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Background and Purpose: People who live longer often live with multimorbidity. Nevertheless, whether the presence of multimorbidity affects pain and disability in older adults with chronic low back pain (LBP) remains unclear. The aim of this study was to investigate whether multimorbidity predicts pain intensity and disability at 6- and 12-month follow-ups in older adults with chronic LBP. Methods: This was a prospective, longitudinal study with 6- and 12-month follow-ups. Participants with chronic LBP (age = 60 years) were recruited and interviewed at baseline, 6 months, and 12 months. Self-reported measures included the number of comorbidities, assessed through the Self-Administered Comorbidity Questionnaire, pain intensity, assessed with the 11-point Numerical Rating Scale, and disability, assessed with the Roland-Morris Disability Questionnaire. Data were analyzed using univariate and multivariate regression models. Results and Discussion: A total of 220 participants were included. The number of comorbidities predicted pain intensity at 6-month (ß = 0.31 [95% CI: 0.12 to 0.50]) and 12-month (ß = 0.29 [95% CI: 0.08 to 0.50]) follow-ups. The number of comorbidities predicted disability at 6-month (ß = 0.55 [95% CI: 0.20 to 0.90]) and 12-month (ß = 0.40 [95% CI: 0.03 to 0.77]) follow-ups. Conclusion: The number of comorbidities at baseline predicted pain and disability at 6-month and 12-month follow-ups in older adults with chronic LBP. These results highlight the role of comorbidities as a predictive factor of pain and disability in patients with chronic LBP, emphasizing the need for timely and continuous interventions in older adults with multimorbidity to mitigate LBP-related pain and disability. [ABSTRACT FROM AUTHOR]

Introduction. Validly and reliably assessing conceptual change is essential for evaluating the effectiveness of pain science education for physiotherapy students. We aimed to 1) evaluate concept of pain before and after a 14-week pain science education university subject, 2) assess structural validity of the Concept of Pain Inventory for Adults (COPI-Adult) in postgraduate entry-level physiotherapy students, and 3) explore possible relationships between baseline variables and baseline COPI-Adult scores. Review of Literature. As the COPI-Adult is a newly developed questionnaire, there is a lack of data regarding its psychometric properties. Subjects. Of 129 enrolled students at an Australian university, 124 (96%) and 114 (88%) completed the baseline and follow-up questionnaires, respectively. Methods. In this prospective cohort study, students who commenced the degree in 2020 or 2021 completed online questionnaires, including the COPI-Adult, at the start and end of their first semester. This semester included a 14-week pain science education subject and other physiotherapy-related subjects. Higher COPI-Adult scores (range = 0–52) indicate better alignment with contemporary pain science. We 1) compared differences in concept of pain before and after the semester, 2) performed a confirmatory factor analysis on the COPI-Adult, and 3) performed exploratory regression analyses. Results. Concept of Pain Inventory for Adults scores increased from baseline (median [interquartile range]: 39 [36–44]) to follow-up (48 [44–51]). The COPI-Adult retained its 1-factor structure, with acceptable internal consistency (Cronbach's alpha = 0.80). Exploratory analysis showed that previously completing a subject on pain was related to higher COPI-Adult baseline scores. Age, gender, and mental health diagnosis did not relate to baseline COPI-Adult scores. Discussion and Conclusion. Following a 14-week pain science education subject embedded within a physiotherapy degree, students improved their concept of pain. The COPI-Adult maintains a 1-factor structure in this population. Completing a previous subject on pain was associated with higher COPI-Adult scores. [ABSTRACT FROM AUTHOR]

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Abstract: The choice of a specific surgical technique should be based on its benefits and harms. Previous reviews have shown that the benefit of surgery over conservative care is not clearly demonstrated in patients with disorders of the cervical spine. Also, no additional benefit of fusion upon anterior decompression techniques could be found. A clear overview of other surgical techniques is lacking. We therefore aimed to assess the benefits and harms of cervical spinal surgery in patients with cervical disorders. We searched MEDLINE, EMBASE, CINAHL, and CENTRAL up to June 2012. Randomized controlled trials (RCTs) were selected which included adults with cervical disorders receiving a surgical intervention and that reported at least 1 clinically relevant outcome measure (eg, pain, function, recovery). Two authors independently assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group and extracted the data. The quality of the evidence was rated using the GRADE method. We included 39 RCTs comparing different surgical interventions. We found low-quality evidence for no difference in effectiveness between various surgical techniques used for anterior discectomy. There is a small, clinically irrelevant benefit on recovery and pain in favour of prosthetic disc surgery when compared with fusion techniques. Unfortunately, in these studies the authors had a clear conflict of interest. The differences in benefits and harms between the various surgical techniques are small. The surgeon, patient, and health care provider can therefore make the choice of any surgical technique based on experience, preferences, or costs. [Copyright &y& Elsevier]

Abstract: The objective of this study is to identify subgroups of patients with non-specific neck pain who are more likely to benefit from either physiotherapy, spinal manipulation therapy, or usual care, on the short- and long-term. Data of three recently finished randomised controlled trials, with similar design and setting, were combined. The combined study population consisted of 329 patients with non-specific neck pain in an adult (18–70years) primary care population in the Netherlands. The primary outcome measure was global perceived recovery and was measured at the end of the treatment period and after 52 weeks of follow-up. Fourteen candidate variables were selected for the analysis. Predictors were identified by multivariable logistic regression analysis and were tested for interaction with treatment. Based on the multivariable models with interaction terms a decision model for treatment choice was developed. The analysis revealed three predictors for recovery of which the effect is modified by treatment: pain intensity (0–10 scale) in the short-term model, age and (no) accompanying low back pain in the long-term model. With these predictors a clinically relevant improvement in recovery rate (up to 25% improvement) can be established in patients receiving a tailored instead of a non-advised treatment. In conclusion we identified three characteristics that facilitate a deliberate treatment choice, to optimise benefit of treatment in patients with non-specific neck pain: age, pain intensity, and (no) accompanying low back pain. [Copyright &y& Elsevier]

We present a systematic review of prospective cohort studies. Our aim was to assess prognostic factors associated with functional recovery of patients with whiplash injuries. The failure of some patients to recover following whiplash injury has been linked to a number of prognostic factors. However, there is some inconsistency in the literature and there have been no systematic attempts to analyze the level of evidence for prognostic factors in whiplash recovery. Studies were selected for inclusion following a comprehensive search of MEDLINE, EMBASE, CINAHL, the database of the Dutch Institute of Allied Health Professions up until April 2002 and hand searches of the reference lists of retrieved articles. Studies were selected if the objective was to assess prognostic factors associated with recovery; the design was a prospective cohort study; the study population included at least an identifiable subgroup of patients suffering from a whiplash injury; and the paper was a full report published in English, German, French or Dutch. The methodological quality was independently assessed by two reviewers. A study was considered to be of ‘high quality’ if it satisfied at least 50% of the maximum available quality score. Two independent reviewers extracted data and the association between prognostic factors and functional recovery was calculated in terms of risk estimates. Fifty papers reporting on twenty-nine cohorts were included in the review. Twelve cohorts were considered to be of ‘high quality’. Because of the heterogeneity of patient selection, type of prognostic factors and outcome measures, no statistical pooling was able to be performed. Strong evidence was found for high initial pain intensity being an adverse prognostic factor. There was strong evidence that for older age, female gender, high acute psychological response, angular deformity of the neck, rear-end collision, and compensation not being associated with an adverse prognosis. Several physical (e.g. restricted range of motion, high number of complaints), psychosocial (previous psychological problems), neuropsychosocial factors (nervousness), crash related (e.g. accident on highway) and treatment related factors (need to resume physiotherapy) showed limited prognostic value for functional recovery. High initial pain intensity is an important predictor for delayed functional recovery for patients with whiplash injury. Often mentioned factors like age, gender and compensation do not seem to be of prognostic value. Scientific information about prognostic factors can guide physicians or other care providers to direct treatment and to probably prevent chronicity. [Copyright &y& Elsevier]

Objectives: Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables., Materials and Methods: A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502)., Results: The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change., Discussion: The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Reanalysis of data from 3 randomized controlled trials., Objective: Development and validation of a prediction rule that estimates the probability of complaints persisting for at least 6 months in patients presenting with nonspecific neck pain in primary care., Summary of Background Data: A substantial proportion of the neck pain patients will develop chronic neck pain. An important question is whether we can identify patients at risk of persistent complaints at the first consultation with the physician, based on their personal characteristics? A prediction model that quantifies prognosis in patients with nonspecific neck pain is not available., Methods: The study population consisted of a sample (n = 468) from the adult primary care population (18-70 years) in The Netherlands presenting with nonspecific neck pain. The primary outcome measure was global perceived recovery measured at 6 months of follow-up. Seventeen baseline characteristics of the patients were included in the analysis. Significant predictors were identified by multivariable backward stepwise logistic regression analysis. A score chart was constructed by using the regression coefficient estimates. The score chart was externally validated in a cohort of patients with nonspecific neck pain (n = 315), who participated in a randomized controlled trial in the United Kingdom (PANTHER-trial)., Results: The multivariable analysis resulted in a set of 9 predictors. The score chart has a discriminative ability of 0.66. External validation of the score chart showed a discriminative ability of 0.65, an adequate calibration, a good fit, and a low explained variation., Conclusion: We developed a score chart, estimating the probability of persistent complaints at 6 months follow-up for patients with nonspecific neck pain. This chart performed well in the study population and external validation population. The prediction which patients are more likely to develop persistent complaints is significantly improved by the score chart.

Study Design: Systematic review., Objective: To review and critically evaluate the past literature for spinal mechanical load as risk factor for low back pain (LBP)., Summary of Background Data: LBP is a costly health problem worldwide, and treatments are often unsuccessful. Therefore, prevention might be more beneficial in the management of LBP. With respect to prevention, the knowledge of risk factors is essential. From the literature, exposures involving spinal mechanical load is frequently discussed as a potential risk factor for LBP. For a better understanding of this risk factor, we performed a systematic review of the literature. Additionally, we evaluated exposures of spinal mechanical load for possible dose-response relations with LBP., Methods: We systematically searched Medline, Embase, PsycINFO, and CINAHL databases (without language restriction) for full-report publications of prospective cohort studies, evaluating spinal mechanical load during work and/or leisure time activities as risk factors for nonspecific LBP in patients (>18 years of age) free of LBP at baseline. We assessed the methodology of each article and extracted information on population, response rates, characteristics of LBP, exposures, and estimated association(s), using standardized forms. We performed a best evidence synthesis of the obtained information., Results: In total, 18 studies were eligible (all rated as high methodologic quality) reporting on 24,315 subjects., Conclusion: We found strong evidence that leisure time sport or exercises, sitting, and prolonged standing/walking are not associated with LBP. Evidence for associations in leisure time activities (e.g., do-it-yourself home repair, gardening), whole-body vibration, nursing tasks, heavy physical work, and working with ones trunk in a bent and/or twisted position and LBP was conflicting. We found no studies, thus no evidence, for an association between sleeping or sporting on a professional level and LBP.

Study Design: An economic evaluation alongside a randomized clinical trial in primary care. A total of 135 patients were randomly allocated to physical therapy added to general practitioners' care (n = 67) or to general practitioners' care alone (n = 68)., Objective: To evaluate the cost-effectiveness of physical therapy and general practitioner care for patients with an acute lumbosacral radicular syndrome (LRS, also called sciatica) compared with general practitioner care only., Summary of Background Data: There is a lack of knowledge concerning the cost-effectiveness of physical therapy in patients with sciatica., Methods: The clinical outcomes were global perceived effect and quality of life. The direct and indirect costs were measured by means of questionnaires. The follow-up period was 1 year. The Incremental Cost-effectiveness Ratio (ICER) between both study arms was constructed. Confidence intervals for the ICER were calculated using Fieller's method and using bootstrapping., Results: There was a significant difference on perceived recovery at 1-year follow-up in favor of the physical therapy group. The additional physical therapy did not have an incremental effect on quality of life. At 1-year follow-up, the ICER for the total costs was 6224 euros (95% confidence interval, -10,419, 27,551) per improved patient gained. For direct costs only, the ICER was 837 euros (95% confidence interval, -731, 3186)., Conclusion: The treatment of patients with LRS with physical therapy and general practitioners'care is not more cost-effective than general practitioners'care alone.

Study Design: This is a prospective cohort study with a follow-up period of 6 months., Objective: To describe the interventions applied by physical therapists in treating patients with complaints of the arm, neck, and/or shoulder., Summary of Background Data: Complaints of the arm, neck, and/or shoulder occur frequently and are usually treated within primary care. Many patients with these complaints are treated with physical therapy., Methods: During a 1-year period, the participating physiotherapists included new consulters with musculoskeletal complaints of the upper extremity. The patients completed a questionnaire at baseline, and the physical therapists completed a treatment record for up to 6 months., Results: Of the 624 patients included in the cohort, physical therapists provided treatment data of 619 patients. The main treatment consisted of exercise therapy (93%) and massage (87%), or a combination of both. More patients with specific complaints received physical methods, and patients with nonspecific complaints were treated with manipulation techniques., Conclusions: The primary treatment of complaints the of arm, neck, and/or shoulder in physiotherapy practice consists of exercise therapy and massage therapy, mostly being a combination of both. Future studies should focus on the effectiveness of exercise therapies, combined or not combined with massage, for patients with complaints of the arm, neck, and/or shoulder.

Study Design: Randomized clinical trial., Objective: To compare the effectiveness of education and advice given by general practitioners (GPs) with education, advice, and active exercise therapy given by physiotherapists (PTs) for patients with whiplash-associated disorders., Summary of Background Data: Available evidence from systematic reviews has indicated beneficial effects for active interventions in patients with whiplash-associated disorders. However, it remained unclear which kind of active treatment was most effective., Methods: Whiplash patients with symptoms or disabilities at 2 weeks after accident were recruited in primary care. Eligible patients still having symptoms or disabilities at 4 weeks were randomly allocated to GP care or physiotherapy. GPs and PTs treated patients according to a dynamic multimodal treatment protocol primarily aimed to increase activities and influence unfavorable psychosocial factors for recovery. We trained all health care providers about the characteristics of the whiplash problem, available evidence regarding prognosis and treatment, and protocol of the interventions. The content of the information provided to patients during treatment depended on the treatment goals set by the GPs or PTs. Also, the type of exercises chosen by the PTs depended on the treatment goals, and it was not explicitly necessary that exercise therapy was provided in all patients. Primary outcome measures included neck pain intensity, headache intensity, and work activities. Furthermore, an independent blinded assessor measured functional recovery, cervical range of motion, disability, housekeeping and social activities, fear of movement, coping, and general health status. We assessed outcomes at 8, 12, 26, and 52 weeks after the accident., Results: A total of 80 patients were randomized to either GP care (n = 42) or physiotherapy (n = 38). At 12 and 52 weeks, no significant differences were found concerning the primary outcome measures. At 12 weeks, physiotherapy was significantly more effective than GP care for improving 1 of the measures of cervical range of motion (adjusted mean difference 12.3 degrees ; 95% confidence interval [CI] 2.7-21.9). Long-term differences between the groups favored GP care but were statistically significant only for some secondary outcome measures, including functional recovery (adjusted relative risk 2.3; 95% CI 1.0-5.0), coping (adjusted mean difference 1.7 points; 95% CI 0.2-3.3), and physical functioning (adjusted mean difference 8.9 points; 95% CI 0.6-17.2)., Conclusions: We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for functional recovery, coping, and physical functioning. Physiotherapy seems to be more effective than GP care on cervical range of motion at short-term follow-up.

Study Design: The authors conducted a cross-sectional analysis., Objective: The objective of this study was to describe the signs and symptoms of pregnant women with pain and dysfunction in the pelvic area., Summary of Background Data: Pelvic pain during pregnancy is common with incidence rates of 48% to 56%. The exact cause of pelvic pain during pregnancy is still unclear. Also unclear is the association between physical examination and the occurrence of pelvic pain during pregnancy., Methods: Pregnant women with pelvic pain were sent for treatment to 2 physical therapy practices between January 1997 and January 2002. A standardized clinical examination protocol and an extensive questionnaire were used to obtain relevant clinical and demographic characteristics., Results: In total, 870 women were included. The average score of the overall severity of the complaints was 7.8 (scale 0-15). Main complaints were located around the sacroiliac joints (76.6%) and the pubic symphysis (57.2%). The area of pain was not related to positive signs in passive hip movements and sacroiliac tests. The highest positive test results were found for Patrick sign (71.7%), active straight leg raise (ASLR) test (66.4%), resisted adduction (54.4%), and passive hip abduction (36.9%). Overall severity of complaints was related to age, number of weeks pregnant, passive hip flexion and internal rotation, and swimming. The total explained variance of these factors was 15.9%. No relationship was found between overall complaints and sacroiliac tests, pelvic pain during a previous pregnancy, extremely painful or type of previous deliveries., Conclusions: Pregnant patients with pelvic pain show a considerable level of complaints. The overall severity of complaints is not related to previous peripartum pelvic pain or type of deliveries or to commonly used tests. Further study on the role of clinical examination, including passive flexion and internal rotation of the hip joints, is recommended.