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Objective. The objective was to investigate the effectiveness of cognitive functional therapy (CFT) in the management of people with chronic nonspecific low back pain (LBP) and explore the variability in available trials to understand the factors which may affect the effectiveness of the intervention. Methods. A systematic review with meta-analyses was conducted. Four databases were searched from inception to October 12, 2023. Randomized controlled trials investigating CFT compared with any control group in patients with nonspecific LBP were included. Mean difference and 95% CIs were calculated for pain, disability, and pain self-efficacy. Certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach. Results. Seven trials were included. Low to moderate certainty of evidence was found that CFT was effective for disability at short, medium, and long term time points compared with alternate treatments, including usual care. Low to moderate certainty of evidence was found that CFT is effective for pain in the short and medium terms and probably in the long term. There was high certainty evidence CFT was effective in increasing pain self-efficacy in the medium and long terms. A single study found CFT was cost-effective compared with usual care. Variability was found in the training and implementation of CFT across the included trials, which may contribute to some heterogeneity in the results. Conclusion. The results show promise in the use of CFT as an intervention likely to effectively manage disability, pain, and self-efficacy in people with chronic nonspecific LBP The number of clinicians trained, their experience, and quality of training (including competency assessment) may be important in achieving optimal effectiveness. Impact. This is the most comprehensive review of CFT to date and included investigation of between-trial differences. CFT is a promising intervention for chronic LBP and high-quality synthesis of evidence of its effectiveness is important for its clinical application. Keywords: Low Back Pain, Cognitive Functional Therapy, Disability, Pain, Systematic Review, Introduction Low back pain (LBP) is one of the most prevalent and burdensome health conditions, and the leading cause of global disability. (1) In Australia, LBP contributes significantly to health [...]

Introduction Low back pain (LBP) commonly impacts older adults, (1) with symptoms and prognosis worsening with age, (2,3) resulting in reduced functioning and increased psychological distress. (4) Among older adults [...], Objective. The purpose of this study was to evaluate the feasibility of a randomized controlled trial investigating the effectiveness of a multimodal program (PAT-Back) compared to best practice advice on pain and disability in older adults with chronic low back pain (LBP) in primary care. Methods. This feasibility study took place in Fortaleza, Northeast Brazil. The PAT-Back intervention consisted of a program including exercises, pain education, and motivational text messages for the in-home component. The control group received an evidence-based educational booklet. Feasibility outcomes were recruitment, adherence and retention rates, level of difficulty of the education and intervention content, perception of utility of mobile technology, and adverse events. The feasibility criteria were previously defined. Results. A total of 248 people were screened, of which 46 older adults were eligible. The retention rate was high (100% in the PAT-Back group and 95% in the control group). The adherence rate to intervention was partially met (60%), whereas the adherence rate to unsupervised exercises was adequate (75%), and perception about safety to perform home exercise was partially acceptable (70%) in the PAT-Back group. In addition, 100% of older adults reported which text messages motivated them to perform the exercises in the PAT-Back group. Difficulty reported by participants in understanding and performing the intervention was small in both groups. Six participants reported transient adverse events in both groups. Conclusion. Older adults accepted both interventions. Results demonstrated that the program is feasible, although minor changes targeting adherence and safety in home exercise are needed. Impact. This feasibility study supports progression to a full trial investigating the effectiveness of a multimodal program (PAT-Back) on pain and disability in older adults with chronic LBP within a primary health care setting in low to middle income countries where such data from the older population are scarce and the burden of LBP is increasing. Keywords: Aged, Feasibility Studies, Low Back Pain, Mobile Health, Physical Exercise

Background Embedded pragmatic clinical trials (ePCTs) present a unique opportunity to study the effectiveness and implementation of health care treatments in real-world clinical settings. (1,2) These trial designs use existing [...], Objective. The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. Methods. Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. Results. Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. Conclusion. In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. Impact. These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts. Keywords: Behavior Therapy, Chronic Pain, Guideline Adherence, Low Back Pain, Models, Musculoskeletal Pain, Organizational, Pain Management, Patient Care Management, Primary Health Care, Telemedicine

Introduction Exercise is an effective guideline-based treatment for chronic low back pain (CLBP), (1) achieving similar effects on pain and disability compared to other conservative interventions. (2-4) A common justification [...], Objective. This study aimed to estimate the proportion of exercise interventions tested in clinical trials of people with chronic low back pain (CLBP) that meet the World Health Organization's (WHO) physical activity guidelines. Methods. A secondary analysis of the 2021 Cochrane review of exercise therapy for CLBP was performed. Data from each study were extracted by 1 reviewer and were checked by a second reviewer. Data extracted related to the frequency, duration and intensity of each exercise intervention, and the proportion of exercise interventions that met the WHO's physical activity guidelines (aerobic, muscle strengthening, or both) were determined. Results. The 249 included trials comprised 426 exercise interventions. Few interventions reported an exercise type and dose consistent with the WHO guidelines (aerobic: 1.6%, muscle strengthening: 5.6%, both: 1.6%). Poor reporting of exercise intensity limited our ability to determine whether interventions met the guidelines. Conclusion. Few interventions tested in clinical trials for people with CLBP prescribe an exercise type and dose consistent with the WHO guidelines. Therefore, they do not appear sufficiently dosed to achieve broader health outcomes. Future trials should investigate the effect of WHO guideline-recommended exercise interventions on patient-reported outcomes (pain and disability) as well as health-related outcomes in people with CLBP Impact. This exploratory analysis showed the lack of exercise interventions in the CLBP literature that meet the WHO's physical activity guidelines. With people in chronic pain groups, such as people with CLBP, being at higher risk for noncommunicable disease, it appears this is a key consideration for exercise practitioners when designing interventions for people with CLBP. Keywords: Aerobic, Exercise, Chronic Low Back Pain, Exercise, Physical Activity, Strengthening Exercise

Introduction Chronic low back pain after spinal surgery is defined as persisting or recurring low back pain with or without sciatica following 1 or more spine surgeries. (1,2) One in [...], Objective. Our aim was to investigate whether cognitive functional therapy (CFT) was more effective than core exercises and manual therapy (CORE-MT) in improving pain and function for patients with chronic low back pain after spinal surgery. Methods. This study was a randomized controlled superiority trial in a university hospital and a private physical therapist clinic in Santa Catarina, Brazil. Eighty participants who were 18 to 75 years old and had chronic low back pain after spinal surgery received 4 to 12 treatment sessions of CFT or CORE-MT once per week for a maximum period of 12 weeks. Primary outcomes were pain intensity (numeric pain rating scale, scored from 0 to 10) and function (Patient-Specific Functional Scale, scored from 0 to 10) after intervention. Results. We obtained primary outcome data for 75 participants (93.7%). CFT was more effective, with a large effect size, than CORE-MT in reducing pain intensity (mean difference [MD] = 2.42; 95% CI = 1.69-3.14; effect size [d] = 0.85) and improving function (MD =-2.47; 95% CI =-3.08 to-1.87; effect size = 0.95) after intervention (mean = 10.4 weeks [standard deviation = 2.17] after the beginning of treatment). The differences were maintained at 22 weeks for pain intensity (MD = 1.64; 95% CI = 0.98-2.3; effect size = 0.68) and function (MD = -2.01; 95% CI = -2.6 to -1.41; effect size = 0.81). Conclusion. CFT was more effective than CORE-MT, with large effect sizes, and may be an option for patients with chronic low back pain after spinal surgery. Impact. CFT reduces pain and improves function, with large effect sizes, compared with CORE-MT. The difference between CFT and CORE-MT was sustained at the midterm follow-up. Treatment with CFT may be an option for patients with chronic low back pain after spinal surgery. Keywords: Behavioral Interventions, Cognitive Therapy, Low Back Pain, Pain Management, Surgery

Introduction The impact of low back pain (LBP) on society and health care and its related cost is well established. (1) For decades, exercise has been studied as a potential [...], Objective. This study aimed to examine the presence of distinct trajectories of adherence to home-based exercise recommendations among people with low back pain (LBP). This study also aimed to identify differences in baseline characteristics among groups. Methods. This study was a secondary analysis of a prospective, multicenter cluster randomized controlled trial investigating the cost-effectiveness of a stratified blended physical therapist intervention compared to usual care physical therapy in patients with LBP. The intervention group received usual care with integrated support via a smartphone app. A total of 208 patients were recruited from 58 primary care physical therapist practices. Baseline data included patient characteristics, physical functioning, pain intensity, physical activity, fear avoidance, pain catastrophizing, self-efficacy, self-management ability, and health-related quality of life. The Exercise Adherence Scale (score range =0-100) was used to measure adherence during each treatment session. Latent class growth analysis was used to estimate trajectories of adherence. Results. Adherence data were available from 173 out of 208 patients (83%). Data were collected during an average of 5.1 (standard deviation [SD] =2.5) treatment sessions, with total treatment duration of 51 (SD =41.7) days. Three trajectory classes were identified: "declining adherence" (12%), "stable adherence" (45%), and "increasing adherence" (43%). No differences in baseline characteristic were found between groups. Conclusion. Three adherence trajectories to exercise recommendations were identified in patients with LBP. However, baseline characteristics cannot identify a patient's trajectory group. Impact. Despite the presence of distinct trajectories of adherence in patients with LBP, physical therapists should not attempt to place a patient in a trajectory group at the start of treatment. Instead, adherence should be closely monitored as treatment progresses and supported when required as part of an ongoing process. Keywords: Adherence, Home-Based Exercise, Low Back Pain, Physical Therapists, Trajectories

2024 APR 27 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Data detailed on failed back surgery syndrome have been presented. According to [...]

2023 NOV 11 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- A new study on lower back pain is now available. According to [...]

2023 NOV 4 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Justin Zenanko, CEO of SynerFuse[TM], announced that SynerFuse[TM] has completed enrollment in [...]

Introduction Low back pain (LBP) is a serious public health problem. It is the main cause of disability throughout the world and absenteeism from work. (1,2 )LBP is defined as [...], Objective. Although commonly prescribed, exercise therapy alone is insufficient for the treatment of low back pain (LBP). Thus, studies recommend a combination of interventions. Photobiomodulation therapy (PBMT) involving low-level laser is an effective intervention for relieving LBP; however, scientific evidence on the effects of laser therapy combined with exercise therapy is scarce and contradictory. The aim of this clinical trial is to evaluate the short-term and long-term effects of the combination of PBMT and an exercise protocol in individuals with persistent nonspecific LBP. Methods. This 2-armed, randomized, placebo-controlled trial with blinded participants, assessors, and therapists will be conducted in the outpatient physical therapy clinic of a university in Diamantina, Brazil. Participants are 90 individuals between 18 and 65 years of age with self-reported LBP. The participants will be randomly allocated to (1) a 6-week exercise program combined with active PBMT at a frequency of twice per week, totaling 12 sessions (n =45), or (2) a 6-week exercise program combined with placebo PBMT (n =45). Clinical outcomes will be measured at baseline as well as at 8 and 20 weeks and 12 months after randomization. The primary outcomes will be pain intensity and disability. The secondary outcomes will be mental health, mobility, disability, and strength of the trunk extensor muscles. Impact. The findings will help determine whether adding PBMT to a physical therapist-supervised exercise protocol is more effective than the exercise protocol alone for persistent LBP. This study has the potential to guide clinical practice toward innovative ways of providing health care. Keywords: Exercise Therapy, Laser Therapy, Low Back Pain

Introduction Chronic low back pain (cLBP) is one of the leading causes of disability around the world. (1,2) Because various biopsychosocial factors contribute to cLBP, (3) clinical guidelines recommend referral [...], Objective. Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care). Methods. This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D. Impact. The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system. Keywords: Costs and Cost Analysis, Cognitive Functional Therapy, Health Care Costs, Interdisciplinary Pain Management, Low Back Pain

Introduction Degenerative spondylolisthesis (DS) is the acquired displacement of a vertebra over the subjacent vertebra due to degenerative changes (.1,2) The etiology of DS is multifactorial, but the disorder is [...], Objective. Exercise is the mainstay of treatment in individuals with low back pain and the first-line option in degenerative spondylolisthesis (DS); however, there is still no consensus surrounding the superiority of any specific exercise program. Thus, the primary aim of this study was to compare the effectiveness of lumbar stabilization exercises and flexion exercises for pain control and improvements of disability in individuals with chronic low back pain (CLBP) and DS. Methods. A randomized controlled trial was conducted in a tertiary public hospital and included 92 individuals over the age of 50 years who were randomly allocated to lumbar stabilization exercises or flexion exercises. Participants received 6 sessions of physical therapy (monthly appointments) and were instructed to execute exercises daily at home during the 6 months of the study. The primary outcome (measured at baseline, 1 month, 3 months, and 6 months) was pain intensity (visual analog scale, 0-100 mm) and disability (Oswestry Disability Index, from 0% to 100%). Secondary outcomes were disability (Roland-Morris Disability Questionnaire, from 0 to 24 points), changes in body mass index, and flexibility (fingertip to floor, in centimeters) at baseline and 6 months, and also the total of days of analgesic use at 6-month follow-up. Results. Mean differences between groups were not significant (for lumbar pain: 0.56 [95% CI = -11.48 to 12.61]; for radicular pain: -1.23 [95% CI = -14.11 to 11.64]; for Oswestry Disability Index: -0.61 [95% CI = -6.92 to 5.69]; for Roland-Morris Disability Questionnaire: 0.53 [95% CI = -1.69 to 2.76]). Conclusion. The findings from the present study reveal that flexion exercises are not inferior to and offer a similar response to stabilization exercises for the control of pain and improvements of disability in individuals with CLBP and DS. Impact. Exercise is the mainstay of treatment in individuals with CLBP and DS; however, there is still no consensus surrounding the superiority of any specific exercise program. This study finds that flexion exercises are not inferior to and offer a similar response to stabilization exercises. Lay Summary. Exercise is the mainstay of treatment in individuals with CLBP and DS, but there is no consensus on the superiority of any specific exercise program. If you have DS, flexion exercises may provide similar effects to stabilization exercises. Keywords: Chronic Low Back Pain, Conservative Treatment, Degenerative Spondylolisthesis, Exercise, Physical Therapy, Spondylolisthesis

Introduction Low back pain (LBP) is the greatest cause of disability worldwide (1) and is associated with great societal and economic burden. (2) Its economic burden is equivalent to the [...], Objective. The authors sought to describe the protocol of a randomized controlled trial that will investigate the effects of the TEXT4myBACK self-management text message intervention compared with control in people with low back pain (LBP). Methods. A single-blind (assessor and statistician), randomized controlled trial with economic analysis and process evaluation will be conducted. A total of 304 people with non-specific LBP of less than 12 weeks will be enrolled and randomly allocated either to TEXT4myBACK intervention or control groups. The TEXT4myBACK intervention group will receive 4 semipersonalized text messages per week providing advice, motivation, and information about LBP, physical activity, sleep, mood, use of care, and medication during 12 weeks. The control group will receive 1 text message with a link to a LBP and diet online information package. Outcomes will be assessed at baseline and 3, 6, and 12 months. The primary outcome will be function assessed with the Patient-Specific Functional Scale. Secondary outcomes will include pain intensity, physical activity participation, sedentary behavior, global impression of change, health-related quality of life, and eHealth literacy. Data on demographic characteristics, smallest worthwhile change (ie, smallest function scored needed to be achieved at the end of the intervention to consider it to be worthwhile), health care utilization, and adverse events (ie, any new health issue that occurs during participation in the study) will be collected. An economic and process evaluation will also be conducted. Impact. This study will assess if a self-management text message intervention is effective and cost-effective in improving function of people with LBP. This study can inform clinical practice of a simple, scalable, and affordable intervention for managing LBP. Keywords: Low Back Pain, Mobile Health, Text Messaging

2023 JUN 24 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Investigators discuss new findings in veterans health. According to news reporting originating [...]

2023 JAN 14 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Fresh data on Musculoskeletal Diseases and Conditions - Lower Back Pain are [...]

Introduction Pregnancy-related low back pain (LBP) affects over one-half of women during pregnancy and is the leading cause for work absenteeism in this population (.1,2) Symptoms tend to persist 12 [...], Objective. More than one-half of pregnant women experience pregnancy-related low back pain (LBP). Pregnancy-related LBP greatly affects activities of daily life, and although many interventions have been proposed, the optimal treatment for pregnancy-related LBP remains unclear. The purpose of this study was to compare conservative care strategies on their efficacy and safety for women with pregnancy-related LBP through systematic review with pairwise meta-analysis and network meta-analysis. Methods. MEDLINE, Embase, the Cochrane Library, AMED, CINAHL, PEDro, PsycINFO, and ClinicalTrials.gov were searched from inception to November 2019. Randomized controlled trials and observational controlled studies were included without restriction to language, sample size, or duration of follow-up. Two independent investigators extracted the data and assessed the risk of bias. The quality of evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. Results. Twenty-three studies were included in the qualitative synthesis (18 randomized controlled trials were included in the network meta-analysis). For women with LBP during pregnancy, progressive muscle relaxation therapy (mean difference = -3.96; 95% CI = -7 . 1 9 t o -0.74; moderate-quality evidence) and Kinesio Taping (mean difference = -3.71; 95% CI = -6.55 to -0.87; low-quality evidence) reduced pain intensity (Visual Analog Scale, range = 0 to 10) compared with placebo. Moderate-quality evidence suggested that transcutaneous electrical nerve stimulation improved physical function (mean difference = -6.33; 95% CI = -10.61 to -2.05; Roland Morris Disability Questionnaire, range = 0-24) compared with placebo. Conclusion. For patients with LBP during pregnancy, progressive muscle relaxation therapy and Kinesio Taping may help to decrease pain, and transcutaneous electrical nerve stimulation may improve physical function. Impact. This review helps fill the gap in evidence regarding optimal treatment for pregnancy-related LBP. Lay Summary. If you have LBP during pregnancy, your physical therapist has evidence to support the use of progressive muscle relaxation therapy and Kinesio Taping to help decrease pain and the use of transcutaneous electrical nerve stimulation to help improve physical function. Keywords: Low Back Pain, Network Meta-Analysis, Pregnancy, Conservative Treatment

Chronic low back pain (low back pain lasting for at least 12 weeks) is one of the most common reasons for people to seek health care. (1) In Brazil, this [...], Objective. Although some studies have shown the clinical benefits of therapeutic exercise in chronic nonspecific low back pain, the effect sizes are generally small to moderate and recurrence rates are high. Transcranial direct current stimulation (tDCS) has been used to modulate pain-processing systems and motor outputs and has the potential to optimize the clinical benefits of therapeutic exercise. However, evidence for this combination is still lacking. The purpose of this protocol for a randomized clinical trial is to investigate whether the combination of tDCS and therapeutic exercise is more effective in relieving pain than therapeutic exercise alone. Methods. This 2-arm, randomized controlled clinical trial will take place at the Federal University of Piaui, Brazil. Sixty patients will be randomized into 2 groups to receive tDCS (real/sham) + exercise therapies for 12 sessions over a period of 4 weeks. Pain intensity, sensory and affective aspects of pain, physical functioning, kinesiophobia, and global perceived effect will be recorded before treatment and at 4 weeks, 3 months, and 6 months after randomization. Data will be collected by an examiner unaware of (blind to) the treatment allocation. Impact. This trial can potentially provide important information and assist in clinical decision-making on the combined use of tDCS to optimize the clinical benefits of therapeutic exercise in patients with chronic nonspecific low back pain.

Persons with low back pain (LBP) represent a significant portion of physical therapy patients, (1) and back problems represent a significant financial burden in the United States at $86 billion [...], Objective. Factors predicting physical therapy utilization for lower back pain (LBP) remain unclear, limiting the development of value-based initiatives. The purpose of this study was to identify important factors that impact the number of physical therapist visits per episode of care for US adults with nonspecific LBP. Methods. This study was a retrospective observational cohort study of a clinical dataset derived from 80 clinics of a single physical therapy provider organization. Research variables were categorized at the individual (patient) level and the organization (therapist, clinic) level. A hierarchical regression model was designed to identify factors influencing the number of physical therapist visits per episode of care. Results. Higher out-of-pocket payments per visit, receipt of "active" physical therapy, longer average visit length, earlier use of physical therapy, and sex of the therapist (male) were found to predict fewer visits per episode of care. Percent change of function, prior receipt of physical therapy by the same provider organization, self-discharge from physical therapy, level of starting function, and therapist certification were found to predict more visits. Of the variance in number of visits, 8.0% was attributable to the health care organization. Conclusions. Individual factors, such as higher out-of-pocket payment, have a significant impact on reducing visits per episode of care and should be considered when developing value-based initiatives to optimize clinical and utilization outcomes. Impact. Payers use consumer-directed healthcare to reduce costs by discouraging utilization of low value services and encouraging use of low-cost providers. LBP is a costly condition for which physical therapy is a high-value treatment. This study shows that non-need factors predict the number of physical therapy visits per episode of care for patients with nonspecific LBP. Insurance benefit plans with lower out-of-pocket payments for physical therapy and higher reimbursement for active physical therapist interventions may facilitate appropriate utilization of high-value treatment for LBP.

2022 MAY 14 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Investigators publish new report on lower back pain. According to news reporting [...]

Chronic low back pain (LBP) is one of the most common, and sometimes most challenging, conditions to treat in an orthopedic setting. Though exercise-based rehabilitation is the standard of care [...], Keywords: Analgesics, Low Back Pain, Exercise Therapy

Background. Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP). Objective. The objective was to investigate the effects [...]

Background. Provider training programs are frequently underevaluated, leading to ambiguity surrounding effective intervention components. Objective. The purpose of this study was to assess the effectiveness of a training program in [...]

Fibromyalgia, osteoarthritis, and low back pain require multimodal, evidence-based treatment plans. Tailoring those plans to the underlying mechanisms of pain is key CASE 1 * Lola A is a 28-year-old [...]

Chronic low back pain (CLBP) is a common condition that frequently causes considerable distress and disability. (1) Many common interventions for CLBP, based on the premise that structural or anatomical [...], Background. Cognitive functional therapy (CFT) has been shown to reduce pain and disability in people with chronic low back pain. Objectives. The purpose of this study was to investigate participants' experience of CFT by comparing participants who reported differing levels of improvement after participation in CFT, potentially yielding insight into the implementation of this approach. Design. This was a noninterventional, cross-sectional, qualitative study with an interpretive description framework. Methods. Individuals who had participated in CFT in 2 physical therapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes postintervention (n = 9), and theoretical sampling (n = 5). This sampling strategy was used to capture a range of participant experiences but was not used to define the final qualitative groupings. Semistructured interviews were conducted 3 to 6 months postintervention. Results. Three groups emerged from the qualitative analysis: large improvers, small improvers, and unchanged. Two themes encapsulating the key requirements in achieving a successful outcome through CFT were identified: (1) changing pain beliefs and (2) achieving independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness, and the experience of control over pain. Independence was achieved by large improvers through newly cultivated problem-solving skills, self-efficacy, decreased fear of pain, and improved stress coping. Residual fear and poor stress coping meant that small improvers were easily distressed and lacked independence. Those who were unchanged continued to feel defined by their pain and retained a biomedical perspective. Conclusions. A successful outcome after CFT is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small improvers may require ongoing support to maintain results. Further study is needed to elucidate the optimal approach for those who were unchanged.

Implementation fidelity has been defined as 'the degree to which an intervention, treatment, or program is implemented as intended' (1(p795)) and helps to increase scientific confidence that changes in study [...], Background. Implementation fidelity is poorly addressed within physical therapy interventions, which may be due to limited research on how to develop and implement an implementation fidelity protocol. Objective. The purpose of this study was to develop a feasible implementation fidelity protocol within a pilot study of a physical therapy-led intervention to promote self-management for people with chronic low back pain or osteoarthritis. Design. A 2-phase mixed-methods design was used. Methods. Phase 1 involved the development of an initial implementation fidelity protocol using qualitative interviews with potential stakeholders to explore the acceptability of proposed strategies to enhance and assess implementation fidelity. Phase 2 involved testing and refining the initial implementation fidelity protocol to develop a finalized implementation fidelity protocol. Specifically, the feasibility of 3 different strategies (physical therapist self-report checklists, independently rated direct observations, and audio-recorded observations) for assessing implementation fidelity of intervention delivery was tested, followed by additional stakeholder interviews that explored the overall feasibility of the implementation fidelity protocol. Results. Phase 1 interviews determined the proposed implementation fidelity strategies to be acceptable to stakeholders. Phase 2 showed that independently rated audio recordings (n=6) and provider self-report checklists (n= 12) were easier to implement than independently rated direct observations (n= 12) for assessing implementation fidelity of intervention delivery. Good agreement (79.8%-92.8%) was found among all methods. Qualitative stakeholder interviews confirmed the acceptability, practicality, and implementation of the implementation fidelity protocol. Limitations. The reliability and validity of assessment checklists used in this study have yet to be fully tested, and blinding of independent raters was not possible. Conclusions. A feasible implementation fidelity protocol was developed based on a 2-phase development process involving intervention stakeholders. This study provides valuable information on the feasibility of rigorously addressing implementation fidelity within physical therapy interventions and provides recommendations for researchers wanting to address implementation fidelity in similar areas.

Despite the plethora of research on low back pain (LBP), clinical trials have not provided conclusive evidence supporting the superiority of any particular intervention. (1,2) This gap is often attributed [...], The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent--new or recurrent--LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

The cause of low back pain (LBP) cannot be definitively identified in the majority of cases, and as such the label 'nonspecific low back pain' (NSLBP) is widely used. (1-3) [...], Background. 'Mechanical Diagnosis and Therapy' (MDT) (also known as the McKenzie method), like other interventions for low back pain (LBP), has been found to have small effects for people with LBP. It is possible that a group of patients respond best to MDT and have larger effects. Identification of patients who respond best to MDT compared with other interventions would be an important finding. Objective. The purpose of the study was to investigate whether baseline characteristics of patients with chronic LBP, already classified as derangement syndrome, can identify those who respond better to MDT compared with Back School. Methods. This study was a secondary analysis of data from a previous trial comparing MDT with Back School in 148 patients with chronic LBP. Only patients classified at baseline assessment as being in the directional preference group (n=140) were included. The effect modifiers tested were: clear centralization versus directional preference only, baseline pain location, baseline pain intensity, and age. The primary outcome measures for this study were pain intensity and disability at the end of treatment (1 month). Treatment effect modification was evaluated by assessing the group versus predictor interaction terms from linear regression models. Interactions ≥ 1.0 for pain and [greater than or equal to] 3 for disability were considered clinically important. Results. Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment. Limitations. The sample (n = 140) was powered to detect the main effects of treatment but not to detect the interactions of the potential treatment effect modifiers. Conclusions. The results of the study suggest older age may be an important factor that can be considered as a treatment effect modifier for patients with chronic LBP receiving MDT. As the main trial was not powered for the investigation of subgroups, the results of this secondary analysis have to be interpreted cautiously, and replication is needed.

People with musculoskeletal low back pain represent a significant portion of patients receiving physical therapy, (1) and back problems are the sixth most costly health condition in the United States [...], Background. Physical therapy decreases low back pain, improves function, and may lead to decreased use of medical services. However, factors predicting physical therapy utilization for patients with low back pain are not well understood. Objectives. The purpose of this study was to identify the impact of out-of-pocket expenditure on physical therapy utilization for US adults with nonspecific low back pain. Design. This study was a secondary analysis of retrospective Medical Expenditure Panel Survey data. Methods. The participants were US adults with nonspecific low back pain. The outcome variable was the number of visits per episode of care. The research variable was out-of-pocket expenditure. Covariate variables were Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) component scores. Descriptive statistics and multiple linear regression analyses were performed. Results. Three hundred fourteen adults met the inclusion criteria and submitted SF-12 scores, representing nearly 4 million adults. Out-of-pocket expenditure, physical component score, and the age-insurance category '18-64 years with public coverage only for all of the year or uninsured all of the year' negatively predicted visits per episode of care in the final regression model. Limitations. Limitations of the study included use of a nonexperimental design, lack of information about symptom severity and content of physical therapy, and SF-12 scores were not taken coincidental with the episode of care. Conclusions. Out-of-pocket expenditure negatively predicts physical therapy utilization. More research is needed to identify all factors influencing physical therapy utilization so that effective health policies may be developed.

Since its beginning in 1965, Medicaid has grown to become the largest single source of health care coverage in the United States, providing insurance to more than 66 million Americans. [...], Background. Medicaid insures an increasing proportion of adults in the United States. Physical therapy use for low back pain (LBP) in this population has not been described. Objective. The study objectives were: (1) to examine physical therapy use by Medicaid enrollees with new LBP consultations and (2) to evaluate associations with future health care use and LBP-related costs. Design. The study was designed as a retrospective evaluation of claims data. Methods. A total of 2,289 patients with new LBP consultations were identified during 2012 (mean age=39.3 years [SD= 11.9]; 68.2% women). The settings in which the patients entered care and comorbid conditions were identified. Data obtained at 1 year after entry were examined, and physical therapy use was categorized with regard to entry setting, early use (within 14 days of entry), or delayed use (>14 days after entry). The 1-year follow-up period was evaluated for use outcomes (imaging, injection, surgery, and emergency department visit) and LBP-related costs. Variables associated with physical therapy use and cost outcomes were evaluated with multivariate models. Results. Physical therapy was used by 457 patients (20.0%); 75 (3.3%) entered care in physical therapy, 89 (3 9%) received early physical therapy, and 298 (13.0%) received delayed physical therapy. Physical therapy was more common with chronic pain or obesity comorbidities and less likely with substance use disorders. Entering care in the emergency department decreased the likelihood of physical therapy. Entering care in physical medicine increased the likelihood. Relative to primary care entry, physical therapy entry was associated with lower 1-year costs. Limitations. A single state was studied. No patient-reported outcomes were included. Conclusions. Physical therapy was used often by Medicaid enrollees with LBP. High rates of comorbidities were evident and associated with physical therapy use. Although few patients entered care in physical therapy, this pattern may be useful for managing costs.

Chronic low back pain (CLBP) has reached epidemic proportions. (12) The 1-year prevalence of an episode of low back pain (LBP) is 38% in the general population. (2) Low back [...], Background. Low back pain (LBP) is an important health problem in all developed countries and is associated with high levels of disability. Evidence-based clinical practice guidelines usually recommend different physical therapy interventions to manage this condition. However, those interventions usually result in small to moderate clinical effects. Recent studies suggest that interventions based on subgroup classifications may improve the effect sizes compared with rehabilitation programs where the same interventions were applied to all patients. Objective. This study will investigate the efficacy of treatment based on a Movement System Impairment (MSI)-based classification model for patients with chronic LBP compared with general exercise. The primary outcomes will be pain intensity and disability at 2 months after randomization. Design. The study is a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor. Setting. The study setting will be a university physical therapy clinic in Brazil. Participants. A total of 148 individuals with chronic LBP will participate in the study. Intervention. Included individuals will be randomly allocated to participate in an 8-week treatment program based on the MSI-based classification or a general exercise program of stretching and strengthening exercises. Measurements. Pain intensity, disability, and global impression of recovery will be assessed by a blinded assessor at baseline and at follow-up appointments after treatment (2 months) and 4 and 6 months after randomization. Limitations. Therapists will not be blinded. Conclusions. The results of this study may contribute to a better understanding of the efficacy of treatments based on classification of participants with chronic LBP into subgroups.

Low back pain (LBP) in pregnancy with or without pelvic girdle pain (henceforth referred to as pregnancy-related LBP) occurs commonly. Although prevalence estimates vary owing to different definitions and diagnostic [...], Background. Low back pain is often accepted as a "normal" part of pregnancy. Despite research suggesting that quality of life for women who are pregnant is adversely affected, most are advised to self-manage. Although the use of acupuncture for the management of persistent nonspecific low back pain has been recommended in recent UK national guidelines, its use in the management of pregnancy-related low back pain remains limited. Objectives. This study aimed to explore the perceptions and experiences of physical therapists involved in treating women who are pregnant and have low back pain with the objective of informing the pretrial training program for a pilot randomized trial (Evaluating Acupuncture and Standard care for pregnant wornEn with Back pain [EASE Back]). Design. A qualitative phenomenological method with purposive sampling was used in the study. Methods. Three focus groups and 3 individual semistructured interviews were undertaken, and an iterative exploratory thematic analysis was performed. To ensure transparency of the research process and the decisions made, an audit trail was created. Results. Twenty-one physical therapists participated, and emergent issues included: a lack of experience in treating pregnancy-related complaints, mixed messages from previous acupuncture education, a mistrust of the current evidence for acupuncture safety and effectiveness, and personal and professional fear of causing harm. Conclusions. The findings suggest that UK physical therapists are reluctant to use acupuncture in the management of pregnancy-related low back pain. The explanations for these findings include perceived lack of knowledge and confidence, as well as a pervasive professional culture of caution, particularly fears of inducing early labor and of litigation. These findings have been key to informing the content of the training program for physical therapists delivering acupuncture within the pilot EASE Back trial.

Stratified care approaches for low back pain (LBP) management are appealing because they involve targeting treatment to subgroups of patients based on key characteristics (eg, psychological factors). (1) Recently, Hill [...], Background. The effectiveness of risk stratification for low back pain (LBP) management has not been demonstrated in outpatient physical therapy settings. Objective. The purposes of this study were: (1) to assess implementation of a stratified care approach for LBP management by evaluating short-term treatment effects and (2) to determine feasibility of conducting a larger-scale study. Design. This was a 2-phase, preliminary study. Methods. In phase 1, clinicians were randomly assigned to receive standard (n=6) or stratified care (n=6) training. Stratified care training included 8 hours of content focusing on psychologically informed practice. Changes in LBP attitudes and beliefs were assessed using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). In phase 2, clinicians receiving the stratified care training were instructed to incorporate those strategies in their practice and 4-week patient outcomes were collected using a numerical pain rating scale (NPRS), and the Oswestry Disability Index (ODI). Study feasibility was assessed to identify potential barriers for completion of a larger-scale study. Results. In phase 1, minimal changes were observed for PABS-PT and HC-PAIRS scores for standard care clinicians (Cohen d = 0.00-0.28). Decreased biomedical (-4.5 ± 2.5 points, d = 1.08) and increased biopsychosocial (+5.5 ± 2.0 points, d = 2.86) treatment orientations were observed for stratified care clinicians, with these changes sustained 6 months later on the PABS-PT. In phase 2, patients receiving stratified care (n=67) had greater between-group improvements in NPRS (0.8 points; 95% confidence interval = 0.1, 1.5; d = 0.40) and ODI (8.9% points; 95% confidence interval=4.1, 13.6; d = 0.76) scores compared with patients receiving standard physical therapy care (n = 33). Limitations. In phase 2, treatment was not randomly assigned, and therapist adherence to treatment recommendations was not monitored. This study was not adequately powered to conduct subgroup analyses. Conclusions. In physical therapy settings, biomedical orientation can be modified, and risk-stratified care for LBP can be effectively implemented. Findings from this study can be used for planning of larger studies.

Nonspecific or common low back pain (LBP) is defined as pain that is located between the costal margins and the inferior gluteal folds and that is not related to fracture, [...], Background. The Godelieve Denys-Struyf method (GDS) is a motor learning intervention that may be applied in group or individualized sessions. Objective. The study objective was to compare the effectiveness of routine physical therapy, group GDS (GDS-G) sessions, and group and individualized GDS (GDS-I) sessions. Design. This was a cluster randomized controlled trial. Setting. The study took place in 21 primary care physical therapy units ('clusters') of the Spanish National Health Service (SNHS). Participants. The participants were 461 people with subacute and chronic low back pain (LBP). Intervention. Clusters were randomized into 3 groups. All participants received medical treatment and a 13-minute group education session on active management. Additional interventions were as follows: control (fifteen 40-minute sessions of transcutaneous electrical nerve stimulation, microwave treatment, and standardized exercises), GDS-G (eleven 50-minute group GDS sessions), and GDS-I (the same 11 sessions plus four 50-minute individualized GDS sessions). Measurements. Primary outcomes at baseline and 2, 6, and 12 months later were LBP and pain referred down the leg (separate pain intensity numeric rating scales) and disability (Roland-Morris Questionnaire [RMQ]). Secondary outcomes were use of medication and self-reported health (mental and physical component summaries of the 12-Item Short-Form Health Survey [SF-12]). Separate linear mixed models for LBP, pain referred down the leg, and disability were developed to adjust for potential confounders. Randomization, outcome assessment, and data analyses were masked. Results. At 12 months, disability improved 0.7 (95% confidence interval [Cl] = -0.4, 1.8) RMQ point in the control group, 1.5 (95% CI=0.4, 2.7) RMQ points in the GDS-I group, and 2.2 (95% a=1.2, 3-2) RMQ points in the GDS-G group. There were no differences in pain. Limitations. The amount of exercise was smaller in the control group, and GDS-I sessions were provided by junior physical therapists. Conclusions. The improvement in disability was slightly higher with group GDS sessions than with the program routinely used in clusters within the SNHS. Adding individualized GDS sessions eliminated this advantage. Further studies should compare the GDS with other types of exercise.

Low back pain is a major health condition associated with a high rate of absenteeism from work and a more frequent use of health services and work leave entitlements. (1) [...], Background. The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain. Objective. The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain. Design. An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted. Setting. This study will be conducted in physical therapy clinics in Sao Paulo, Brazil. Participants. The participants will be 148 patients seeking care for chronic nonspecific low back pain. Intervention. Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks). Measurements. The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor. Limitations. Therapists will not be blinded. Conclusions. This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.

Chronic low back pain is a common, disabling, and costly condition, and advanced practice registered nurses (APRNs) must carefully evaluate patients before considering long-term opioid therapy as a management strategy. [...]

Randomized controlled trials and systematic reviews evaluating the effectiveness of interventions for patients with chronic, nonspecific low back pain (LBP) typically demonstrate small treatment effects. (1-2) It has been proposed [...], Background. Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions. Objective. The aim of this study was to identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity. Design. This study was a secondary analysis of the results of a randomized controlled trial. Methods. One hundred seventy-two patients with chronic low back pain were enrolled in the trial, which was conducted in Australian physical therapy clinics. The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization. The putative effect modifiers (psychosocial features, physical activity level, walking tolerance, and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0-10 scale) were taken at baseline and at 2, 6, and 12 months by a blinded assessor. Results. Self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12-month function (interaction: 2.72; 95% confidence interval=1.39 to 4.06). Participants with high scores on the clinical instability questionnaire (5:9) did 0.76 points better with motor control exercises, whereas those who had low scores ( Limitations. The psychometric properties of the instability questionnaire have not been fully tested. Conclusions. A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercises or graded activity.

Clinical practice guidelines are considered useful tools for quality improvement. (1) However, successful implementation is necessary to decrease the gap between research and current practice and to reduce costs and [...], Background. Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. Objective. The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). Design. A cluster randomized controlled trial was conducted. Setting and Participants. Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). Intervention. Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. Measurements. Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0-100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20-100). Results. Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3-9 to 13.4). No group differences were found on self-reflection. Limitations. The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. Conclusions. Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.

Worldwide, low back pain (LBP) is a costly and prevalent condition that can lead to substantial morbidity, high levels of disability, and decreased quality of life. Lifetime, annual, and point [...], Background. Numerous clinical practice guidelines (CPGs) have been developed to assist clinicians in care options for low back pain (LBP). Knowledge of CPGs has been marginal across health-related professions. Objective. The aims of this study were: (1) to measure US-based physical therapists' knowledge of care recommendations associated with multidisciplinary LBP CPGs and (2) to determine which characteristics were associated with more correct responses. Design. A cross-sectional survey was conducted. Methods. Consenting participants attending manual therapy education seminars read a clinical vignette describing a patient with LBP and were asked clinical decisionmaking questions regarding care, education, and potential referral. Descriptive statistics illustrating response accuracy and binary logistic regression determined adjusted associations between predictor variables and appropriate decisions. Results. A total of 1,144 of 3,932 surveys were eligible for analysis. Correct responses were 55.9% for imaging, 54.7% for appropriate medication, 62.0% for advice to stay active, 92.7% for appropriate referral with failed care, and 16.6% for correctly answering all 4 questions. After adjustment, practicing in an outpatient facility was significantly associated with a correct decision on imaging. Female participants were more likely than male participants to correctly select proper medications, refer the patient to another health care professional when appropriate, and answer all 4 questions correctly. Participants reporting caseloads of greater than 50% of patients with LBP were more likely to select proper medications, give advice to stay active, and answer all 4 questions correctly. Participants attending more continuing education were more likely to give advice to stay active and older, and more experienced participants were more likely to appropriately refer after failed care. Limitations. There was potential selection bias, which limits generalizability. Conclusions. The survey identified varied understanding of CPGs when making decisions that were similar in recommendation to the CPGs. No single predictor for correct responses for LBP CPGs was found.

Chronic low back pain (CLBP) is defined as back pain of more than 12 weeks' duration between the lower ribs and above the gluteal folds, with or without leg pain. [...], Background. Pilates exercise is recommended for people with chronic low back pain (CLBP). In the literature, however, Pilates exercise is described and applied differently to treat people with CLBP. These differences in the definition and application of Pilates exercise make it difficult to evaluate its effectiveness. Objective. The aim of this study was to establish consensus regarding the definition and application of Pilates exercise to treat people with CLBP. Methods. A panel of Australian physical therapists who are experienced in treating people with CLBP using Pilates exercise were surveyed using the Delphi technique. Three electronic questionnaires were used to collect the respondents' opinions. Answers to open-ended questions were analyzed thematically, combined with systematic literature review findings, and translated into statements about Pilates exercise for people with CLBP. Participants then rated their level of agreement with these statements using a 6-point Likert scale. Consensus was achieved when 70% of the panel members strongly agreed, agreed, or somewhat agreed (or strongly disagreed, disagreed, or somewhat disagreed) with an item. Results. Thirty physical therapists completed all 3 questionnaires and reached consensus on the majority of items. Participants agreed that Pilates exercise requires body awareness, breathing, movement control, posture, and education. It was recommended that people with CLBP should undertake supervised sessions for 30 to 60 minutes, twice per week, for 3 to 6 months. Participants also suggested that people with CLBP would benefit from individualized assessment and exercise prescription, supervision and functional integration of exercises, and use of specialized equipment. Limitations. Item consensus does not guarantee the accuracy of findings. This survey reflects the opinion of only 30 physical therapists and requires validation in future trials. Conclusion. These findings contribute to a better understanding of Pilates exercise and how it is utilized by physical therapists to treat people with CLBP. This information provides direction for future research into Pilates exercise, but findings need to be interpreted within the context of study limitations.

Chronic low back pain (CLBP) is common, affecting approximately 23% of people in their lifetime. (1-3) This condition leads to significant disability and is associated with a large socioeconomic burden. [...], Background. The effectiveness of Pilates exercise for treating people with chronic low back pain (CLBP) is yet to be established. Understanding how to identify people with CLBP who may benefit, or not benefit, from Pilates exercise and the benefits and risks of Pilates exercise will assist in trial design. Objectives. The purpose of this study was to establish a consensus regarding the indications, contraindications, and precautions of Pilates exercise and the potential benefits and risks of Pilates exercise for people with CLBP. Methods. A panel of 30 Australian physical therapists experienced in the use of Pilates exercise were surveyed using the Delphi technique. Three electronic questionnaires were used to collect participant opinions. Answers to open-ended questions were analyzed thematically, combined with research findings, and translated into statements about Pilates exercise. Participants then rated their level of agreement with statements using a 6-point Likert scale. Consensus was achieved when 70% of panel members agreed or disagreed with an item. Results. Thirty physical therapists completed the 3 questionnaires. Consensus was reached on 100% of items related to the benefits, indications, and precautions of Pilates exercise, on 50% of items related to risks, and on 56% of items related to contraindications. Participants agreed that people who have poor body awareness and maladaptive movement patterns may benefit from Pilates exercise, whereas those with pre-eclampsia, unstable spondylolisthesis, or a fracture may not benefit. Participants also agreed that Pilates exercise may improve functional ability, movement confidence, body awareness, posture, and movement control. Limitations. The findings reflect the opinions of only 30 Australian physical therapists and not all health professionals nationally or internationally. These findings, therefore, need to be verified in future research trials. Conclusions. These findings contribute to a better understanding of the indications, contraindications, and precautions of Pilates exercise and the benefits and risks of Pilates exercise for people with CLBP. This information can assist in design of future trials examining the effectiveness of Pilates exercise.

Nonspecific low back pain (LBP) is defined as pain, muscle tension, or stiffness localized below the costal margin of the back and above the inferior gluteal folds, with or without [...], Background. Physical therapy influences chronic pain by means of the specific ingredient of an intervention as well as contextual factors including the setting and therapeutic alliance (TA) between provider and patient. Objective. The purpose of this study was to compare the effect of enhanced versus limited TA on pain intensity and muscle pain sensitivity in patients with chronic low back pain (CLBP) receiving either active or sham interferential current therapy (IFC). Design. An experimental controlled study with repeated measures was conducted. Participants were randomly divided into 4 groups: (1) AL (n=30), which included the application of active IFC combined with a limited TA; (2) SL (n=29), which received sham IFC combined with a limited TA; (3) AE (n=29), which received active IFC combined with an enhanced TA; and (4) SE (n=29), which received sham IFC combined with an enhanced TA. Methods. One hundred seventeen individuals with CLBP received a single session of active or sham IFC. Measurements included pain intensity as assessed with a numerical rating scale (PI-NRS) and muscle pain sensitivity as assessed via pressure pain threshold (PPT). Results. Mean differences on the PI-NRS were 1.83 cm (93% CI = 14.3-20.3), 1.03 cm (95% 0=6.6-12.7), 3-13 cm (95% 0=27.2-33.3), and 2.22 cm (95% 0=18.9-25.0) for the AL, SL, AE, and SE groups, respectively. Mean differences on PPTs were 1.2 kg (95% CI = 0.7-1.6), 0.3 kg (95% CI=0.2-0.8), 2.0 kg (95% 0=1.62.5), and 1.7 kg (95% 0=1.3-2.1), for the AL, SL, AE, and SE groups, respectively. Limitations. The study protocol aimed to test the immediate effect of the TA within a clinical laboratory setting. Conclusions. The context in which physical therapy interventions are offered has the potential to dramatically improve therapeutic effects. Enhanced TA combined with active IFC appears to lead to clinically meaningful improvements in outcomes when treating patients with CLBP.