Exercise for the intervertebral disc: a 6-month randomised controlled trial in chronic low back pain.

BACKGROUND CONTEXT: Muscle, bone and tendon respond anabolically to mechanical forces. Whether the intervertebral disc (IVD) can benefit from exercise is unclear. PURPOSE: To examine whether exercise can beneficially affect IVD characteristics. STUDY DESIGN/SETTING: This is a single-blinded 6-month randomised controlled trial (ACTRN12615001270505) in an exercise and physiotherapy clinic. PATIENT SAMPLE: Forty patients with chronic non-specific low back pain (NSCLBP) are included in this study. OUTCOME MEASURES: The primary outcome was lumbar IVD T2 time (MRI). Secondary outcomes included IVD diffusion coefficient and IVD expansion with short-duration lying. METHODS: Twenty patients progressively loaded their lumbar IVDs (exercise) via an exercise programme involving progressive upright aerobic and resistance exercises targeting the trunk and major muscle groups and were compared to twenty patients who performed motor control training and manual therapy (control). Testing occurred at baseline, 3 months and 6 months. RESULTS: Seventeen exercise and fifteen control patients completed the interventions. There were no group-by-time differences in T2 time of the entire IVD (exercise 94.1 ± 10.0 ms vs. control 96.5 ± 9.3 ms, p = 0.549). Exercise patients had shorter T2 time in the posterior annulus at 6 months (82.7 ± 6.8 ms vs. 85.1 ± 8.0 ms, p = 0.028). Exercise patients showed higher L5/S1 apparent diffusion coefficients and decreased IVD height at 3 months (both p ≤ 0.050). After adjustments for multiple comparisons, differences lost statistical significance. Per-protocol and intent-to-treat analyses yielded similar findings. CONCLUSIONS: This trial found that 6 months of exercise did not benefit the IVD of people with NSCLBP. Based on this index study, future studies could investigate the effect of exercise on IVD in different populations, with different types, durations and/or intensities of exercise, and using different IVD markers. These slides can be retrieved under Electronic Supplementary Material.

Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy.

BACKGROUND: An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice. PURPOSE: This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). STUDY DESIGN: Cohort Study. METHODS: Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy. RESULTS: Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%. CONCLUSION: In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. CLINICAL RELEVANCE: These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.

A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy.

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

Predictors of substantial improvement in physical function six months after lumbar surgery: is early post-operative walking important? A prospective cohort study.

BACKGROUND: Resuming walking after lumbar surgery is a common focus of early post-operative rehabilitation, however there is no knowledge about whether increased walking is associated with better functional outcomes. This study aimed to determine whether time spent walking in the week after lumbar surgery, along with co-morbidities, pre-operative pain duration, pre-operative physical activity or function, or surgical variables predict substantial improvement in physical function six months after lumbar surgery. METHODS: A prospective cohort study design was utilized. Participants undergoing lumbar surgery (discectomy, decompression, fusion) were recruited between April and November 2016. Predictor variables were collected pre-operatively (age, sex, smoking status, obesity, diabetes, depression, anxiety, pre-operative pain duration, neurological deficit, physical activity levels, mobility restriction, function) and early post-operatively (post-operative walking time, surgical procedure, single/multi-level surgery). Outcome variables (physical function, back pain and leg pain severity) were measured pre-operatively and six-months post-operatively. Logistic regression analysis was used to establish prediction of substantial improvement in outcome at six months. RESULTS: Participants (N = 233; 50% female; age 61 (SD = 14) years) who walked more in the first post-operative week were more likely to have substantially improved function on the Oswestry Disability Questionnaire at six months (OR 1.18, 95%CI 1.02-1.37), as were participants with < 12 months pre-operative pain (OR 2.71, 95%CI 1.28-5.74), and those with lower pre-operative function (OR 4.02, 95%CI 2.33-6.93). Age < 65 years (OR 2.36, 95%CI 1.14-4.85), and < 12 months pre-operative pain (OR 3.52 95%CI 1.69-7.33) predicted substantial improvement on the SF-36 Physical Component Summary. There were no significant predictors for substantial improvement in either leg or back pain. CONCLUSIONS: Walking time in the week after lumbar surgery is one of several predictors of substantial improvement in function at six months. Further research is required to determine whether intervention designed to increase walking early after lumbar surgery results in improved longer-term recovery of function. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), registration number 12616000747426 . Retrospectively registered on the 7th of June 2016.

Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy.

OBJECTIVE: To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs). DESIGN: Prospective inception cohort study. SETTING: Primary care private physiotherapy clinics in Melbourne, Australia. PARTICIPANTS: Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale. RESULTS: Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome. CONCLUSIONS: This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.

Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management.

Multidirectional instability of the shoulder is a type of glenohumeral joint shoulder instability. There are discrepancies in the definition and classification of this condition, which can make diagnosis and treatment selection challenging. Knowledge of contributing factors, the typical clinical presentation, and current best evidence for treatment options can assist in the diagnosis and appropriate treatment selection for this pathology. The purpose of this article is to present an overview of the current literature regarding the etiology, classification, assessment, and management of multidirectional instability of the glenohumeral joint.

Exercise-based management versus surgery for multidirectional instability of the glenohumeral joint: a systematic review.

BACKGROUND: The most commonly recommended treatment for multidirectional instability (MDI) is exercise-based management, followed by surgery if exercise management fails. We aimed to evaluate the effectiveness of exercise-based management compared with surgery in patients with MDI. Secondary aims were to identify effective protocols and any adverse effects associated with exercise or surgery. METHOD: The Cochrane database of systematic reviews, MEDLINE, EMBASE, CINAHL, PEDro, Current Contents, AMED, AMI, Ausport and Clinical Trials Registers were searched for published and unpublished studies from inception date to August 2014, using the key words multidirectional instability, and glenohumeral and exercise and surgery. Selection criteria included all study designs (except case reports and case series) and participants with MDI where both exercise-based management and surgery were compared in the same study. Inclusion criteria were not limited by outcomes. Risk of bias was assessed using Cochrane criteria. The GRADE approach was used to synthesise the evidence. RESULTS: 4 non-randomised studies met the inclusion criteria. Risk of bias was high in all 4 studies. GRADE assessment revealed very low-quality evidence that surgery was superior to exercise therapy for impairment outcome measures, and exercise was favoured over surgery for patient-reported outcome measures. SUMMARY: The effect of exercise-based management compared with surgery for MDI is difficult to determine due to participant heterogeneity and a high level of bias across included studies.

Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial.

BACKGROUND: Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders. METHODS: This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models. RESULTS: Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone. CONCLUSIONS: 10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant. CLINICAL TRIAL REGISTRATION: ACTRN12609000834257.

The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review.

BACKGROUND: The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise. METHODS: The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence. RESULTS: The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength. CONCLUSIONS: The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Exercise prescription variables predict reductions in pain intensity in adults with chronic low back pain: secondary analysis of a randomised controlled trial.

Objectives: The relationship between exercise training variables and clinical outcomes in low back pain (LBP) is unclear. The current study aimed to explore the relationship between exercise training parameters and pain intensity in individuals with chronic LBP. Methods: This study is a secondary analysis of a previously reported randomised controlled trial comparing the effects of general strength and conditioning to motor control exercises and manual therapy. This secondary analysis includes adults with chronic LBP (n=20) randomised to the general strength and conditioning programme only. Primary outcomes of this analysis were exercise training parameters (time under tension, rating of perceived exertion (RPE), session duration, session-RPE and training frequency) and pain intensity (0-100 mm visual analogue acale) measured every 2 weeks from baseline to 6 months follow-up. Linear mixed models with random effects (participants) and allowance for heterogeneity of variance (study date) were used to determine the association between pain intensity and training parameters over time. Results: Mean (95% CI) pain intensity decreased over time from baseline to 6 months follow-up by 10.7 (2.8 to 18.7) points (p=0.008). Over the 6-month intervention, lower pain intensity was associated with higher RPE (ß (95% CI) -27.168 (-44.265 to -10.071), p=0.002), greater time under tension (-0.029 (-0.056 to -0.001), p=0.040) and shorter session duration (1.938 (0.011 to 3.865), p=0.049). Conclusion: During 6 months of general strength and conditioning, lower pain intensity was associated with higher participant-reported training intensity, greater volume and shorter session duration. To ensure positive outcomes to exercise training, these variables should be monitored on a short-term basis. Trial registration number: ACTRN12615001270505.

DOSage of Exercise for chronic low back pain disorders (DOSE): protocol for a systematic review with dose-response network meta-analysis.

Chronic low back disorders are the leading cause of direct and indirect healthcare burden globally. Exercise training improves pain intensity, mental health and physical function. However, the optimal prescription variables are unknown. We aim to compare the efficacy of various exercise dosages for chronic low back disorders to identify the optimal prescription variables. Six databases (Medline, SPORTDiscus, CINAHL, PsycINFO, EMBASE and CENTRAL), trial registries (ClinicalTrials.gov and WHO International Clinical Trials Registry Platform) and reference lists of prior systematic reviews will be searched, and we will conduct forward and backward citation tracking. We will include peer-reviewed randomised controlled trials (individual, cluster or cross-over trials) published in English or German language comparing exercise training to other exercise training or non-exercise training interventions (conservative, non-surgical, non-pharmacological, non-invasive treatments, placebo, sham, usual/standard care, no-treatment control, waitlist control) in adults with chronic low back disorders. Outcomes will include pain intensity, disability, mental health, adverse events, adherence rate, dropout rate and work capacity. Version 2 of the Cochrane risk-of-bias tool will be employed. The dose will be categorised as cumulative dose (total and weekly minutes of exercise training) and individual dose prescription variables (intervention duration, session duration, frequency and intensity). Dose-response model-based network meta-analysis will be used to assess the comparative efficacy of different exercise doses to determine a dose-response relationship. The certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation. Information about optimal exercise training dosage will help in enhancing treatment outcomes.

Understanding how individualised physiotherapy or advice altered different elements of disability for people with low back pain using network analysis.

PURPOSE: The Oswestry Disability Index (ODI) is a common aggregate measure of disability for people with Low Back Pain (LBP). Scores on individual items and the relationship between items of the ODI may help understand the complexity of low back disorders and their response to treatment. In this study, we present a network analysis to explore how individualised physiotherapy or advice might influence individual items of the ODI, and the relationship between those items, at different time points for people with LBP. METHODS: Data from a randomised controlled trial (n = 300) comparing individualised physiotherapy versus advice for low back pain were used. A network analysis was performed at baseline, 5, 10, 26 and 52 weeks, with the 10 items of the Oswestry Disability Index modelled as continuous variables and treatment group (Individualised Physiotherapy or Advice) modelled as a dichotomous variable. A Mixed Graphical Model was used to estimate associations between variables in the network, while centrality indices (Strength, Closeness and Betweenness) were calculated to determine the importance of each variable. RESULTS: Individualised Physiotherapy was directly related to lower Sleep and Pain scores at all follow-up time points relative to advice, as well as a lower Standing score at 10-weeks, and higher Lifting and Travelling scores at 5-weeks. The strongest associations in the network were between Sitting and Travelling at weeks 5 and 26, between Walking and Standing at week 10, and between Sitting and Standing scores at week 52. ODI items with the highest centrality measures were consistently found to be Pain, Work and Social Life. CONCLUSION: This study represents the first to understand how individualised physiotherapy or advice differentially altered disability in people with LBP. Individualised Physiotherapy directly reduced Pain and Sleep more effectively than advice, which in turn may have facilitated improvements in other disability items. Through their high centrality measures, Pain may be considered as a candidate therapeutic target for optimising LBP management, while Work and Socialising may need to be addressed via intermediary improvements in lifting, standing, walking, travelling or sleep. Slower (5-week follow-up) improvements in Lifting and Travelling as an intended element of the Individualised Physiotherapy approach did not negatively impact any longer-term outcomes. TRIALS REGISTRATION: ACTRN12609000834257.

Protection motivation theory screening tool for predicting chronic low back pain rehabilitation adherence: analysis of a randomised controlled trial.

OBJECTIVE: To explore a protection motivation theory screening tool for predicting rehabilitation adherence. DESIGN: Analysis of a randomised controlled trial. SETTING: An exercise physiology and physiotherapist clinic. PARTICIPANTS: Patients with chronic low back pain (n=40). INTERVENTIONS: General strength and conditioning (GSC) compared with motor control and manual therapy. Primary and secondary outcome measures: predicting patient adherence to supervised sessions and dropout using the Sports Injury Rehabilitation Beliefs Scale, seven-item barriers checklist and Positive and Negative Affect Schedule and Sports Injury Rehabilitation Adherence Scale. RESULTS: Average attendance was 77% (motor control and manual therapy) and 60% (GSC) with eight dropouts. No Sports Injury Rehabilitation Adherence Scale values other than 5 across all three components were recorded. Treatment efficacy (p=0.019), self-efficacy (p=0.001), rehabilitation value (p=0.028) and injury severity (p=0.002) positively correlated with susceptibility (the extent of vulnerability to having health problems from not taking action). Rehabilitation value positively correlated with self-efficacy (p=0.005). Injury severity positively correlated with rehabilitation value (p=0.011). The final model for number of cancellations included rehabilitation value only and accounted for approximately 12% of variance (p=0.033). CONCLUSIONS: Perceived value of rehabilitation should be considered by clinicians in the rehabilitation setting to improve treatment adherence in patients with chronic low back pain. TRIAL REGISTRATION NUMBER: ACTRN12615001270505.

Exercise may impact on lumbar vertebrae marrow adipose tissue: Randomised controlled trial.

BACKGROUND: Animal and human cross-sectional data suggest that bone marrow adipose tissue (MAT) may respond to mechanical loads and exercise. We conducted the first randomised controlled trial of exercise on MAT modulations in humans. METHODS: Forty patients with chronic non-specific low back pain (NSCLBP) were enrolled in a six-month single-blinded randomised controlled trial (ACTRN12615001270505). Twenty patients loaded their spines via progressive upright aerobic and resistance exercises targeting major muscle groups (Exercise). Twenty patients performed non-weightbearing motor control training and manual therapy (Control). Testing occurred at baseline, 3-months (3mo) and 6-months (6mo). Lumbar vertebral fat fraction (VFF) was measured using magnetic resonance imaging axial mDixon sequences. RESULTS: When compared to baseline (percent change), lumbar vertebral fat fraction (VFF; measured using magnetic resonance imaging axial mDixon sequences) was lower in Exercise at 3mo at L2 (-3.7[6.8]%, p = 0.033) and L4 (-2.6[4.1]%, p = 0.015), but not in Control. There were no between-group effects. The effects of Exercise on VFF were sex-specific, with VFF lower in men at L2, L3, L4 at 3mo and at L1, L2, L3 and L4 at 6mo (p all ≤ 0.05), but not in women. Leg and trunk lean mass were increased at 3mo in Exercise. Changes in VFF correlated significantly with changes in total fat (ρ = 0.40) and lean (ρ = -0.41) masses, but not with lumbar BMD (ρ = -0.10) or visceral adipose tissue volume (ρ = 0.23). CONCLUSIONS: This trial provided first prospective evidence in humans that a moderate exercise intervention may modulate lumbar VFF as a surrogate measure of MAT at 3mo, yet not 6mo. The effect of exercise on MAT may be more prominent in males than females.

Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders.

BACKGROUND: Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups. METHODS/DESIGN: A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes. DISCUSSION: This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.

How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data.

PURPOSE: Individualised physiotherapy is an effective treatment for low back pain. We sought to determine how this treatment works by using randomised controlled trial data to develop a Bayesian Network model. METHODS: 300 randomised controlled trial participants (153 male, 147 female, mean age 44.1) with low back pain (of duration 6-26 weeks) received either individualised physiotherapy or advice. Variables with potential to explain how individualised physiotherapy works were included in a multivariate Bayesian Network model. Modelling incorporated the intervention period (0-10 weeks after study commencement-"early" changes) and the follow-up period (10-52 weeks after study commencement-"late" changes). Sequences of variables in the Bayesian Network showed the most common direct and indirect recovery pathways followed by participants with low back pain receiving individualised physiotherapy versus advice. RESULTS: Individualised physiotherapy directly reduced early disability in people with low back pain. Individualised physiotherapy exerted indirect effects on pain intensity, recovery expectations, sleep, fear, anxiety, and depression via its ability to facilitate early improvement in disability. Early improvement in disability, led to an early reduction in depression both directly and via more complex pathways involving fear, recovery expectations, anxiety, and pain intensity. Individualised physiotherapy had its greatest influence on early change variables (during the intervention period). CONCLUSION: Individualised physiotherapy for low back pain appears to work predominately by facilitating an early reduction in disability, which in turn leads to improvements in other biopsychosocial outcomes. The current study cannot rule out that unmeasured mechanisms (such as tissue healing or reduced inflammation) may mediate the relationship between individualised physiotherapy treatment and improvement in disability. Further data-driven analyses involving a broad range of plausible biopsychosocial variables are recommended to fully understand how treatments work for people with low back pain. TRIALS REGISTRATION: ACTRN12609000834257.

Network meta-analysis for comparative effectiveness of treatments for chronic low back pain disorders: systematic review protocol.

INTRODUCTION: Chronic low back pain disorders (CLBDs) present a substantial societal burden; however, optimal treatment remains debated. To date, pairwise and network meta-analyses have evaluated individual treatment modes, yet a comparison of a wide range of common treatments is required to evaluate their relative effectiveness. Using network meta-analysis, we aim to evaluate the effectiveness of treatments (acupuncture, education or advice, electrophysical agents, exercise, manual therapies/manipulation, massage, the McKenzie method, pharmacotherapy, psychological therapies, surgery, epidural injections, percutaneous treatments, traction, physical therapy, multidisciplinary pain management, placebo, 'usual care' and/or no treatment) on pain intensity, disability and/or mental health in patients with CLBDs. METHODS AND ANALYSIS: Six electronic databases and reference lists of 285 prior systematic reviews were searched. Eligible studies will be randomised controlled/clinical trials (including cross-over and cluster designs) that examine individual treatments or treatment combinations in adult patients with CLBDs. Studies must be published in English, German or Chinese as a full-journal publication in a peer-reviewed journal. A narrative approach will be used to synthesise and report qualitative and quantitative data, and, where feasible, network meta-analyses will be performed. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, including the network meta-analysis extension (PRISMA-NMA). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for network meta-analysis will be implemented for assessing the quality of the findings. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review of the published data. Findings will be disseminated via peer-reviewed publication. PROSPERO REGISTRATION NUMBER: PROSPERO registration number CRD42020182039.

The validity of using activity monitors to detect step count after lumbar fusion surgery.

Purpose: Measuring step count using activity monitors is an increasingly popular method of quantifying physical activity, however it is unknown whether gait irregularities or the use of gait aids affect the accuracy of these devices. This study evaluates the validity of the ActivPAL3, Fitbit Flex, and Jawbone UP Move activity monitors for measuring step count in hospital inpatients after lumbar fusion.Methods: The ActivPAL3 was tested on the thigh, the Fitbit, and the Jawbone were tested on the wrist and thigh, each monitor was tested 20 times. Validity was examined by calculating the percentage of steps detected by each monitor compared to the criterion measure of observed step count, the Standard Error of Measurement, and the Intraclass Correlation Coefficient.Results: The ActivPAL3 detected 85% (SD 27%) of observed steps. On the wrist, the Fitbit detected 24% (SD 34%) and the Jawbone detected 17% (SD 40%) of observed steps. On the thigh, the Fitbit detected 66% (SD 42%) and the Jawbone detected 22% (SD 35%) of observed steps.Conclusion: The ActivPAL3 activity monitor is a sufficiently valid tool to detect step count immediately after lumbar fusion. Wrist worn monitors are not recommended in this population, particularly with patients using gait aids.Implications for RehabilitationWalking may be quantified using activity monitoring, as both an assessment tool and as an adjunct to treatmentThe ActivPAL3 is sufficiently valid for use after lumbar fusion surgeryThe Fitbit Flex and Jawbone UP Move had low accuracy, particularly when a gait aid was used.

Physical activity patterns of patients immediately after lumbar surgery.

Purpose: To describe the physical activity patterns of patients in the first week after lumbar surgery, and to investigate factors that potentially limit walking time early after surgery.Materials and methods: Adults undergoing lumbar decompression, discectomy and/or fusion surgery (N = 216, mean age 62 years, SD 13.9) were invited to participate. Walking time and step count were recorded for the first seven post-operative days, using an ActivPAL accelerometer. Participants recorded daily pain scores, supervision requirements while walking, and any complications that prevented walking.Results: On the first post-operative day, participants spent an average of 17 min (SD 20) walking, by Day 6, participants spent an average of 53 min (SD 38) walking. Participants who reported minor post-operative complications had a significantly lower step count than those without complications (p < 0.01). A lower step count was associated with a longer time to achieve independent mobility (r= -0.60, 95% CI -0.68 to -0.50), and a longer hospital admission (r= -0.70, 95% CI -0.76 to -0.63).Conclusions: This study found that patients walk for less than an hour a day over the week after lumbar surgery. Further research is required to investigate whether intervention designed to increase walking time improves post-operative activity and longer-term patient outcome.IMPLICATIONS FOR REHABILITATIONWhile resuming walking after lumbar surgery is a common focus of early rehabilitation, little is known about how much walking patients do, or how walking impacts recovery.The findings from this study describe activity patterns early after lumbar surgery, which may be used to inform patients about normal post-operative recovery.A lower post-operative step count was associated with several patient factors, including a fusion procedure and more severe post-operative pain, which may be used to guide peri-operative care and rehabilitation protocols.

Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review.

BACKGROUND: Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach. PURPOSE: The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP. STUDY DESIGN: Systematic review METHODS: Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted. RESULTS: Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention. CONCLUSIONS: This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.