrasound.
33
Yet the benefi ts of this approach continue
to be exclusively promoted, in spite of
mounting scientifi c evidence that ques-
tions the underlying basis of this clini-
cal belief system. This includes evidence
that the motor control characteristics of
non-specifi c low back pain (NSLBP) and
NSCLBP commonly lie in fi ndings of:
increased co-contraction (stability) of 1.
trunk muscles
38
39
and guarded spinal
movement
40
;
hyperactivity of trunk muscles 2.
(including muscles such as erector
spinae, lumbar multifi dus, pelvic
oor and transverse abdominal wall)
in NSCLBP and PGP disorders
18
41
42
;
an inability of the back muscles to 3.
relax
18
40
;
a tendency for earlier onsets of the 4.
antero-lateral abdominal wall mus-
cles during rapid arm movements
rather than timing delays
43
;
It’s time for change with the
management of non-specifi c
chronic low back pain
Peter O’Sullivan
Correspondence to
Professor Peter O’Sullivan, Professor/Specialist
Musculoskeletal Physiotherapist, Curtin University,
GPO Box U1987, Perth, WA 6845, Australia;
p.osullivan@curtin.edu.au
BJSM Online First, published on August 4, 2011 as 10.1136/bjsm.2010.081638
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in some cases, trunk muscle hypertro-5.
phy in muscles such as lumbar mul-
tifi dus
44
and quadratus lumborum
45
have been documented in LBP sport
populations.
Further to this, there is evidence for:
a lack of association between muscle 1.
density (degeneration) of lumbar
multifudus and LBP in a recent large
population study
46
;
a lack of association between changes 2.
in transversus abdominus muscle tim-
ing
47
and lumbar multifi dus cross-sec-
tional area
13
as a predictor of positive
outcomes (disability levels) in RCTs.
This body of research challenges current
practice and beliefs and is a counter view
to previous literature. Some of the appar-
ent confl ict within the literature appears
to have arisen where the results of stud-
ies with small sample sizes, investigating
subjects with recurrent LBP
48
49
, have been
extrapolated to the broad NSCLBP popu-
lation without the results of these studies
being reproduced in these populations or
in larger groups.
The physiotherapy, manual therapy and
medical professions have long focused
on trying to fi nd the magic ‘technique’,
‘muscle’, ‘injection’ or ‘surgical technique’
required to solve the problem of NSCLBP
and PGP disorders. This reductionist
approach to dealing with complex disor-
ders in a simplistic manner clearly hasn’t
delivered for our patients
50
and contradicts
current knowledge that NSCLBP should
be considered within a multidimensional
bio-psycho-social framework. In fact, it
has been proposed that single-dimen-
sional approaches may in fact exacerbate
chronic disorders reinforcing a cumulative
feedback loop.
29
In response to the calls to manage
NSCLBP from a bio-psycho-social per-
spective, a number of RCTs have tested
cognitive behavioural approaches to more
effectively manage the disorder. Yet sys-
tematic reviews of these approaches have
failed to demonstrate greater effi cacy than
other active conservative approaches in
managing NSCLBP.
51
Possible reasons
for this failure may relate to the lack of
patient-centred and targeted manage-
ment
52
as well as a failure to address other
dimensions such as neuro-physiological
factors and maladaptive lifestyle and
movement behaviours known to be asso-
ciated with NSCLBP disorders.
18
20
30
There is strong evidence that NSCLBP
disorders are associated with a complex
combination of physical behavioural,
lifestyle, neuro-physiological (peripheral
and central nervous system changes),
psychological/cognitive and social fac-
tors.
12
20
30
These factors together have the
potential to promote maladaptive cognitive
behaviours (negative beliefs, fear, avoid-
ance, catastrophising, hypervigilance),
53
pain behaviours (pain communicative and
avoidant behaviours)
54
and movement
behaviours,
30
setting up a vicious cycle
of pain sensitisation and reinforcing dis-
ability. Changes in immune and neuro-
endocrine function linked to altered stress
responsiveness coupled with activation of
the pain neuro-matrix in the brain may
result in tissue hyperalgesia and altered
neuro-muscular responses.
11
It is thought
that these processes are mediated by envi-
ronmental/genetic interactions.
55
The balance and contribution of these
different factors will likely vary for each
individual. For example, it is known that
not all NSCLBP disorders are associated
with signifi cant psychosocial factors.
17
56
However, there is strong evidence that
disability and factors such as sick leave are
best predicted by factors such as negative
back pain beliefs, fear and distress.
17
57
Futhermore, psychological factors such as
fear and catastrophising commonly asso-
ciated with disabling pain have lifestyle,
physical, neuro-muscular
40
as well as neu-
ro-biological consequences, highlighting
that the mind and the body are inextrica-
bly linked.
11
There is also growing evidence that
NSCLBP disorders can be broadly cat-
egorised or subgrouped based on different
psychosocial/coping behaviours,
17
58
59
neuro-physiological characteristics,
15
56
pain behaviours
54
and movement
behaviours,
18
30
providing greater poten-
tial for targeting of multidimensional
interventions.
60
These broad subgroups,
rather than being rigid entities which are
characterised by prediction rules,
61
may
provide a framework for the clinician to
tailor management to patients in a more
targeted person- centred multidimensional
manner.
30
58
59
There is emerging evidence to support
this view that patient-centred multidimen-
sional targeted behavioural approaches
have greater effi cacy than current practice
for the management of NSCLBP disorders
in primary care settings. Asenlöf et al
62
63
compared individually tailored treatment
targeting activity levels, motor behaviour
and cognitions, demonstrating superior
outcomes to exercise therapy. A patient-
centred multidimensional behavioural
approach called ‘classifi cation-based cog-
nitive functional therapy’ that targets
maladaptive cognitive, lifestyle, pain and
movement behaviours was more effective
(greater effect sizes) than manual therapy
and exercise for localised NSCLBP.
64
Hill
et al
65
employed a patient-centred strati-
cation approach to target physiotherapy
treatment based on psychosocial risk pro-
le, demonstrating superior outcomes and
cost saving over standard physiotherapy
care. Further research into this patient-
centred multidimensional approach is
clearly required but recent evidence is
encouraging for improved outcomes.
Other behavioural therapies such as
mindfulness meditation,
66
acceptance and
commitment therapy,
67
brain-directed
therapies
68
69
and targeted medical man-
agement
70
hold hope for the multidisci-
plinary management of some of the highly
complex and disabling central nervous
system pain disorders.
In spite of this emerging evidence,
recent research highlights that health
professionals dealing with LBP disorders
have diffi culty accurately identifying
psycho-social risk in their patients, limit-
ing their capacity to target management.
71
It appears that specifi c training in behav-
ioural aspects of a patients presentation
is required to enable health professionals
to identify psycho-social risk factors and
maladaptive movement behaviours from
a clinical examination.
72
There is also
growing evidence to support the criti-
cal role that the quality of the therapeu-
tic relationship plays in the management
of pain disorders.
73
Practitioner-related
factors such as communication skills,
empathy, level of confi dence and beliefs
have an important infl uence on patient
outcomes and compliance to treatment.
74
Conversely, patient beliefs and expecta-
tions also have a profound infl uence on
health disorder outcomes.
75
With all this in mind, the challenges for
the future in more effectively dealing with
NSCLBP disorders are likely to involve
primary healthcare providers shifting rig-
idly held biomedical beliefs and develop-
ing greater skills and knowledge across a
number of domains. These skills are likely
to include:
Greater understanding of the complex 1.
multidimensional nature of NSCLBP.
Developing diagnostic skills to clearly 2.
differentiate specifi c pathology as a
driver of pain from NSLBP disorders.
Develop more effective communica-3.
tion skills utilising empathy, refl ec-
tive questioning and motivational
interviewing techniques in order
to listen to the patients’ story and
explore their pain beliefs, fears,
coping strategies, life stresses, psy-
cho-social factors, pain behaviour,
impairments and goals. This allows
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O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638 3 of 4
for the development of an effective
therapeutic relationship and the accu-
rate interpretation of clinical infor-
mation within a bio-psycho-social
framework in order to identify the
primary drivers of pain and disability.
This in turn provides the capacity to
clearly outline the vicious cycle of the
disorder in a patient-centred way.
Identifi cation of maladaptive cog-4.
nitive behaviours (negative beliefs,
stress responsiveness, provocative
coping strategies, hypervigilance,
fear, catastrophising, anxiety, depres-
sion etc).
Identifying neuro-physiological pro-5.
cesses such as central and peripheral
sensitisation.
The analysis and interpretation of pain 6.
communicative and avoidant behav-
iours
54
and movement and postural
behaviours
30
in order to determine
adaptive (protective) from maladap-
tive (provocative) behaviours.
30
Synthesising and interpreting clini-7.
cal information across multiple
domains.
Developing multidimensional and 8.
exible interventions that target
maladaptive cognitive, lifestyle, pain
and movement behaviours in an inte-
grated manner.
Facilitation of behavioural change in 9.
patients by enhancing clinical skills
such as empathy, motivation, sup-
port, creativity, goal setting, fl exible
person-centred functional rehabilita-
tion programmes and clear feedback.
Developing clear multidisciplinary 10.
approaches to management where
indicated.
Developing a broad framework for 11.
subgrouping of NSCLBP patients
from a multidimensional perspec-
tive.
17
30
52
58
This will allow the
broad categorisation of LBP disorders
based on the presence of dominant
psycho-social, neuro-physiological,
lifestyle and movement behaviours
that act as drivers for the disorder.
Adopting the routine use of screening 12.
tools in clinical practice in order to
identify risk and targets for change to
better direct management.
65
76
This approach will likely focus less on
treating the structure or signs and symp-
toms of a disorder in NSCLBP disorders
and more on targeting the different combi-
nations of beliefs, cognitive, pain, lifestyle
and movement behaviours that underlie
and drive disorders. Implementation of
this approach will require a paradigm
shift in ‘beliefs’ of health professionals
in terms of how we understand and deal
with NSCLBP disorders. This will involve
abandoning ineffective practices, learning
new skills, adopting and integrating new
approaches. This new knowledge and
skill needs to be trained at undergradu-
ate and graduate levels and promoted
actively within the professions that deal
with these disorders.
77
There is also a
mandate to educate the public in order to
reinforce more positive back pain beliefs
to reduce the burden for both individu-
als and society.
78
This will invariably lead
to health insurers abandoning the ongo-
ing funding of non-effi cacious treatment
approaches.
Further research is clearly needed to bet-
ter identify the underlying mechanisms
associated with disabling NSCLBP dis-
orders and their development across the
lifespan. This will likely involve a greater
understanding of genetic/environmental
interactions associated with the devel-
opment of the nervous system, tissue
sensitisation and associated maladaptive
behaviours, tracking from early life to ado-
lescence and into adulthood. Developing
a greater understanding of those people
resilient to these disorders may also be
illuminating. Early screening and targeted
management of risk groups, based on
the identifi cation of the mechanisms that
drive them, may aid in the prevention of
pain chronicity and disability. Innovative
multidimensional, patient-centred and
targeted approaches to management for
these complex disorders need to be further
developed and adequately tested.
Characteristics such as hope, positive
help seeking and adaptability are traits
of resilience that we need to equip our
patients with, who suffer with disabling
NSCLBP.
12
Adopting a positive multi-
dimensional perspective of health that
is person focused may allow us to view
NSCLBP in a new light, providing hope
for our patients and an environment for
innovation, discovery and change.
Acknowledgements The author would like to
acknowledge the support of Joao Paulo Caneiro in the
preparation of this manuscript.
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.
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non-specific chronic low back pain
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... 30,32,33 While for some their pain characteristics appear clearly defi ned, LBP for many presents as a mixed picture refl ecting a combination of both peripheral and central pain mechanisms (see Fig. 45-1 ). 6 PLBP has also been associated with brain changes such as a loss of grey matter, increased resting brain state, changes in the sensorimotor cortex (i.e. body schema alterations) and loss of endogenous pain inhibition. ...
... 4,5 A key consideration in interpreting this literature both then and now was the concern that study designs were essentially taking a 'magic bullet' approach to LBP treatment. 6 In other words, a presumption underlying the design of most randomized trials was that a treatment would either 'succeed' or 'fail' for nearly anyone with LBP regardless of clinical presentation. This presumption contradicted the experience of expert clinicians working with patients with LBP who described patterns of clinical fi ndings that were presumed to defi ne subgroups of patients with LBP who would preferentially respond to a particular type of treatment. ...
... There is strong evidence that CLBP is associated with a complex interaction of bio-psycho-social factors [2,3,7,16,27]. Although many of these factors are potentially modifiable, most existing interventions are based on a biomedical model focusing on the structure or disease, and do not target a patientcentered approach for each case of chronic low back pain [24]. ...
Article
Cognitive functional therapy (CFT) is a physiotherapy-led intervention which has evolved from an integration of foundational behavioral psychology and neuroscience within the physiotherapist practice directed at the multidimensional nature of chronic low back pain (CLBP). The current evidence about the comparative effectiveness of CFT for CLBP is still scarce. We aimed to investigate whether CFT is more effective than core training exercise and manual therapy (CORE-MT) in pain and disability in patients with CLBP. A total of 148 adults with CLBP were randomly assigned to receive five one-hour individualised sessions of either CFT (n = 74) or CORE-MT (n = 74) within a period of 8 weeks. Primary outcomes were pain intensity (numeric pain rating scale, 0-10) and disability (Oswestry Disability Index, 0-100) at 8 weeks. Patients were assessed pre-intervention, at 8 weeks, 6 and 12 months after the first treatment session. Altogether, 97.3% (n=72) of patients in each intervention group completed the 8 weeks of the trial. CFT was more effective than CORE-MT in disability at 8 weeks (MD= -4.75; 95% CI -8.38 to -1.11; p=0.011, effect size= 0.55), but not in pain intensity (MD= -0.04; 95% CI -0.79 to 0.71; p=0.916). Treatment with CFT reduced disability, but the difference was not clinically important compared with CORE-MT post-intervention (short term) in patients with CLBP. There was no difference in pain intensity between interventions, and the treatment effect was not maintained in the mid-term and long-term follow-ups.
... In Germany, the highest prevalence of chronic back pain (CBP) is found among adults aged 70 years and older (28%) (Von Der Lippe et al. 2021). CBP is a complex multidimensional disorder, in which kinesiophobia, fear-avoidance beliefs and passive coping strategies may often occur (Waddell 2004;O'Sullivan 2012). Therefore, multidisciplinary treatment programs including psychological interventions in addition to physical treatment have become standard in the treatment of CBP patients. ...
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Full-text available
Immersive Virtual Reality (VR) with head-mounted displays (HMD) can be a promising tool for increasing adherence to exercise in older adults. However, there is little known about the effectiveness of an interactive multimodal therapy in VR for older chronic back pain (CBP) patients. The aim of the exploratory randomized controlled trial was to examine the preliminary effectiveness of a VR multimodal therapy for older adults with CBP in a laboratory setting over a period of four weeks. The intervention group (IG; n = 11) received a multimodal pain therapy in VR (movement therapy and psychoeducation) and the control group (CG; n = 11) received a conventional multimodal pain therapy (chair-based group exercises and psychoeducation in a group setting). Although the VR therapy (IG) did not reach the pain intensity reduction of the CG (IG: MD = 0.64, p = .535; CG: MD = 1.64, p = .07), both groups showed a reduction in pain intensity on the Numeric Rating Scale. The functional capacity in the IG improved from Visit 1, $$\overline{x }$$ x ¯ = 73.11% to Visit 2, $$\overline{x }$$ x ¯ = 81.82% (MD = 8.71%; p = .026). In the changes of fear avoidance beliefs and general physical and mental health, no significance was achieved in either group. Although the IG did not reach a significant pain intensity reduction compared to the CG, the results of the present study showed that a pain intensity reduction can be achieved with the current VR application.
... Furthermore, there may be potentially negative influences of using assessment techniques to determine pelvic alignment, and how these findings are conveyed to patients. When verbal messages like 'upslip', 'torsion' or 'out of place' are conveyed in clinical settings, they can increase patients' perceived vulnerability, compromising their long-term recoveries and fuelling the chronicity of pain [38,39]. Therefore, it is questionable whether clinicians should continue to advocate these assessments and treatments which focus on pelvic asymmetry. ...
Article
Background Assessments and treatments focused on pelvic asymmetry are common amongst health professionals. However, there is no clear evidence for the reliability of palpatory examinations for pelvic landmarks. Objectives This review aimed to investigate the reliability of palpatory examinations for pelvic landmarks. Methods A systematic search was undertaken using eight databases from inceptions to 2021 January 8th, to identify relevant primary studies. Methodological quality of included studies was evaluated using quality appraisal tool for studies of diagnostic reliability (QAREL). Data on kappa statistics were synthesized quantitatively. Results 10 papers were included. Six papers had moderate methodological quality (50–70% in QAREL). Four pelvic landmarks, including anterior superior iliac spine, posterior superior iliac spine, sacral sulcus or inferior lateral angle were examined. For both inter-rater and intra-rater reliability, kappa statistics were consistently lower than 0.60 regardless of examiners’ qualifications or experience levels, or standardisation trainings. As a result of meta-analyses, pooled kappa statics were consistently lower than 0.06 for all landmarks. Conclusions Consistent evidence was found to suggest that palpatory examinations of pelvic landmarks to detect pelvic asymmetry do not have an acceptable reliability. Therefore, the current evidence does not support the use of these tests in clinical or educational settings.
... The eligibility criteria were clinical trials and studies conducted in people over 18 years old with chronic non-specific low back pain [18]. The main intervention was global postural re-education. ...
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Background: The aim of this systematic review and meta-analysis was to evaluate the global postural re-education (GPR) program's effectiveness compared to other exercise programs in subjects with persistent chronic low back pain. Methods: A systematic review and meta-analysis were carried out using PRISMA2020. An electronic search of scientific databases was performed from their inception to January 2021. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. Four meta-analyses were performed. The outcomes analyzed were disability due to back pain and pain. The risk of bias and quality of evidence were evaluated. The final search was conducted in March. Results: Seven trials were included, totaling 334 patients. The results showed improvement in pain measured by Visual Analogue Scale (VAS) (Standardised Mean Difference (SMD) = -0.69; 95% Confidence Interval (CI), -1.01 to -0.37; p < 0.0001), Numerical Pain Scale (NRS) (SMD = -0.40; 95% CI, -0.87 to 0.06); p = 0.022), VAS + NRS (SMD = -1.32; 95% CI, -1.87 to -0.77; p < 0.0001) and function (Roland Morris Disability Questionnaire (RMDQ)) (SMD = -0.55; 95% CI, -0.83 to -0.27; p < 0.0001) after GPR treatment. Conclusion: This meta-analysis provides reliable evidence that GPR may be an effective method for treating LBP by decreasing pain and improving function, with strong evidence.
... [4] Though several risk factors including age and lifestyle factors have been identified [4], the causes of LBP remain unknown. To understand the complexity of LBP and to improve treatment, the World Health Organization proposed a biopsychosocial approach [5,6] which acknowledges that LBP is not simply a result of nociceptive input. Multifactorial contributors seem to play an important role in persistent disabling LBP. ...
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Objectives To determine LBP prevalence in urban and rural communities and to assess back beliefs and treatment seeking behaviour for the first time in Suriname, a multi-ethnic country in the Caribbean community. Methods A cross-sectional community-based survey using the Community Oriented Program for the Control of Rheumatic Diseases methodology was performed between April 2016 and July 2017. Information on LBP prevalence and LBP-related treatment seeking, beliefs about LBP (Back Beliefs Questionnaire (BBQ)), level of disability (Oswestry Disability Index), and the risk of developing persistent disabling pain (Start Back Screening Tool) was collected. Results A total of 541 out of 2902 individuals reported current acute or chronic LBP. It was more prevalent in urban (20.2%) than in rural (13.7%) communities, especially in females and older adults (>55 years). Individuals from rural areas (median BBQ = 18.00 (14.00–22.00)) had significantly more negative beliefs than the urban population (median BBQ = 25.00 (19.00–31.00)) (p < 0.001). Maroons displayed more negative beliefs than Creole (p = 0.040), Hindustani (p < 0.001), Javanese (p < 0.001) and Mixed ethnicity (p < 0.001). At least 75% of the LBP population sought care, especially from a western healthcare practitioner. Seeking treatment and having a higher risk to develop persistent disabling pain was significantly associated with more disability (p < 0.001). Age ≥45 years (p < 0.001), Indigenous ethnicity (p < 0.05), and functional disability (p < 0.001) were factors influencing treatment seeking. Conclusions LBP is a prevalent health problem in the Surinamese urban community, especially in older adults and among females. Most individuals experiencing LBP visited a western healthcare practitioner and had more negative beliefs compared with other communities.
Article
Background: Low back pain (LBP) is a prevalent disorder and leading cause of disability worldwide. In Saudi Arabia, patients with LBP are dispensed with educational materials to supposedly facilitate their recuperation. Objective: Appraise the suitability of educational materials provided for people with LBP in Saudi Arabia to determine whether they meet the needs of patients, inform self-management, and are consistent with clinical practice guidelines. Methods: A qualitative data collection method was used, and content analyses were conducted to analyse data based on manifest content. Educational items in English and Arabic were collected from relevant health providers in Saudi Arabia. Results: Seventeen educational materials were sourced from: Ministry of Health hospitals (n= 10), military hospitals (n= 4), private hospitals (n= 2), and a multidisciplinary healthcare association (n= 1). Six identified sub-themes comprise: epidemiological/anatomical data about LBP (n= 6); causes/risk factors (n= 10); exercise (n= 14) and physical activity-related (n= 3) recommendations; treatment-related recommendations (n= 2); general health and lifestyle-related recommendations (n= 8); and postural and ergonomics-related recommendations (n= 13). A common theme emerged, that 'the content of educational materials hindered reassurance and self-management for people with LBP.' Conclusion: The reviewed educational materials fail to adequately report information that assure patients or inform their self-management among the Saudi population with LBP. Further, reviewed items are heavily influenced by the biomedical model of pain.
Article
Objective: To evaluate efficacy and tolerability of the nonbenzodiazepine antispasmodic pridinol (PRI), as an add-on treatment in patients with muscle-related pain (MRP). Methods: Exploratory retrospective analysis of depersonalized routine data provided by the German Pain e-Registry (GPeR) focusing on pain intensity, pain-related disabilities in daily life, wellbeing, and drug-related adverse events (DRAEs).Primary endpoint based on a global response composite of a) a clinically relevant analgesic response (relative improvement ≥50% and/or absolute improvement ≥ the minimal clinical important difference) for pain intensity and disability in combination with b) an improvement in wellbeing (all at end of treatment vs. baseline), and c) lack of any DRAEs. Results: Between January 1, 2018, and December 31, 2020, the GPeR collected information on 121,803 pain patients of whom 1,133 (0.9%; 54.5% female, mean ± SD age: 53.9 ± 11.8 years) received add-on PRI for the treatment of (mostly acute) MRP originating predominantly in the (lower) back (43.2%), lower limb (26.4%) or should/neck (21.1%). Average daily dose was 7.8 ± 1.8 (median 9, range 1.5-13.5) mg, duration of treatment 12.0 ± 10.2 (median 7, range 3-63) days. In total, 666 patients (58.8%) reported a complete, 395 (34.9%) a partial and 72 (6.4%) patients no response - either because of lack of efficacy (n = 2, 0.2%) or DRAEs (n = 70, 6.2%). In response to PRI, 41.7% of patients documented a reduction of at least one other pain medication and 30.8% even the complete cessation of any other pharmacological pain treatments. Conclusion: Based on this real-world data of the German Pain e-Registry, add-on treatment with PRI in patients with acute MRP under real-world conditions in daily life was well tolerated and associated with an improvement of pain intensity, pain-related disabilities, and overall wellbeing.
Article
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Introduction Illness Perceptions (IPs) may play a role in the management of persistent low back pain. The mediation and/or moderation effect of IPs on primary outcomes in physiotherapy treatment is unknown. Methods A multiple single-case experimental design, using a matched care physiotherapy intervention, with three phases (phases A-B-A’) was used including a 3 month follow up (phase A’). Primary outcomes: pain intensity, physical functioning and pain interference in daily life. Analyzes: linear mixed models, adjusted for fear of movement, catastrophizing, avoidance, sombreness and sleep. Results Nine patients were included by six different primary care physiotherapists. Repeated measures on 196 data points showed that IPs Consequences, Personal control, Identity, Concern and Emotional response had a mediation effect on all three primary outcomes. The IP Personal control acted as a moderator for all primary outcomes, with clinically relevant improvements at 3 month follow up. Conclusion Our study might indicate that some IPs have a mediating or a moderating effect on the outcome of a matched care physiotherapy treatment. Assessing Personal control at baseline, as a relevant moderator for the outcome prognosis of successful physiotherapy management of persistent low back pain, should be further eplored.
Article
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Background There is a need for effective health service solutions to provide greater structure and support for implementing evidence-based practice in back pain care. Patient involvement in developing these solutions is crucial to increase relevance, acceptability and uptake. Objectives To determine patients' perceived needs and barriers to best-practice back pain care, and potential solutions to better address care needs. The study is the third in a series of needs assessment studies feeding into the ‘idea generation’ for service design in a large teaching hospital in a culturally and linguistically diverse community in metropolitan Sydney, Australia. Design We conducted a combination of focus groups and in-depth interviews using an interpretive description approach. We used inductive thematic analysis to identify the main themes. Setting and Participants We purposively sampled patients with diverse characteristics from the neurosurgery and physiotherapy outpatient clinics, in particular those whose primary language was English, Arabic, Persian or Mandarin. Non-English audio recordings were translated and transcribed by bilingual researchers. Results There were 24 participants (focus groups = 9; individual interviews = 15) when data saturation was reached. The analysis identified three key themes with several subthemes around what service designers needed to understand in helping people with back pain in this setting: (1) This is who I am; (2) It's not working for me; and (3) What I think I need. Discussion and Conclusion This study highlights that perceived unmet needs of patients are underpinned by unhelpful beliefs about the causes of and solutions for back pain, misaligned care expectations, unclear expectations of the hospital role and fragmentations in the health system. To design and implement a service that can deliver better back pain care, several solutions need to be integrated around: developing new resources that challenge unhelpful beliefs and set realistic expectations; improving access to education and self-management resources; focusing on individualized care; using a collaborative multidisciplinary approach within the hospital; and better connecting with and directing primary health care services. Patient or Public Contribution A consumer representative of the Western Sydney Local Health District provided input during study conceptualisation and is duly recognized in the Acknowledgements section.
Article
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Exercise benefits patients with chronic nonspecific low back pain; however, the most effective type of exercise remains unknown. This study compared outcomes after motor control exercises, sling exercises, and general exercises for low back pain. This was a randomized controlled trial with a 1-year follow-up. The study was conducted in a primary care setting in Norway. The participants were patients with chronic nonspecific low back pain (n=109). The interventions in this study were low-load motor control exercises, high-load sling exercises, or general exercises, all delivered by experienced physical therapists, once a week for 8 weeks. The primary outcome measure was pain reported on the Numeric Pain Rating Scale after treatment and at a 1-year follow-up. Secondary outcome measures were self-reported activity limitation (assessed with the Oswestry Disability Index), clinically examined function (assessed with the Fingertip-to-Floor Test), and fear-avoidance beliefs after intervention. The postintervention assessment showed no significant differences among groups with respect to pain (overall group difference) or any of the outcome measures. Mean (95% confidence interval) group differences for pain reduction after treatment and after 1 year were 0.3 (-0.7 to 1.3) and 0.4 (-0.7 to 1.4) for motor control exercises versus sling exercises, 0.7 (-0.6 to 2.0) and 0.3 (-0.8 to 1.4) for sling exercises versus general exercises, and 1.0 (-0.1 to 2.0) and 0.7 (-0.3 to 1.7) for motor control exercises versus general exercises. The nature of the interventions made blinding impossible. This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain.
Article
Background: Diagnoses and treatments based on movement system impairment syndromes were developed to guide physical therapy treatment. Objectives: This masterclass aims to describe the concepts on that are the basis of the syndromes and treatment and to provide the current research on movement system impairment syndromes. Results: The conceptual basis of the movement system impairment syndromes is that sustained alignment in a non-ideal position and repeated movements in a specific direction are thought to be associated with several musculoskeletal conditions. Classification into movement system impairment syndromes and treatment has been described for all body regions. The classification involves interpreting data from standardized tests of alignments and movements. Treatment is based on correcting the impaired alignment and movement patterns as well as correcting the tissue adaptations associated with the impaired alignment and movement patterns. The reliability and validity of movement system impairment syndromes have been partially tested. Although several case reports involving treatment using the movement system impairment syndromes concept have been published, efficacy of treatment based on movement system impairment syndromes has not been tested in randomized controlled trials, except in people with chronic low back pain.
Article
This article aims to show how people with chronic back pain manage the status passage from being well persons to becoming “pain afflicted” patients and how they see their own progression through the pain career path. This is examined through in-depth narrative interviews. The data were processed through thematic analysis. It was found that during the transition, a change in perceived identity occurs and that people grieve over the loss of their former selves, their future, social relationships, and occupational careers. The article also reflects on the value of narratives in revealing transformations over time. This technique is intended to capture evolving self-understandings of personal identity as persons negotiate the path through complex and critical life events.
Article
Study Design: The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement. Objectives: To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Summary of Background Data: Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. Methods: While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the contralateral deltoid was evaluated using fine‐wire and surface electrodes. Results: Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. Conclusions: The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.
Article
Design. Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. Objectives. To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. Summary of Background Data. In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new “belief” questionnaires and “sophisticated” performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. Methods. One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. Results. Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. Conclusion. A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy programm—in addition to improving physical function—appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.
Article
The primary purpose of the present study was to examine the temporal stability of communicative and protective pain behaviors in patients with chronic back pain. The study also examined whether the stability of pain behaviors could be accounted for by patients’ levels of pain severity, catastrophizing, or fear of movement. Patients (n = 70) were filmed on two separate occasions (i.e., baseline, follow-up) while performing a standardized lifting task designed to elicit pain behaviors. Consistent with previous studies, the results provided evidence for the stability of pain behaviors in patients with chronic pain. The analyses indicated that communicative and protective pain behavior scores did not change significantly from baseline to follow-up. In addition, significant test–retest correlations were found between baseline and follow-up pain behavior scores. The results of hierarchical multiple regression analyses further showed that pain behaviors remained stable over time even when accounting for patients’ levels of pain severity. Regression analyses also showed that pain behaviors remained stable when accounting for patients’ levels of catastrophizing and fear of movement. Discussion addresses the potential contribution of central neural mechanisms and social environmental reinforcement contingencies to the stability of pain behaviors. The discussion also addresses how treatment interventions specifically aimed at targeting pain behaviors might help to augment the overall impact of pain and disability management programs.
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As the biopsychosocial model of health has become increasingly understood, it has become clear that there are complex, interdependent relationships between the physical and biomedical features of low back pain and the psychological and social factors that present concomitantly. Epidemiological studies have not only highlighted that psychological and social factors are associated with back pain and disability but also have shed light on the way in which these factors serve as prognostic indicators, or obstacles to recovery, predicting which patients will have a poor prognosis. Integrating the assessment of these obstacles to recovery into physical therapist practice and using this information to guide clinical decision making have the potential to improve the quality of care offered by physical therapists by improving the targeting of treatments to individuals and enhancing the therapist-patient relationship and adherence to management advice and treatment programs. In turn, such approaches may improve both patients' clinical outcomes and the efficiency and effectiveness of service provision, helping direct interventions to those who need them. This article summarizes the key challenges to embedding psychosocial perspectives within physical therapist practice for patients with low back pain and the opportunities that could be realized by doing so, and it highlights new developments in research, clinical practice, and education that are shaping future directions in this field.
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The STarT Back Screening Tool (SBST) is validated to subgroup primary care patients with back pain into risk groups relevant to initial decision-making. However, it remains unclear how the tool's allocation of individuals compares with subjective clinical decision-making. We evaluated agreement between clinicians and the SBST's allocation to risk subgroups, and explored reasons for differences observed. Twelve primary care back pain patients underwent a video-recorded clinical assessment. The SBST was completed on the same day. Clinical experts (3 general practitioners, 3 physiotherapists, and 3 pain management specialists) individually reviewed the patient videos (4 each), blind to SBST allocation. Their task was to subgroup patients into low, medium, or high-risk groups. Interrater agreement between clinicians was "fair" (κ=0.28), with consistent allocation between experts in 4 of 12 patients. There was observed agreement with the SBST in 17 of 36 cases (47%) and Cohen's weighted κ was 0.22, indicating fair agreement. Two reasons for differences emerged. Clinicians tailor their decisions according to patient expectations and demands for treatment and clinicians use knowledge of difficult life circumstances that may be unrelated back pain. Clinicians make inconsistent risk estimations for primary care patients with back pain when using intuition alone, with little agreement with a formal subgrouping tool. Unlike clinicians, the SBST could not make a sophisticated synthesis of patient preferences, expectations, and previous treatment history. Although acknowledging the limitations of back pain subgrouping tools, more research is needed to test whether their use improves consistency in primary care decision-making.