Recent clinical practice guidelines for the management of low back pain: a global comparison.

BACKGROUND: Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world. METHODS: MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS: Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture. CONCLUSIONS: Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.

Identifying multi-resolution clusters of diseases in ten million patients with multimorbidity in primary care in England.

BACKGROUND: Identifying clusters of diseases may aid understanding of shared aetiology, management of co-morbidities, and the discovery of new disease associations. Our study aims to identify disease clusters using a large set of long-term conditions and comparing methods that use the co-occurrence of diseases versus methods that use the sequence of disease development in a person over time. METHODS: We use electronic health records from over ten million people with multimorbidity registered to primary care in England. First, we extract data-driven representations of 212 diseases from patient records employing (i) co-occurrence-based methods and (ii) sequence-based natural language processing methods. Second, we apply the graph-based Markov Multiscale Community Detection (MMCD) to identify clusters based on disease similarity at multiple resolutions. We evaluate the representations and clusters using a clinically curated set of 253 known disease association pairs, and qualitatively assess the interpretability of the clusters. RESULTS: Both co-occurrence and sequence-based algorithms generate interpretable disease representations, with the best performance from the skip-gram algorithm. MMCD outperforms k-means and hierarchical clustering in explaining known disease associations. We find that diseases display an almost-hierarchical structure across resolutions from closely to more loosely similar co-occurrence patterns and identify interpretable clusters corresponding to both established and novel patterns. CONCLUSIONS: Our method provides a tool for clustering diseases at different levels of resolution from co-occurrence patterns in high-dimensional electronic health records, which could be used to facilitate discovery of associations between diseases in the future.

Having multiple long-term conditions is linked to worse health, poorer quality of life, and difficulties accessing healthcare. Identifying groups, or 'clusters' of diseases that are more likely to occur together in one person may help healthcare services to better meet the needs of those with multiple conditions. Our study aims to identify clusters of similar diseases, based not only on the diseases someone has now, but on the order in which they developed them. We compare a range of methods and find that our strategy performs best at explaining diseases that are already known to be linked, whilst also identifying new clusters of diseases. These methods could be used in future to better understand how diseases occur together, which could help the design of more efficient healthcare services.

Assigning disease clusters to people: A cohort study of the implications for understanding health outcomes in people with multiple long-term conditions.

Background: Identifying clusters of co-occurring diseases may help characterise distinct phenotypes of Multiple Long-Term Conditions (MLTC). Understanding the associations of disease clusters with health-related outcomes requires a strategy to assign clusters to people, but it is unclear how the performance of strategies compare. Aims: First, to compare the performance of methods of assigning disease clusters to people at explaining mortality, emergency department attendances and hospital admissions over one year. Second, to identify the extent of variation in the associations with each outcome between and within clusters. Methods: We conducted a cohort study of primary care electronic health records in England, including adults with MLTC. Seven strategies were tested to assign patients to fifteen disease clusters representing 212 LTCs, identified from our previous work. We tested the performance of each strategy at explaining associations with the three outcomes over 1 year using logistic regression and compared to a strategy using the individual LTCs. Results: 6,286,233 patients with MLTC were included. Of the seven strategies tested, a strategy assigning the count of conditions within each cluster performed best at explaining all three outcomes but was inferior to using information on the individual LTCs. There was a larger range of effect sizes for the individual LTCs within the same cluster than there was between the clusters. Conclusion: Strategies of assigning clusters of co-occurring diseases to people were less effective at explaining health-related outcomes than a person's individual diseases. Furthermore, clusters did not represent consistent relationships of the LTCs within them, which might limit their application in clinical research.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis.

BACKGROUND: With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use. OBJECTIVE: The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches. METHODS: The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS). RESULTS: A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted. CONCLUSIONS: mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Identifying potential biases in code sequences in primary care electronic healthcare records: a retrospective cohort study of the determinants of code frequency.

OBJECTIVES: To determine whether the frequency of diagnostic codes for long-term conditions (LTCs) in primary care electronic healthcare records (EHRs) is associated with (1) disease coding incentives, (2) General Practice (GP), (3) patient sociodemographic characteristics and (4) calendar year of diagnosis. DESIGN: Retrospective cohort study. SETTING: GPs in England from 2015 to 2022 contributing to the Clinical Practice Research Datalink Aurum dataset. PARTICIPANTS: All patients registered to a GP with at least one incident LTC diagnosed between 1 January 2015 and 31 December 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of diagnostic codes for an LTC in (1) the first and (2) the second year following diagnosis, stratified by inclusion in the Quality and Outcomes Framework (QOF) financial incentive programme. RESULTS: 3 113 724 patients were included, with 7 723 365 incident LTCs. Conditions included in QOF had higher rates of annual coding than conditions not included in QOF (1.03 vs 0.32 per year, p<0.0001). There was significant variation in code frequency by GP which was not explained by patient sociodemographics. We found significant associations with patient sociodemographics, with a trend towards higher coding rates in people living in areas of higher deprivation for both QOF and non-QOF conditions. Code frequency was lower for conditions with follow-up time in 2020, associated with the onset of the COVID-19 pandemic. CONCLUSIONS: The frequency of diagnostic codes for newly diagnosed LTCs is influenced by factors including patient sociodemographics, disease inclusion in QOF, GP practice and the impact of the COVID-19 pandemic. Natural language processing or other methods using temporally ordered code sequences should account for these factors to minimise potential bias.

The impacts of social restrictions during the COVID-19 pandemic on the physical activity levels of over 50-year olds: The CHARIOT COVID-19 Rapid Response (CCRR) cohort study.

OBJECTIVES: To quantify the associations between shielding status and loneliness at the start of the COVID-19 pandemic, and physical activity (PA) levels throughout the pandemic. METHODS: Demographic, health and lifestyle characteristics of 7748 cognitively healthy adults aged >50, and living in London, were surveyed from April 2020 to March 2021. The International Physical Activity Questionnaire (IPAQ) short-form assessed PA before COVID-19 restrictions, and up to 6 times over 11 months. Linear mixed models investigated associations between shielding status and loneliness at the onset of the pandemic, with PA over time. RESULTS: Participants who felt 'often lonely' at the outset of the pandemic completed an average of 522 and 547 fewer Metabolic Equivalent of Task (MET) minutes/week during the pandemic (95% CI: -809, -236, p<0.001) (95% CI: -818, -275, p<0.001) than those who felt 'never lonely' in univariable and multivariable models adjusted for demographic factors respectively. Those who felt 'sometimes lonely' completed 112 fewer MET minutes/week (95% CI: -219, -5, p = 0.041) than those who felt 'never lonely' following adjustment for demographic factors. Participants who were shielding at the outset of the pandemic completed an average of 352 fewer MET minutes/week during the pandemic than those who were not (95% CI: -432, -273; p<0.001) in univariable models and 228 fewer MET minutes/week (95% CI: -307, -150, p<0.001) following adjustment for demographic factors. No significant associations were found after further adjustment for health and lifestyle factors. CONCLUSIONS: Those shielding or lonely at pandemic onset were likely to have completed low levels of PA during the pandemic. These associations are influenced by co-morbidities and health status.

What do we mean by 'self-management' for chronic low back pain? A narrative review.

BACKGROUND: Chronic low back pain (CLBP) is a highly prevalent musculoskeletal condition affecting 60-80% of the general population within their lifetime. Given the large numbers of people affected, self-management approaches have been introduced as a way to manage this condition with endorsement by the national institute for health and care excellence. Interventions are often termed self-management without defining either content or goals. Our study sought to determine the content, characteristics, and evidence for self-management of CLBP. METHODS: This narrative review was conducted using a systematic approach to search journal articles in English that focused on CLBP self-management. MEDLINE, EMBASE, CINAHL, and PsycINFO databases were used to identify publications with terms relating to back pain and self-management from January 2016 until January 2022. RESULTS: In total, 15 studies were found suitable for inclusion in the review. Core components of self-management strategies include exercise, education, and psychological interventions, but there was a lack of consistency with respect to content. Intervention characteristics were either under-reported or varied. Furthermore, outcome measures used to assess these self-management programmes were diverse, mainly focusing on functional disability and pain intensity. CONCLUSIONS: Inconsistencies in the content of self-management interventions, intervention characteristics, and outcome measures used for assessing self-management programmes were found across the literature. Current self-management approaches do not consider the complex biopsychosocial nature of CLBP. A consensus on the key components of self-management interventions, and how they should be evaluated, will pave the way for research to determine whether self-management can effectively manage CLBP.

Recommendations from Diabetes UK's 2022 diabetes and physical activity workshop.

AIMS: To describe the process and outputs of a workshop convened to identify key priorities for future research in the area of diabetes and physical activity and provide recommendations to researchers and research funders on how best to address them. METHODS: A 1-day research workshop was conducted, bringing together researchers, people living with diabetes, healthcare professionals, and members of staff from Diabetes UK to identify and prioritise recommendations for future research into physical activity and diabetes. RESULTS: Workshop attendees prioritised four key themes for further research: (i) better understanding of the physiology of exercise in all groups of people: in particular, what patient metabolic characteristics influence or predict the physiological response to physical activity, and the potential role of physical activity in beta cell preservation; (ii) designing physical activity interventions for maximum impact; (iii) promoting sustained physical activity across the life course; (iv) designing physical activity studies for groups with multiple long-term conditions. CONCLUSIONS: This paper outlines recommendations to address the current gaps in knowledge related to diabetes and physical activity and calls on the research community to develop applications in these areas and funders to consider how to stimulate research in these areas.

Movement Foundations. The perceived impact of a digital rehabilitation tool for returning to fitness following a period of illness, including COVID-19 infection: a qualitative study.

Digital interventions can increase physical activity (PA) levels in adults. However, the COVID-19 pandemic highlighted the complexities faced when guiding people to start or return to PA following illness or inactivity. A digital tool, Movement Foundations, was developed to provide remote guidance on building strength and capacity across functional movement patterns, with graduated progression based on user responses and input. This qualitative study aimed to explore the perceived impacts of using the tool. Nine participants aged over 35 years from the healthcare and academic healthcare sectors were recruited to use it and were subsequently interviewed. Thematic analysis identified three themes falling under the overarching concept of 'Capability, Opportunity and Motivation-Behaviour (COM-B) Plus', encompassing: skills and capacity for movement; opportunities, motivations and barriers for movement; and a personalised, safe space in which to develop. Participants felt that the digital tool increased their capacity and confidence in movement and positively impacted their daily activities. External factors such as illness and stress clouded perceptions of the impacts of PA. Time, work pressures and needing equipment were still considered significant barriers to PA. Still, participants appreciated the flexibility and non-prescriptive nature of the tool and felt that it helped movement to become opportunistic and habitual. Increased capacity for PA and feeling the subsequent physical and mental effects positively influenced motivation. Structure and guidance, with graduated progress, were seen as protective. Guided self-reflection helped participants understand their capacity and limitations with regard to movement and promoted motivation. Although acquiring technical skills to guide movement may be important for those recovering from illness, participants found that a structure promoting individualised guidance, graduated progression and guided self-reflection were important motivational factors for continuing use. Digital interventions should consider these aspects when seeking to promote habitual PA.

Creating a sport and exercise medicine undergraduate syllabus: a delphi study.

BACKGROUND: Sport and Exercise Medicine (SEM) is a growing speciality in the United Kingdom (UK). This growth has not been replicated in SEM teaching at an undergraduate level and SEM-related topics in schools of medicine in the UK are under-represented. As SEM continues to develop as a specialty it is important to consider how it is embedded at all levels of training. The aim of this project was to establish a consensus on SEM-related skills and knowledge relevant for undergraduate medical students in the UK, ultimately creating a curriculum of learning objectives (LOs). METHODS: A modified Delphi survey was utilised to seek consensus on LOs suitable for incorporation into UK medical school curricula. An expert panel with adequate knowledge in the field was recruited. The initial curriculum was created by the research team using already established postgraduate SEM curricula. All learning objectives were sent to the expert panel for opinions in phases. Levels of agreement and comments made by the expert panel were reviewed after each phase until a consensus on each learning objective was made. RESULTS: The expert panel was made up of 45 individuals, with 35 also completing phase 2 (78% retention rate). The initial curriculum contained 58 learning objectives separated into 9 themes. In phase 1 31% (18/58) were accepted outright, 48% (28/58) were altered and 19% (11/58) were rejected. Two additional learning objectives were added. Of the 49 LOs included in phase 2, 98% (48/49) were accepted. The final curriculum was made up of 9 sub-themes and 48 LOs. CONCLUSION: Sport and Exercise Medicine is a broad ranging and rapidly growing speciality. It is important to establish SEM education in all levels of medical education, including undergraduate level. This is the first published version of a Delphi SEM curriculum for undergraduate medical teaching.

UK Doctors Delivering Physical Activity Advice: What Are the Challenges and Possible Solutions? A Qualitative Study.

Despite strategies to enable Health Care Professionals (HCPs) to give physical activity (PA) advice to patients, this appears to be rarely done in consultations. The aims of the present study were to gain an understanding of doctors' awareness of current PA guidelines and to explore their opinions on barriers and solutions. A qualitative approach using semi-structured interviews was adopted. This study included 15 doctors currently working in the UK's National Health Service (NHS). A thematic analysis approach was used to analyse the transcripts. Four themes and twelve sub-themes were deciphered. Intrinsic factors limiting the delivery of PA advice included a lack of knowledge of PA guidelines and PA being an afterthought. Barriers to delivering PA guidance included a lack of PA education, time pressures, and patient engagement. Solutions included staff training, incorporating PA into undergraduate training, and encouraging staff to be physically active. Methods to optimise PA guidance included individualised PA advice, local exercise services and schemes, utilising online and visual resources, and motivational interviewing. This study provides an updated insight into doctors' opinions on barriers and solutions to discussing PA with patients. It is clear that further work is needed to ensure greater awareness of PA guidelines amongst clinicians.

Creating a Sport and Exercise Medicine Masters syllabus for doctors: a Delphi study.

Objective: Sport and Exercise Medicine (SEM) Masters curricula vary. This Delphi study is aimed to create a consensus curriculum for doctors undertaking SEM Masters courses. Methods: A modified Delphi survey was used. An expert panel was established of individuals deemed to have adequate knowledge of the field. The research group developed the initial draft of the curriculum by collating and reviewing previously published UK-based postgraduate SEM-related curricula. There were two phases. In phase 1 the expert group either accepted, rejected or modified each learning objective (LO). During phase 2 the expert group were asked to accept or reject each LO that did not get accepted outright previously. The research group analysed the levels of agreements and the comments given by the expert panel after each phase. Results: The expert panel consisted of 45 individuals, with 35 completing phase 2 (78% retention rate). Of the 136 LOs initially collated: 71 (52%) were accepted outright, 60 (44%) were altered in some way and reincluded in phase 2, and 5 (4%) were removed after phase 1. The research group added 2 (1%) new LOs on reflection over comments made by the expert panel. The final curriculum contained 133 LOs, divided into 11 subthemes. Conclusions: The findings will better inform educators when developing SEM Masters curricula and inform students what they should look for when considering an SEM Masters. This consensus curriculum is an important step in standardising postgraduate SEM education.

Health, Lifestyle, and Psycho-Social Determinants of Poor Sleep Quality During the Early Phase of the COVID-19 Pandemic: A Focus on UK Older Adults Deemed Clinically Extremely Vulnerable.

Background: Several studies have assessed the impact of COVID-19-related lockdowns on sleep quality across global populations. However, no study to date has specifically assessed at-risk populations, particularly those at highest risk of complications from coronavirus infection deemed "clinically-extremely-vulnerable-(COVID-19CEV)" (as defined by Public Health England). Methods: In this cross-sectional study, we surveyed 5,558 adults aged ≥50 years (of whom 523 met criteria for COVID-19CEV) during the first pandemic wave that resulted in a nationwide-lockdown (April-June 2020) with assessments of sleep quality (an adapted sleep scale that captured multiple sleep indices before and during the lockdown), health/medical, lifestyle, psychosocial and socio-demographic factors. We examined associations between these variables and sleep quality; and explored interactions of COVID-19CEV status with significant predictors of poor sleep, to identify potential moderating factors. Results: Thirty-seven percent of participants reported poor sleep quality which was associated with younger age, female sex and multimorbidity. Significant associations with poor sleep included health/medical factors: COVID-19CEV status, higher BMI, arthritis, pulmonary disease, and mental health disorders; and the following lifestyle and psychosocial factors: living alone, higher alcohol consumption, an unhealthy diet and higher depressive and anxiety symptoms. Moderators of the negative relationship between COVID-19CEV status and good sleep quality were marital status, loneliness, anxiety and diet. Within this subgroup, less anxious and less lonely males, as well as females with healthier diets, reported better sleep. Conclusions: Sleep quality in older adults was compromised during the sudden unprecedented nation-wide lockdown due to distinct modifiable factors. An important contribution of our study is the assessment of a "clinically-extremely-vulnerable" population and the sex differences identified within this group. Male and female older adults deemed COVID-19CEV may benefit from targeted mental health and dietary interventions, respectively. This work extends the available evidence on the notable impact of lack of social interactions during the COVID-19 pandemic on sleep, and provides recommendations toward areas for future work, including research into vulnerability factors impacting sleep disruption and COVID-19-related complications. Study results may inform tailored interventions targeted at modifiable risk factors to promote optimal sleep; additionally, providing empirical data to support health policy development in this area.

Impact of social restrictions during the COVID-19 pandemic on the physical activity levels of adults aged 50-92 years: a baseline survey of the CHARIOT COVID-19 Rapid Response prospective cohort study.

OBJECTIVES: Physical inactivity is more common in older adults, is associated with social isolation and loneliness and contributes to increased morbidity and mortality. We examined the effect of social restrictions to reduce COVID-19 transmission in the UK (lockdown), on physical activity (PA) levels of older adults and the social predictors of any change. DESIGN: Baseline analysis of a survey-based prospective cohort study. SETTING: Adults enrolled in the Cognitive Health in Ageing Register for Investigational and Observational Trials cohort from general practitioner practices in North West London were invited to participate from April to July 2020. PARTICIPANTS: 6219 cognitively healthy adults aged 50-92 years completed the survey. MAIN OUTCOME MEASURES: Self-reported PA before and after the introduction of lockdown, as measured by metabolic equivalent of task (MET) minutes. Associations of PA with demographic, lifestyle and social factors, mood and frailty. RESULTS: Mean PA was significantly lower following the introduction of lockdown from 3519 to 3185 MET min/week (p<0.001). After adjustment for confounders and prelockdown PA, lower levels of PA after the introduction of lockdown were found in those who were over 85 years old (640 (95% CI 246 to 1034) MET min/week less); were divorced or single (240 (95% CI 120 to 360) MET min/week less); living alone (277 (95% CI 152 to 402) MET min/week less); reported feeling lonely often (306 (95% CI 60 to 552) MET min/week less); and showed symptoms of depression (1007 (95% CI 612 to 1401) MET min/week less) compared with those aged 50-64 years, married, cohabiting and not reporting loneliness or depression, respectively. CONCLUSIONS AND IMPLICATIONS: Markers of social isolation, loneliness and depression were associated with lower PA following the introduction of lockdown in the UK. Targeted interventions to increase PA in these groups should be considered.

Imaging the lung: the old ways and the new.

Our understanding of lung biology can be greatly enhanced by studying embryonic and postnatal lung development, and the perturbations which occur during disease. Imaging techniques provide a unique insight into these processes. A wide variety of imaging techniques have been used to study the lungs at various stages of development and disease, ranging from histological stains to more novel techniques such as single plane illumination microscopy (SPIM), intravital microscopy (IVM), and micro-computed tomography (micro-CT). Each of these tools can be used to elicit different information about the lungs and each has its own unique advantages and disadvantages for pulmonary research. In this review we assess some of the most commonly-used and novel imaging techniques available for lung research today.