Predictors for global perceived effect after physiotherapy in patients with neck pain: an observational study

Objective

To investigate the prognostic importance of a number of sensorimotor and psychological factors for global perceived effect (GPE) after physiotherapy in patients with neck pain. In addition to baseline values, change scores were used as independent variables to identify treatment-modifiable factors.

An integrated care pathway for the management of low back pain

Low back pain is a disabling condition that is responsible for a considerable amount of health service expenditure [HMSO, London, 1994, p. 1; The Back Pain Revolution. Churchill Livingstone, London, 1999]. Following national recommendations from the Clinical Standards Advisory Group [HMSO, London, 1994, p. 1] and the Royal College of General Practitioner Guidelines [Royal College of General Practice, London, 1996, 1999], local initiatives have attempted to integrate this advice into care pathways for low back pain. This paper will detail the background development, construction and audit of an integrated care pathway for the management of patients with acute low back pain in North Staffordshire.     

The effect of a physiotherapy education compared with a non-healthcare education on the attitudes and beliefs of students towards functioning in individuals with back pain: An observational, cross-sectional study

Objectives

To investigate the difference in attitudes: (1) between first and fourth year physiotherapy students towards functioning in individuals with back pain; and (2) between physiotherapy students and non-healthcare students towards functioning in individuals with back pain.

Design

Observational, cross-sectional study.

Setting

Glasgow Caledonian University, Scotland, UK.

Participants

First year physiotherapy (n = 61) and non-healthcare students (n = 61), and fourth year physiotherapy (n = 62) and non-healthcare students (n = 62).

Main outcomes

All participants completed the Health Care Providers’ Pain and Impairment Relationship Scale (range 15 to 105). This questionnaire measures attitudes towards functioning in individuals with back pain.

Results

Fourth year physiotherapy students had more positive attitudes towards functioning in individuals with back pain than first year physiotherapy students [57.4 vs 66.6 (mean difference −9.2, 95% confidence interval −12.2 to −6.1, P < 0.01)]. Similarly, fourth year non-healthcare students had more positive attitudes towards functioning in individuals with back pain compared with first year non-healthcare students [69.2 vs 65.3 (mean difference −3.9, 95% confidence interval −7.2 to −0.5, P = 0.03)]. Physiotherapy students had more positive attitudes than non-healthcare students in the first year [66.6 vs 69.2 (mean difference −2.6, 95% confidence interval −5.5 to 0.4, P = 0.08)] and the fourth year [57.4 vs 65.3 (mean difference −7.9, 95% confidence interval −11.4 to −4.4, P < 0.01)] of study.

Conclusion

These findings suggest that physiotherapy education brings about positive student attitudes towards functioning in individuals with back pain. This may be partly attributable to receiving a university degree education, but would appear to be further enhanced by specifically receiving a physiotherapy degree. This may facilitate students to become more evidence-based practitioners following qualification.     

Potential impact of early physiotherapy in the emergency department for non-traumatic neck and back pain

BACKGROUND: Musculoskeletal complaints, especially non-traumatic neck and back pain, are routinely encountered in the emergency department (ED) and lead to ED overcrowding, a burgeoning wait time for physiotherapy and outpatient orthopedic reviews. The study aimed to evaluate the impact of early physiotherapy evaluation and treatment (EPET) vs. standard care (SC) on clinical outcomes for patients presenting to the ED with non-traumatic neck and back pain.     

The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy

Objective: To determine the correlation between the Quebec Task Force Classification (QTFC) system and outcome in patients with non-specific low back pain (LBP).

Methods: Forty-nine patients who were treated in outpatient physical therapy clinics of Catholic Health System (CHS) of Western New York (WNY) were classified according to the QTFC at the initial examination by physical therapists (PTs) with training in Mechanical Diagnosis and Therapy (MDT). The patient’s perceived level of function was assessed with the Focus On Therapeutic Outcomes (FOTO) tool at the initial examination, 2 weeks following the initiation of physical therapy and again at discharge.

Results: A linear regression model between acuity and change in FOTO score was performed and demonstrated statistical significance (P<0·05) as the more favorable outcome was found with the more acute patients. Spearman correlations between change in FOTO score and QTFC, duration of treatment and acuity of condition, and number of visits and change in FOTO score were not found to be statistically significant.

Conclusions: The patients treated in this study demonstrated functional improvement in an average of eight visits, indicating efficacious care. Future research is needed to determine prioritized intervention strategies for designated LBP classifications.     

A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

Objective

To investigate the difference in outcome between patients treated with group exercise, physiotherapy or osteopathy.

Design

Prospective study of patients referred at random to one of three treatments, with follow-up 6 weeks after discharge and after 12 months.

Setting

National Health Service physiotherapy department at St Albans City Hospital, part of the West Hertfordshire Musculoskeletal Therapy Service.

Participants

Two hundred and thirty-nine patients aged 18-65 years recruited from referrals to the physiotherapy department with chronic low back pain.

Interventions

Eligible patients were randomised to group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

Main outcomes

Oswestry Disability Index (ODI), EuroQol-5D, shuttle walking test and patients’ subjective responses to pain and treatment.

Results

All three treatments indicated comparable reductions in mean (95% confidence intervals) ODI at 6-week follow-up: group exercise, −4.5 (−0.9 to −8.0); physiotherapy, −4.1 (−1.4 to −6.9); and osteopathy, −5.0 (−1.6 to −8.4). Attendance rates were significantly lower among the group exercise patients. One-to-one therapies provided evidence of greater patient satisfaction.

Conclusion

The study supports the use of a variety of approaches for the treatment of chronic low back pain. Particular attention needs to be given to the problems of attracting enough participants for group sessions, as these can be difficult to schedule in ways that are convenient for different participants.     

Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain

Pain Pattern Classification (PPC) and Directional Preference (DP) have shown merit as reliable and predictable clinical solutions to help reduce the burden posed by low back pain (LBP). We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes. We hypothesized that (1) patients who demonstrated DP Centralization (CEN) would have lower pain intensity and disability at follow-up than patients who demonstrated Non-DP Non-CEN, and (2) the prevalence of DP at first examination would be lowest for patients with chronic LBP and are greater than 65 years old. First examination and follow-up data were completed by 639 patients. Clinical outcome measures, including pain intensity and disability, were collected at first examination and follow-up. Baseline comparisons were made between groups with first examination data only and groups with first examination data and follow-up data. A Pearson’s chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used for the continuous variables. A Turkey’s range test was used to determine differences in follow-up pain intensity and disability for LBP dual-classifications. Multiple regression was used to investigate DP prevalence considering risk adjusted factors. Overall prevalence of DP was 84.5% and prevalence was lowest for patients with sub-acute symptoms. No significant difference existed for the prevalence of DP for patients based on age. Patients classified as DP CEN had, on average, 1.99 pain intensity units less than patients classified as Non-DP Non-CEN at follow-up. Patients classified as DP CEN had, on average, 3.43 RMDQ units less than patients classified as Non-DP Non-CEN at follow-up.These findings support previous reports, verifying the association between LBP dual-classification schemes and clinical outcomes.     

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study

Objectives: The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.

Methods: International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.

Results: The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively.

Discussion: Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.

Level of Evidence: 2b     

Mobilisation is feasible in intensive care patients receiving vasoactive therapy: An observational study

Background

Mobilisation of intensive care unit (ICU) patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive therapy. There is a lack of published data to guide clinicians about the safety and feasibility of mobilising patients receiving vasoactive therapy.

The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy

The aim of this study was to determine the extent to which a number of distinct cognitive factors were differentially related to the levels of pain and disability reported by 183 chronic low back pain (CLBP) patients presenting for physiotherapy. After adjusting for demographics, the cognitive factors accounted for an additional 30% of the variance in pain intensity, with functional self-efficacy (beta=-0.40; P<0.001) and catastrophizing (beta=0.21; P<0.01) both uniquely contributing to the prediction of outcome. The cognitive factors also explained an additional 32% of the variance in disability after adjusting for demographics and pain intensity (total R(2)=0.61). Higher levels of functional self-efficacy (beta=-0.43; P<0.001) and lower levels of depression (beta=0.23; P<0.01) were uniquely related to lower levels of disability. Our findings clearly show that there is a strong association between cognitive factors and the levels of pain and disability reported by CLBP patients presenting for physiotherapy. Functional self-efficacy emerged as a particularly strong predictor of both pain intensity and disability. In view of our findings it would seem that targeting specific cognitive factors should be an integral facet of physiotherapy-based treatments for CLBP.     

Physiotherapists’ assessment and management of psychosocial factors (Yellow and Blue Flags) in individuals with back pain

Abstract

Background: Personal and work-related psychosocial factors play an important role in persisting symptoms and delaying return to work in individuals with back pain. Therefore, it is essential that physiotherapists have the motivation and skills to assess and manage psychosocial factors as part of back pain management.

Objectives: To systematically review and summarize the literature on physiotherapists’ perceptions of and skills in assessing and managing psychosocial factors (Yellow and Blue Flags) in individuals with back pain.

Methods: Searches were conducted of the: Ovid versions of MEDLINE, PsycINFO and EMBASE; EBSCO CINAHL; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials (Clinical Trials); and Physiotherapy Evidence Database (PEDro) from inception until end October 2011.

Results: There were 384 hits of which 17 papers describing 15 studies met the inclusion criteria; these were: two randomized controlled trials; two observational studies; six survey based studies; two qualitative studies; and three using Delphi consensus development. Studies found that although physiotherapists theoretically support a biospychosocial management approach to back pain, in practice few are doing so adequately, even following training in cognitive behavioral principles. Physiotherapists expressed reluctance to engage in the management of work-related psychosocial factors (Blue Flags), perceiving that tackling work issues was outside their professional role.

Conclusions: Despite evidence of the barriers to doing so, we put out a call to action that physiotherapists embrace the importance of integrating psychosocial factors in their everyday professional practice. In particular, gaining confidence in tackling Blue Flags is critical to establish physiotherapists as essential players in combating the growing public health concern of worklessness.     

Directional preference constructs for patients’ neck pain in the absence of centralization

Objectives: We conducted a secondary analysis of a prospective, observational cohort study to (1) report the prevalence of Directional Preference (DP) constructs at first examination for patients with cervical spine challenges, and (2) determine the association between DP constructs and clinical outcomes at discharge from physical therapy.

Methods: We analyzed data collected from 718 consecutive patients who presented to outpatient, private practice clinics with primary complaints of non-specific neck pain; 200 patients met the inclusion criteria and completed first examination and discharge data. Statistical analysis determined the association between DP constructs at first examination and clinical outcomes at discharge.

Results: The findings in this investigation were that (1) the most prevalent DP constructs at first examination were related to ROM and pain intensity including Patient Reported Improvement in ROM (79.5%), Increase in Spine ROM (32.5%), and Pain Intensity Change (15.0%), (2) all DP groups improved and met the MCID for disability and pain intensity change at discharge except for the group that did not exhibit Increase in Spine ROM for pain intensity, (3) no clinically significant differences in pain intensity or disability existed between DP groups at discharge, and (4) 28.5% and 6.5% of patients exhibited a relative increase in cervical spine extension and flexion ROM, respectively, post-repeated movement testing on the first examination.

Discussion: The most prevalent DP constructs at first examination were related to ROM and pain intensity, and each was associated with a comparable clinical trajectory in terms of pain and disability outcomes at discharge. The findings of this study help Mechanical Diagnosis and Therapy (MDT) providers understand the common DP constructs encountered in routine clinical practice and their relation to pain and disability outcomes for patients with cervical spine challenges.

Level of Evidence: 2b     

The role of cognitive-behavioural therapy in the management of pain in patients with sickle cell disease

Painful crisis is the most common manifestation of sickle cell disease and accounts for the second greatest number of admissions with an average length of stay of 7 days in central London. Despite this frequency of admissions, the management of pain is fraught with problems. This is not surprising since the psychological challenges presented by sickle cell disease are manifold, resulting in significant psychological distress for some individuals. This paper considers the literature on the psychosocial impact of sickle cell disease, and the American research evidence which suggests that pain management strategies that incorporate a psychological intervention can significantly reduce psychological distress as well as hospital admissions. Britain has been slow to incorporate psychology in the pain management strategies, and we have embarked on research to fill this gap. Although this research constitutes work in progress, an argument is put forward for utilizing the cognitive-behavioural perspective in the management of pain in sickle cell disease and we conclude by giving a brief summary of pilot work which is both the foundation and justification for the current ongoing research.     

Skill training preferences and technology use in persons with neck and low back pain

Background: Neck pain (NP) and low back pain (LBP) are highly prevalent. Exercise therapy helps, but effect sizes and therapy compliance remain low. Client-centred therapy and technology use may play a role to improve therapy outcomes. To offer technology supported rehabilitation matching patient’s goals, training preferences for rehabilitation and technology familiarity need to be known.

Purpose: This study aims to (1) inventory training preferences and motives, (2) evaluate whether these change during rehabilitation, and (3) evaluate familiarity with using technologies, in persons with NP/LBP.

Method: Semi-structured interviews were conducted with regard to training preferences and usage of mainstream technological devices.

Results: Persons with NP (n?=?40) preferred to train on “lifting”, “prolonged sitting” and “driving a car”. Persons with LBP (n?=?40) preferred to train on “household activities”, “lifting” and “prolonged walking”. Motives were predominantly “ability to work” and “ability to do free time occupations”. Preferences shifted in ranking but remained the same during rehabilitation. Participants were familiar with the surveyed technologies.

Conclusion: Persons with NP or LBP prefer to train on exercises supporting the improvement of everyday life skills. They use technologies in their professional and personal life, which may lower the threshold for the adoption of rehabilitation technologies.

• Implications for rehabilitation

• Persons with neck pain (NP) and persons with low back pain (LBP) prefer to train on specific activities that limit their functional ability during daily tasks. The underlying motives linked to preferred training activities are predominantly “being able to work” and “being able to perform free time occupations”.

• Persons with NP and persons with LBP are accustomed to the use of mainstream technologies and the integration of these technologies in rehabilitation settings seems feasible.

• In order to enable technology supported rehabilitation that is client-centred, technologies need to offer an extensive number of exercises that support (components of) patient training preferences.

     

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background

Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians.

Aim

To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations.

Design

Prospective, multicentred national study, data collection and improvement phase.

Setting

All NHS boards in Scotland (n = 14) plus two private provider sites.

Participants

One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain.

Method

A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting.

Results

Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle.

Conclusion

It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.     

Perception of subjective visual vertical and horizontal in patients with chronic neck pain: a cross-sectional observational study

Previous studies have shown that chronic neck pain (CNP) patients have a larger spread of perceptual errors for subjective visual vertical (SVV) than those exhibited by asymptomatic controls. The current study investigated whether this was also the case for perception of subjective visual horizontal (SVH) and whether there was a correlation between the two measurements. Fifty patients with CNP were compared with a group of 50 age- and gender-matched controls. All subjects were required to complete a test to measure SVH as well as SVV using the computerised rod and frame (CRAF) test. These tests were conducted under various frame conditions. No difference was found between the errors of the CNP and control groups in the absence of a surrounding frame. When a tilted frame was added to the CRAF test, the range of errors observed in the CNP group increased for both SVV and SVH. In particular, significantly more CNP patients fell outside the reference range of errors and a subgroup of patients, characterised by higher neck pain disability indices, was identified who demonstrated higher than expected errors for both SVV and SVH. However no conclusion could be drawn with regards to the direction of error asymmetry and laterality of pain as those patients with unilateral pain exhibited errors both towards and away from the affected area.     

Effectiveness of standard cervical physiotherapy plus diaphragm manual therapy on pain in patients with chronic neck pain: A randomized controlled trial

BackgroundLiterature concerning the effect of diaphragm treatment to reduce neck pain symptoms is scarce. Aim of this trial was to investigate the effects of diaphragm manual therapy associated with standard physiotherapy treatment on pain in patients with Chronic Neck Pain (CNP).MethodsIn a private practice clinic, subjects with CNP were randomly assigned to receive three 30-min treatment sessions of standard cervical physiotherapy and Diaphragm Manual Therapy (DMT) or Sham Diaphragm Technique (SDT). Participants and assessors were blinded to the assignment. Primary outcome was pain, secondary outcomes were cervical active range of motion, pain pressure threshold, disability and quality of life measured at baseline, before and after each session, at 3 and 6-months. Adverse events were monitored. A non-parametric multivariate approach (combined permutation test) was applied to assess the effect of the treatment on all the outcomes. An intention to treat analysis was performed.ResultsForty patients were randomly allocated to DMT and SDT groups. Combined permutation test showed a significant higher improvement in DMT group compared to SDT group (p-value = 0.0002). The between-group comparisons on single outcomes showed a statistically significant improvement only for pain pressure threshold on upper trapezius (adjusted p-value = 0.029). No adverse events related to the intervention were registered.ConclusionsIn patients with CNP, addition of diaphragm manual techniques to standard cervical treatment seems to give a better global outcome, but this improvement is of unclear clinical relevance; the primary outcome seems not to have a role. Further studies are needed to confirm and clarify these results.Trial registrationRelease Date: July 18, 2017 Registered in ClinicalTrial.gov database ID: NCT03223285A.