Evaluation of the physical management of low back pain

ERICA (European Research Into Consumer Affairs) is engaged in research into problems faced, notably by the underprivileged, in the countries of the European Economic Community (EEC). An early project investigated dial-a-ride systems for the transport of disabled people in six EEC countries. The object was to discover their successes and failures and pass on the information. In spite of national differences, many of the problems were the same. So, since the aim of all ERICA's research is action, the first step has been to publish guidelines for any voluntary organization or local authority aiming to set up a dial-a-ride.     

Physical therapy management of low back pain: an exploratory survey of therapist approaches

BACKGROUND AND PURPOSE: Since the release of acute low back pain management guidelines in 1994, little was known about the effect of these guidelines on clinical practice. The purpose of this study was to examine physical therapists' reported management of acute and subacute lumbar impairment. SUBJECTS: One in 10 registered physical therapists who were randomly selected from southern Ontario, Canada, (n=454) and all registered physical therapists from northern Ontario (n=331) were surveyed. METHODS: In the questionnaire, case scenarios covered 3 areas related to the management of lumbar impairment: (1) physical examination, (2) treatment and recommendations, and (3) therapists' beliefs regarding its management. RESULTS: Five hundred sixty-nine questionnaires were returned (response rate=72.5%). Only data obtained for therapists (n=274) whose weekly workload included more than 10% of people with lumbar impairment were used in the analysis. Overall, patient education, exercise, and electrotherapeutic and thermal modalities were the preferred interventions for acute lumbar impairment (symptom onset of less than 5 weeks) with or without sciatica, whereas exercise and work modification were preferred for subacute lumbar impairment (symptom onset of 5 weeks or longer). There was a trend of using electrotherapeutic and thermal modalities with uncertain effectiveness. Only 46.3% of the therapists agreed or strongly agreed that practice guidelines were useful for managing lumbar impairment. DISCUSSION AND CONCLUSION: Although the physical therapists surveyed, in general, followed the guidelines in managing acute lumbar impairment, they felt uncertain regarding the value of practice guidelines. Future research should focus on identifying effective treatment approaches and exploring the effectiveness of practice guidelines.     

The knowledge of low back pain management between physical therapists and family practice physicians

Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians.

Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests.

Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30–4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19–0.66]).

Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.     

Psychologically informed practice for management of low back pain: future directions in practice and research

In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed "psychologically informed practice," is offered as a "middle way" between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the "flags" framework, with psychologically informed practice requiring routine and specific consideration of "yellow flags" and "blue flags" (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification-but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential "black flags"). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment.     

Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice--challenges and opportunities

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.     

Clinical guidelines versus clinical practice in the management of low back pain

To date, there have been limited data on the implementation of evidenced-based clinical guidelines for low back pain (LBP). The aim of this study was to assess current management of LBP and evaluate to what extent clinical practice now reflects clinical guidelines. This survey involved the collection and analysis of data from the records of 200 patients who had been referred to a large teaching hospital with LBP Analysis indicated a high use of X-rays, with little evidence of initial biopsychosocial assessment. The most popular treatments were advice, active exercises and McKenzie therapy. Manipulation was rarely used. Overall, a low use of electrotherapy was recorded. The results emphasise how little the clinical guidelines have influenced the decisions of clinicians, and highlight the need to address the barriers to adopting an evidence-based approach in this area.     

Massage therapy versus traditional therapy for low back pain relief: implications for holistic nursing practice

This study explored whether there is a significant difference in perceived low back pain relief between patients receiving massage versus traditional therapy, using a 2-variable by 3-variable fully crossed, factorial, comparative research design. Statistical results showed slightly more efficacy for traditional therapy; however, the additional benefits of massage add to its value for holistic nursing practice.     

Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs

BACKGROUND AND PURPOSE: Elevated fear-avoidance beliefs are believed to be a precursor of chronic disability, yet effective intervention options have not been described in the literature. The purpose of this case report is to describe physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs. CASE DESCRIPTION: The patient was a 42-year-old sales manager with acute low back pain. The patient had no previous history of activity-limiting low back pain and initially had limitations in straight leg raising, limitations in lumbar movement, and elevated fear-avoidance beliefs. INTERVENTION: Treatment-based classification and graded exercise were used. OUTCOME: Disability, fear-avoidance beliefs, and pain decreased 4 weeks after starting physical therapy. Six months later, disability and fear-avoidance beliefs had increased, but were still improved when compared with the initial measurements. DISCUSSION: Disability and fear-avoidance beliefs improved following a fear-avoidance-based physical therapy intervention. Research is warranted to investigate the effectiveness of this approach.     

Psychological factors in low back pain

Even though low back pain is one of the commonest diseases, little is known about its aetiology, its natural history and its treatment. This may explain why the myth exists that low back pain is often psychogenic in origin or that psychological factors are often at least involved in low back pain. The aim of the early studies on low back pain and psychological factors was to try to divide these pains into functional (psychogenic) and organic, according to the aetiology. The aim of the studies was to predict the quality and success of the treatment. According to the current view, it is not meaningful to try to dichotomize low back pain in this way. According to the earlier literature, both conversion hysteria and psychoses were the main cause of psychogenic low back pain. More recent studies do not, however, support this view. It seems that the most common psychiatric disturbances associated with low back pain are neuroses and neurotic traits. There is controversy as to how often psychological factors are involved in low back pain. Population studies have shown that this association may be weaker than was thought earlier. It seems that individuals who suffer from low back pain, more often than others, have aggression problems and weaknesses in their ego function and more frequently have problems in interpersonal relations and sexual problems. There is no clear picture of what kind of psychotherapy is best suited to low back pain patients who have mental problems. The results attained by learning therapy and also with multidisciplinary ward programs seem quite promising.     

A clinical contrast: physical therapists with low back pain treating patients with low back pain

Abstract

Patients with low back pain (LBP) often display faulty beliefs and cognitions regarding their pain experience. Pain neuroscience education (PNE) aims to alter the pain experience by targeting these faulty beliefs and cognitions. One PNE strategy aims specifically to reframe commonly held beliefs about tissues by patients with LBP as the single source of pain. In line with this reasoning, it is hypothesized that physical therapists (PT) treating patients with LBP may indeed experience similar, if not worse, pain experiences while treating a patient with LBP. To date, this assumption has never been studied. A PT LBP questionnaire was developed, validated and distributed to a convenience sample of attendees of an international PT conference. One-hundred and ten PTs completed the questionnaire for a 71% response rate. Ninety percent of the PTs reported having experienced LBP, with 27% at the conference experiencing LBP at the time. Of the PTs that have experienced LBP 75% reported not having received any imaging; 81% no formal diagnoses, 58% no treatment and 86% not having missed work due to LBP. Eighty-six percent of therapists reported having experienced LBP while treating a patient with LBP, with 50% convinced their LBP was higher than the LBP experienced by the patient they were treating. The results from this study indicate PTs often treat patients with LBP while suffering LBP. It is suggested that this knowledge may potentially help patients with LBP reconceptualize their LBP experience leading to expedited recovery.     

Education in the management of low back pain: literature review and recall of key recommendations for practice

IntroductionTherapeutic patient education (TPE) is a continuous medical care process whose role in lower back pain (LBP) has yet to be well defined.ObjectiveTo evaluate the role and impact of TPE in the medical and surgical management of LBP.MethodA non-systematic literature review.ResultsFew formal TPE programmes have been rigorously evaluated in the context of LBP. In most cases, TPE tools have been combined with other interventional measures that vary according to the conceptual models used – thus limiting the extent to which the effect of TPE alone can be judged. Information that complies with the guidelines modifies knowledge and inappropriate beliefs. Whether formalized or not, TPE appears to modify (i) the physical disability and pain related to LBP and (ii) the patient's choice of therapy (e.g. surgery). The impact appears to be more marked in the (sub)acute phases.DiscussionNational and international guidelines suggest that TPE based on a biopsychosocial model has a positive impact on the patients’ behaviour and treatment compliance. The cost/benefit ratio appears to be favourable.ConclusionTherapeutic patient education appears to reduce the negative consequences of fear-avoidance behaviour and thus promotes treatment compliance in LBP patients, from the acute phase onwards.     

Conservative management of low back pain

Back pain is prevalent worldwide, but back pain disability has reached epidemic proportions in many industrialised societies. Few patients have serious medical pathology or direct neurological involvement requiring surgery. Although the causes remain unclear, physical stress and its consequences on discs, facet joints and supporting soft tissues at work or leisure are important, sometimes aggravated by adverse psychosocial factors. Modern management emphasises the role of self-care, beginning in primary care with the first episode. Without root compression, bed rest should not exceed 48 hours. Emphasis is on encouraging a rapid return to physical fitness and other activities, including employment, acknowledging that returning to a normal life may require working through pain. Medication facilitates this. No one should remain in pain beyond six weeks without being referred to a specialist service for a physical and psychosocial assessment by appropriately trained professionals and with consultant support for investigation, pain management and rehabilitation when needed.     

ICU护士职业性腰背痛情况调查分析

目的:探讨ICU护士职业性腰背痛的发生情况及高危因素,为制定腰背痛预防措施提供依据。方法:2010~2014年通过对某三级甲等医院重症监护室8名曾发生腰背痛护士进行质性研究直观的对ICU护士职业性腰背痛进行研究与分析。结果:通过分析发现ICU护士在岗前培训、工作中防护及休息时锻炼3个方面需要进行改善,才有可能减轻职业性腰背痛的发生。结论:通过加强培训、适度心理疏导、完善医疗设备等措施改善ICU护士的腰背痛状况。     

Risk factors for low back pain and sciatica

So far, eight prospective studies and 50 cross-sectional or retrospective studies have focused on risk factors for low back syndromes. Half of these have been published during the 1980s. Hard physical work and, in particular, frequent lifting and postural stress are likely to result in disc degeneration, low back pain and sciatica. Physical strain may also have prophylactic effects, as physical leisure activity and muscular strength are negatively associated with the risk of low back pain. Much evidence points to driving motor vehicles being causally associated with low back pain and sciatica. A probably causal relationship exists between body height and risk of sciatica, but height is not necessarily predictive of other types of low back pain. Obesity, smoking, psychological distress and poor general health also carry increased risk of low back pain, but their causal role is questionable. Although none of the suspected risk factors can be described as having been conclusively investigated epidemiologically, the results of published studies show that there are modifiable factors contributing to low back pain. The overall potential of primary prevention is great if adequate tools for intervention can be developed.