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Low back pain is the leading cause of disability globally. Most prevalence data for low back pain come from high-income countries. Data from low-and middle-income countries such as Nepal are currently lacking. This study aimed to estimate one-month prevalence of low back pain in Nepal using a nationally representative sample and present the prevalence estimates by socio-demographic characteristics. We used national population-based survey data from the World Health Organisation (WHO) STEPwise Approach to Non-communicable Disease Risk Factor Surveillance (STEPS) survey conducted in Nepal from February to May 2019 with people aged 15 to 69 years. We reported the age-standardised low back pain prevalence (95% CI). We used univariate and multivariable logistic regression to assess the associations between sociodemographic variables and the presence of low back pain and results were presented as odds ratios. A total of 5593 people aged 15 to 69 years participated in the survey. The response rate was 86.4%. The age-standardised prevalence of activity limiting low back pain was 23.2% (95% CI: 21.9% to 24.5%). Older people were more likely to have low back pain than younger people. For example, people aged 55–69 years had over 4 times higher odds of having low back pain than people aged 15–24 years [odds ratio: 4.06 (95%CI= 2.57 to 6.42)]. Females had 1.74 times higher odds of having low back pain than males [odds ratio: 1.74 (95%CI= 1.45 to 2.09)]. The results of our study show that a quarter of adults are affected by low back pain in Nepal; with women and older people more likely to experience low back pain. more...

Patient decision aids are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. Research shows that patient decision aids increase knowledge, accuracy of risk perceptions, alignment of care with patient values and preferences, and patient involvement in decision making. Some patient decision aids can reduce the use of invasive and potentially low-value procedures. On this basis, clinical practice guidelines and international organisations have begun to recommend the use of patient decision aids and shared decision making as a strategy to reduce medical overuse. Although patient decision aids hold promise for improving healthcare, there are fundamental issues with patient decision aids that need to be addressed before further progress can be made. The problems with patient decision aids are: (1) Guidelines for developing patient decision aids may not be sufficient to ensure developers select the best available evidence and present it appropriately; (2) Biased presentation of low-certainty evidence is common and (3) Biased presentation of low-certainty evidence is misleading, and could inadvertently support, low-value care. We explore these issues in the article and present a case study of online patient decision aids for musculoskeletal pain. We suggest ways to ensure patient decision aids help patients understand the evidence and, where possible, support high-quality care. more...

Spinal cord stimulators, devices implanted surgically to treat chronic back pain, have been used since the 1960s. However, recent research does not support their effectiveness and suggests a significant risk of harm. Studies comparing spinal cord stimulation to non-surgical treatments or placebo devices have shown small benefits, but the evidence is uncertain. Adverse events reported in Australia indicate serious harms, with around half due to device malfunctions. The high costs of the procedure, along with industry influence and lack of convincing evidence, raise questions about the widespread use of spinal cord stimulators in Australia. However, there are alternative therapies being researched that show promise in treating chronic pain. [Extracted from the article] more...

We used a scoping review design to map the available evidence describing the use of reassurance in clinical practice, interventions to increase the delivery of reassurance, and reassurance-related outcome measures. We searched CINAHL, MEDLINE, EMBASE and Cochrane Central from inception to October 2024. Publications were included if they described the use of reassurance or reassurance-related outcome measures in patients with non-specific low back pain (LBP) presenting to primary care. We did not exclude publications on the basis of study design. Data were extracted and charted in accordance with study aims. We included 88 publications describing 66 primary studies. Twenty-one papers described how clinicians used reassurance in primary care, including: information provided (n=16), frequency of use (n=6), challenges providing reassurance (n=7), and importance of individualising reassurance (n=11). Reassurance interventions were investigated in 46 trials. Reassurance interventions were delivered verbally by clinicians to individuals (n=29) or groups (n=14), or via educational materials (n=18). Only one trial measured how reassured the patient felt after the intervention using a single-item non-validated question. Thirty-six trials used indirect measurements of reassurance success, including reductions in: fear-avoidance (n=23), worry (n=8), anxiety (n=8), pain catastrophising (n=10), and further healthcare utilisation (n=12). Relatively few papers have described how clinicians use reassurance in primary care. Reassurance interventions were investigated in 46 trials; however, reassurance was rarely the primary component of the intervention and was often delivered as part of an education intervention. There are no validated measures to directly assess how reassured a patient feels after an intervention. more...

IMPORTANCE: Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. OBJECTIVE: To determine the effectiveness of intensive patient education for patients with acute low back pain. DESIGN, SETTING, AND PARTICIPANTS: This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks’ duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. INTERVENTIONS: All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. RESULTS: Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, –0.3 [95% CI, –1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, –1.6 points on a 24-point scale [95% CI, –3.1 to –0.1]) and 3 months (mean difference, –1.7 points, [95% CI, –3.2 to –0.2]) but not at 6 or 12 months. CONCLUSIONS AND RELEVANCE: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. TRIAL REGISTRATION: Australian Clinical Trial Registration Number: 12612001180808 more...

Objectives(1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.DesignSystematic review.Data sourcesMEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including the National Guideline Clearinghouseand Canadian Medical Association Infobase.Eligibility criteria for selecting studiesEvidence-based clinical practice guidelines.Data extractionTwo review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.Results78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.Summary/conclusionThe number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data. more...

ObjectiveTo investigate whether characteristics of schoolbag use are risk factors for back pain in children and adolescents.Data sourcesElectronic searches of MEDLINE, EMBASE and CINAHL databases up to April 2016.Eligibility criteria for selecting studiesProspective cohort studies, cross-sectional and randomised controlled trials conducted with children or adolescents. The primary outcome was an episode of back pain and the secondary outcomes were an episode of care seeking and school absence due to back pain. We weighted evidence from longitudinal studies above that from cross-sectional. The risk of bias of the longitudinal studies was assessed by a modified version of the Quality in Prognosis Studies tool.ResultsWe included 69 studies (n=72 627), of which five were prospective longitudinal and 64 cross-sectional or retrospective. We found evidence from five prospective studies that schoolbag characteristics such as weight, design and carriage method do not increase the risk of developing back pain in children and adolescents. The included studies were at moderate to high risk of bias. Evidence from cross-sectional studies aligned with that from longitudinal studies (ie, there was no consistent pattern of association between schoolbag use or type and back pain). We were unable to pool results due to different variables and inconsistent results.Summary/conclusionThere is no convincing evidence that aspects of schoolbag use increase the risk of back pain in children and adolescents. more...

•Patient education is recommended in the primary care management of acute low back pain.•The PREVENT Trial is the first placebo-controlled randomized trial to evaluate the efficacy of patient education.•Statistical analysis plans increase the transparency around how researchers plan to estimate and interpret treatment effects from randomized trials.•This protocol describes the pre-specified principles, methods, and procedures to be adhered to in the statistical analysis of the PREVENT trial data. more...

•Reassurance is a frequently utilized yet poorly understood clinical skill.•Emotional distress is an important driver of healthcare use.•Diagnostic test results are not reassuring.•Some attempts at reassurance can increase rather than decrease concern.•Patient education is a promising way for clinicians to manage emotional distress. more...

•Facilitators/barriers to target the altered nervous system in chronic low back pain.•Effective pain communication creates positive attitudes and empowerment.•Some approaches increase while others interfere with intervention coherence.•Face-to-face and online components increase confidence in performing the treatment.•People outside the treatment team also impact the acceptability of the treatment. more...

IMPORTANCE: Reassurance is a core aspect of daily medical practice, yet little is known on how it can be achieved. OBJECTIVE: To determine whether patient education in primary care increases reassurance in patients with acute or subacute low back pain (LBP). DATA SOURCES: Medline, EMBASE, Cochrane Central Register for Controlled Trials, and PsychINFO databases were searched to June 2014. DESIGN: Systematic review and meta-analysis of randomized and nonrandomized clinical trials. STUDY SELECTION: To be eligible, studies needed to be controlled trials of patient education for LBP that were delivered in primary care and measured reassurance after the intervention. Eligibility criteria were applied, and studies were selected by 2 independent authors. MAIN OUTCOMES AND MEASURES: The primary outcomes were reassurance in the short and long term and health care utilization at 12 months. DATA EXTRACTION AND SYNTHESIS: Data were extracted by 2 independent authors and entered into a standardized form. A random-effects meta-analysis tested the effects of patient education compared with usual care on measures of reassurance. To investigate the effect of study characteristics, we performed a preplanned subgroup analysis. Studies were stratified according to duration, content, and provider of patient education. RESULTS: We included 14 trials (n = 4872) of patient education interventions. Trials assessed reassurance with questionnaires of fear, worry, anxiety, catastrophization, and health care utilization. There is moderate- to high-quality evidence that patient education increases reassurance more than usual care/control education in the short term (standardized mean difference [SMD], −0.21; 95% CI, −0.35 to −0.06) and long term (SMD, −0.15; 95% CI, −0.27 to −0.03). Interventions delivered by physicians were significantly more reassuring than those delivered by other primary care practitioners (eg, physiotherapist or nurse). There is moderate-quality evidence that patient education reduces LBP-related primary care visits more than usual care/control education (SMD, −0.14; 95% CI, −0.28 to −0.00 at a 12-month follow-up). The number needed to treat to prevent 1 LBP-related visit to primary care was 17. CONCLUSIONS AND RELEVANCE: There is moderate- to high-quality evidence that patient education in primary care can provide long-term reassurance for patients with acute or subacute LBP. more...

•There is little guidance for physical therapists on how best to provide first line care for people with low back pain.•Providing validation to patients seems important.•The AxEL-Q is a valid and reliable tool that could help to guide physical therapy consultations.•Physical therapists could consider focusing patient education and advice on messages about cause, severity, and imaging, and in doing so remove barriers to physical activity more...

•Mediation analyses can help identify key treatment targets of interventions.•Adapting interventions to best influence treatment targets can improve outcomes.•Patient education targeting self-efficacy and back beliefs may reduce disability in acute low back pain.•The role of pain catastrophizing in acute low back pain is unclear. more...