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.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Treating non-specific chronic low back pain through the Pilates Method

The goal of this study is to review and analyze scientific articles where the Pilates Method was used as treatment for non-specific chronic low back pain (CLBP). Articles were searched using the Medline, EMBASE, PEDro, CINAHL, and SPORTDICUS databases. The criteria used for inclusion were randomized controlled trials (RCT) and clinical controlled trials (CCT) published in English where therapeutic treatment was based on the Pilates Method. The analysis was carried out by two independent reviewers using the PEDro and Jadad Scales. Two RCTs and one CCT were selected for a retrospective analysis. The results of the studies analyzed all demonstrate positive effects, such as improved general function and reduction in pain when applying the Pilates Method in treating non-specific CLBP in adults. However, further research is required to determine which specific parameters are to be applied when prescribing exercises based on the Pilates Method with patients suffering from non-specific CLBP. Finally, we believe that more studies must be carried out where the samples are more widespread so as to give a larger representation and more reliable results.     

Stabilisation exercises for low back pain: a systematic review

Objectives

To examine the literature to determine if stabilisation exercises are effective for the treatment of pain and dysfunction in patients with low back pain.

Data sources

PubMed (MEDLINE), CINAHL, AMED, PEDro and the Cochrane Library were searched up to October 2006.

Review methods

Inclusion criteria were: randomised clinical trials; in English; full publications; subjects were adults with low back pain; one group received specific stabilisation exercises as the primary intervention; and outcome measures included some measure of pain and/or function. Following a systematic search of major databases, articles were scored according to the PEDro criteria for quality. Due to heterogeneity of specific interventions, control groups, duration of follow-up, outcome measures and study population, a meta-analysis was not conducted. A qualitative review was undertaken that focused on study quality, study population and type of control group.

Results

In total, 18 trials were included in the review; a large number of trials were excluded. There was little evidence to support the use of stabilisation exercises for acute low back pain. There was some evidence to support the use of stabilisation exercises in chronic back pain, with the majority of high-quality trials showing a significant difference in favour of stabilisation exercises. Overall, however, the evidence was conflicting, and significant differences favouring stabilisation exercises were less likely when they were compared with active treatment control groups rather than inactive control groups.

Conclusions

There may be a role for specific stabilisation exercises in some patients with chronic low back pain, but these are no more effective than other active interventions.     

Thermography evaluation of low back pain in pregnant women: Cross-sectional study

BackgroundLow back pain during pregnancy is very common and thermography seems to be a promising method of evaluation for pregnant women, because it is painless and safe. The aim of the present study was to evaluate low back pain, during pregnancy, using thermography together with artificial intelligence.MethodsA cross-sectional study was carried out with pregnant women recruited from a university hospital. The following data were collected: (a) clinical data; (b) physical assessment with mobility and low back pain provocation tests; and (c) thermograms acquisitions, in a controlled environment. Artificial intelligence and the statistical tests were used to compare the groups’ mean: with low back pain (LBP) and without low back pain (WLBP).ResultsThirty pregnant women took part, with fifteen in each group. The mean ± Standard Deviation temperature of the lumbar region in both groups were 32.7 ± 1.05 °C and 32.6 ± 1.01 °C for LBP and WLBP, respectively. There was not any difference in temperature between the groups; however, the artificial intelligence software found thermogram differences between groups; furthermore, the correlation between pain intensity and functionality was found.ConclusionThermography associated with artificial intelligence analyses demonstrated to be a promising method as an adjunct to clinical evaluation.     

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.     

A bio-psycho-social approach for treating sub-acute low back pain

Purpose.?This article examines the distinctive opportunities and challenges involved in treating sub-acute low back pain (LBP). Several risk factors have been identified. Thus, a multi-disciplinary design and a comprehensive bio-psycho-social approach seem to be the best modality of intervention to improve outcome.

Method.?The relevant literature on various factors that are supposed to improve outcome is summarised and discussed.

Results.?A controversial on the rehabilitation benefits still exists. From one side, meta-analytic studies provide a small evidence of effectiveness. Most treatments for chronic LBP provide weak results and the benefits can be just transient. From the other side, comprehensive bio-psycho-social approaches seem to be the best modality of intervention to facilitate physical outcome and return to work.

Conclusion.?This article reflects the conviction that clinicians with a special knowledge on LBP problems and researchers with a special knowledge on health policy will better work together. Their targets are outcome and cost-benefit ratio by taking into account the economical and political milieu of the country where the research is carried out.     

Using consensus methods in developing clinical guidelines for exercise in managing persistent low back pain

Objectives

To generate expert consensus evidence for the purpose of developing more complete guidelines for people with persistent low back pain than is possible using current research evidence alone. Gaps in research evidence lead to incomplete practice recommendations unless a scientific process can provide supplementary consensus evidence that is a basis for additional recommendations.

Design

A modified Nominal Group Technique (NGT). This followed a systematic review indicating incomplete research evidence.

Setting

UK-wide coordinated by the Chartered Society of Physiotherapy.

Participants

Twenty-three individuals selected for their expertise as clinicians, researchers, managers and patients.

Methods

Three stages: a first-round questionnaire of clinical questions unanswered by the systematic review; an electronic conference for outstanding questions unanswered by the first questionnaire; and a second-round questionnaire for these outstanding questions. All three stages were carried out electronically.

Results

Of 17 clinical questions unanswered by the systematic review, consensus evidence was generated for 14 questions by the modified NGT and this led to 14 recommendations for practice. Consensus was not reached for the remaining three questions.

Conclusions

The modified NGT was a practical and cost-effective way of generating consensus evidence from a UK-wide group. The consensus evidence was the basis of appropriately graded recommendations for effective care of people with persistent low back pain. Consensus methods have been little used in physiotherapy to date but are likely to be valuable in developing clinically useful, evidence-based tools for future practice.     

An evidence map of yoga for low back pain

ObjectiveYoga is being increasingly studied as a treatment strategy for a variety of different clinical conditions, including low back pain (LBP). We set out to conduct an evidence map of yoga for the treatment, prevention and recurrence of acute or chronic low back pain (cLBP).MethodsWe searched Medline, Cochrane Database of Systematic Reviews, EMBASE, Allied and Complementary Medicine Database and ClinicalTrials.gov for randomized controlled trials (RCT), systematic reviews or planned studies on the treatment or prevention of acute back pain or cLBP. Two independent reviewers screened papers for inclusion, extracted data and assessed the quality of included studies.ResultsThree eligible systematic reviews were identified that included 10 RCTs (n = 956) that evaluated yoga for non-specific cLBP. We did not identify additional RCTs beyond those included in the systematic reviews. Our search of ClinicalTrials.gov identified one small (n = 10) unpublished trial and one large (n = 320) planned clinical trial. The most recent good quality systematic review indicated significant effects for short- and long-term pain reduction (n = 6 trials; standardized mean difference [SMD] −0.48; 95% CI, −0.65 to −0.31; I² = 0% and n = 5; SMD −0.33; 95% CI, −0.59 to −0.07; I² = 48%, respectively). Long-term effects for back specific disability were also identified (n = 5; SMD −0.35; 95% CI, −0.55 to −0.15; I² = 20%). No studies were identified evaluating yoga for prevention or treatment of acute LBP.ConclusionEvidence suggests benefit of yoga in midlife adults with non-specific cLBP for short- and long-term pain and back-specific disability, but the effects of yoga for health-related quality of life, well- being and acute LBP are uncertain. Without additional studies, further systematic reviews are unlikely to be informative.     

Slump stretching in the management of non-radicular low back pain: a pilot clinical trial

The purpose of this study was to determine if slump stretching results in improvements in pain, centralization of symptoms, and disability in patients with non-radicular low back pain (LBP) with likely mild to moderate neural mechanosensitivity. Thirty consecutive patients referred to physical therapy by their primary care physician for LBP who met all eligibility criteria including a positive slump test but who had a negative straight-leg-raise test (SLR) agreed to participate in the study. All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the modified Oswestry Disability Index (ODI). Patients were randomized to receive lumbar spine mobilization and exercise (n = 14) or lumbar spine mobilization, exercise, and slump stretching (n = 16). All patients were treated in physical therapy twice weekly for 3 weeks for a total of 6 visits. Upon discharge, outcome measures were re-assessed. Independent t-tests were used to assess differences between groups at baseline and discharge. No baseline differences existed between the groups (P > .05). At discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI, P < .001), pain (.93 points on the NPRS, P = .001), and centralization of symptoms (P < .01) than patients who did not. The results suggest that slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms. Future studies should examine whether these benefits are maintained at a longer-term follow-up.     

国内护理人员腰背痛患病率的Meta分析

目的 评价国内护理人员腰背痛的患病率情况.方法 系统检索PubMed、Springer、OVID、中国期刊网、万方及维普数据库有关国内护理人员腰背痛患病率的研究文献,对纳入的文献采用Meta分析的方法进行腰痛患病率的定量合并.结果 护理人员腰痛患病率的合并值为72％(65％～79％),并得出不同科室、工龄、文献发表时间以及文献质量各亚组的患病率.结论 国内护理人员腰背痛患病率较高,而ICU护士较其他科室护士的患病率高,工龄越长,腰痛的患病率也越高.     

Physiotherapists' knowledge,attitudes and practices regarding clinical prediction rules for low back pain

Clinical Prediction Rules (CPRs) have been developed to assist in the physiotherapy management of low back pain (LBP) although little is known about the factors that may influence their implementation in clinical practice. This study used qualitative research methodology to explore the knowledge, attitudes and practices/behaviours of physiotherapists in relation to these tools. Four semi-structured focus groups involving 26 musculoskeletal physiotherapists were conducted across three Australian geographic regions. A fictitious LBP case scenario was developed and used to facilitate group discussion. Participant knowledge of CPRs was found to be mixed, with some clinicians never having previously encountered the term or concept. LBP CPRs were often conceptualised as a formalisation of pattern recognition. Attitudes towards CPRs expressed by study participants were wide-ranging with several facilitating and inhibiting views identified. It was felt that more experienced clinicians had limited need of such tools. Only a small number of participants expressed that they had ever used LBP CPRs in clinical practice. To optimise the successful adoption of an LBP CPR, researchers should consider avoiding the use of the term ‘rule’ and ensure that the tool and its interface are uncomplicated and easy to use. Understanding potential barriers, the needs of clinicians and the context in which CPRs will be implemented will help facilitate the development of tools with the highest potential to positively influence physiotherapy practice.     

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.     

Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain

We examined mindfulness in people with chronic low back pain who were attending a multidisciplinary pain management programme. Participants completed questionnaires at baseline (n=116) and after a 3-month cognitive-behaviourally informed multidisciplinary intervention (n=87). Self-reported mindfulness was measured before and after the intervention, and relationships were explored between mindfulness, disability, affect and pain catastrophizing. Mindfulness increased following participation in the intervention, and greater mindfulness was predictive of lower levels of disability, anxiety, depression and catastrophizing, even when pain severity was controlled. Mediator analyses suggested that the relationship between mindfulness and disability was mediated by catastrophizing. It is possible that cognitive-behavioural interventions and processes can affect both catastrophizing and mindfulness.     

Fascial manipulation vs. standard physical therapy practice for low back pain diagnoses: A pragmatic study

Background

Connective tissue mobility alters motor unit recruitment, but the restoration of fascial mobility allows for optimal motor function. The Fascial Manipulation^® (FM^®) method is a multiplanar approach that assesses and treats the mobility of deep fascia in specific anatomical locations where motor units converge.