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Objectives: The objective of this study was to review and assess the methodological quality of randomized controlled trials that test physical therapy interventions for low back pain., Study Design and Setting: This is a systematic review of trials of physical therapy interventions to prevent or treat low back pain (of any duration or type) in participants of any age indexed on the Physiotherapy Evidence Database (PEDro). Existing PEDro scale ratings were used to evaluate methodological quality., Results: This review identified 2,215 trials. The majority of trials were for adults (n = 2136, 96.4%), low back pain without specific etiology (n = 1,863, 84.1%), and chronic duration (n = 947, 42.8%). The quality of trials improved over time; however, most were at risk of bias. Less than half of the trials concealed allocation to intervention (n = 813, 36.7%), used intention-to-treat principles (n = 778, 35.1%), and blinded assessors (n = 810, 36.6%), participants (n = 174, 7.9%), and therapists (n = 39, 1.8%). These findings did not vary by the type of therapy., Conclusion: Most trials that test physical therapy interventions for low back pain have methodological limitations that could bias treatment effect estimates. Greater attention to methodological features, such as allocation concealment and the reporting of intention-to-treat effects, would improve the quality of trials testing physical therapy interventions for low back pain., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Eyetracking is commonly used to investigate attentional bias. Although some studies have investigated the internal consistency of eyetracking, data are scarce on the test-retest reliability and agreement of eyetracking to investigate attentional bias. This study reports the test-retest reliability, measurement error, and internal consistency of 12 commonly used outcome measures thought to reflect the different components of attentional bias: overall attention, early attention, and late attention. Healthy participants completed a preferential-looking eyetracking task that involved the presentation of threatening (sensory words, general threat words, and affective words) and nonthreatening words. We used intraclass correlation coefficients (ICCs) to measure test-retest reliability (ICC > .70 indicates adequate reliability). The ICCs(2, 1) ranged from -.31 to .71. Reliability varied according to the outcome measure and threat word category. Sensory words had a lower mean ICC (.08) than either affective words (.32) or general threat words (.29). A longer exposure time was associated with higher test-retest reliability. All of the outcome measures, except second-run dwell time, demonstrated low measurement error (<6%). Most of the outcome measures reported high internal consistency (α > .93). Recommendations are discussed for improving the reliability of eyetracking tasks in future research.

Question: What are staff and patients' perceptions of physiotherapists working in the emergency department (ED)?, Design: Systematic review of qualitative studies., Participants: Staff working in EDs and patients presenting to the ED and managed by ED physiotherapists., Outcome Measures: Perceptions of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction, grouping (codes), and abstraction of findings., Results: Eight studies, which had sought the perceptions of 138 patients and 122 ED staff members, were included. Three main themes emerged: role of physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education, non-pharmacological pain management and activity resumption, especially through exercise therapy. Having broad knowledge to assess and treat different health conditions was seen as facilitating the work of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal communication skills. ED staff expressed concerns regarding the additional time that physiotherapists spent with patients. Some patients felt that performing exercises in the ED was inappropriate and painful., Conclusions: ED physiotherapists were mostly well accepted by patients and ED staff, and their work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira GE, Traeger AC, O'Keeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy 64: 229-236]., (Copyright © 2018 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Prognostic screening in patients with low back pain (LBP) offers a practical approach to guiding clinical decisions. Whether screening is helpful in secondary care is unclear. This prospective cohort study in adults with LBP placed on outpatient clinic waiting lists, compared the performance of the short-form Orebro Musculoskeletal Pain Screening Questionnaire, the Predicting the Inception of Chronic Pain Tool, and the STarT Back Tool. We assessed predictive validity for outcome at 4-month follow-up, by calculating estimates of discrimination, calibration, and overall performance. We applied a decision curve analysis approach to describe the clinical value of screening in this setting via comparison with a 'treat-all' strategy. Complete data were available for 89% of enrolled participants (n = 195). Eighty-four percent reported 'poor outcome' at follow-up. The area under the receiver operating characteristic curve (95% confidence interval) was .66 (.54-.78) for the Orebro Musculoskeletal Pain Screening Questionnaire, .61 (.49-.73) for the Predicting the Inception of Chronic Pain Tool, and .69 (.51-.80) for the STarT Back Tool. All instruments were miscalibrated and underestimated risk. The decision curve analysis indicated that, in this setting, prognostic screening does not add value over and above a treat-all approach. The potential for LBP patients to be misclassified using screening and the high incidence of nonrecovery indicate that care decisions should be made with the assumption that all patients are 'at risk.', Perspective: This article presents a head-to-head comparison of 3 LBP screening instruments in a secondary care setting. Early patient screening is likely to hold little clinical value in this setting and care pathways that consider all patients at risk of a poor outcome are suggested to be most appropriate., (Copyright © 2017 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Background: Statistical analysis plans increase the transparency of decisions made in the analysis of clinical trial results. The purpose of this paper is to detail the planned analyses for the PREVENT trial, a randomized, placebo-controlled trial of patient education for acute low back pain., Results: We report the pre-specified principles, methods, and procedures to be adhered to in the main analysis of the PREVENT trial data. The primary outcome analysis will be based on Mixed Models for Repeated Measures (MMRM), which can test treatment effects at specific time points, and the assumptions of this analysis are outlined. We also outline the treatment of secondary outcomes and planned sensitivity analyses. We provide decisions regarding the treatment of missing data, handling of descriptive and process measure data, and blinded review procedures., Conclusions: Making public the pre-specified statistical analysis plan for the PREVENT trial minimizes the potential for bias in the analysis of trial data, and in the interpretation and reporting of trial results., Trial Registration: ACTRN12612001180808 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808)., (Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Introduction: Reassurance is the removal of fears and concerns about illness. In practice reassurance for non-specific conditions, where a diagnosis is unclear or unavailable, is difficult and can have unexpected effects. Many clinical guidelines for non-specific conditions such as low back pain recommend reassurance. Until recently, there was little evidence on how to reassure patients effectively., Results: High distress causes patients to consult more often for low back pain. To reduce distress, clinicians should provide structured education, which is effective in the short- and long-term. A newly developed online prognostic tool has the potential to improve the quality of reassurance and reduce the number of inappropriate interventions provided for low back pain., Conclusion: Targeted reassurance, including enhanced, prognosis-specific education, could optimize reassurance and possibly prevent disabling symptoms., (Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Purpose: To determine whether emotional distress reported at the initial consultation affects subsequent healthcare use either directly or indirectly via moderating the influence of symptoms., Methods: Longitudinal observational study of 2891 participants consulting primary care for low back pain. Negative binomial regression models were constructed to estimate independent effects of emotional distress on healthcare use. Potential confounders were identified using directed acyclic graphs., Results: After the initial consultation, participants had a mean (SD) of one (1.2) visit for back pain over 3 months, and nine (14) visits for back pain over 12 months. Higher reports of anxiety during the initial consultation led to increased short-term healthcare use (IRR 1.06, 95 % CI 1.01-1.11) and higher reports of depression led to increased long-term healthcare use (IRR 1.04, 95 % CI 1.02-1.07). The effect sizes suggest that a patient with a high anxiety score (8/10) would consult 50 % more frequently over 3 months, and a person with a high depression score (8/10) would consult 30 % more frequently over 12 months, compared to a patient with equivalent pain and disability and no reported anxiety or depression., Conclusions: Emotional distress in the acute stage of low back pain increased subsequent consultation rates. Interventions that target emotional distress during the initial consultation are likely to reduce costly and potentially inappropriate future healthcare use for patients with non-specific low back pain.