Swimming for low back pain: A scoping review.

BACKGROUND: Guidelines recommend exercise for treatment of chronic low back pain and prevention, but the amount and quality of evidence for different exercise modes is highly variable. Swimming is commonly recommended by health professionals, but the extent and quality of research supporting its relationship with back pain is not clear. OBJECTIVES: The aim of this scoping review was to map the extent, characteristics and findings of research investigating the relationship between swimming and low back pain. DESIGN: Scoping review. METHOD: Four electronic databases (MEDLINE, EMBASE, CINAHL, and SPORT Discus) were searched from inception to February 2023. We included primary studies and reviews that reported an association between swimming and low back pain. Hydrotherapy studies were excluded. RESULTS: 3093 articles were identified, and 44 studies included. Only one randomised controlled trial and one longitudinal cohort study were included. Most studies were cross-sectional (37/44; 84.1%), included competitive athletes (23/39; 59.0%), and did not primarily focus on the association between swimming and low back pain in the aims (41/44; 93.2%). Instead, most data available were largely incidentally collected or a secondary outcome. The reported associations between swimming and low back pain were highly variable regardless of whether the comparison was to other sports (odds ratio: 0.17 to 17.92) or no sport (odds ratio: 0.54 to 3.01). CONCLUSION: Most available literature investigating swimming and low back pain is cross-sectional in design. We did not identify any clear pattern of association between swimming and low back pain, based on the available literature.

Reducing use of seclusion on a male medium secure forensic ward.

The reduction of restrictive practices is a priority for mental health inpatient services. Often such practices are considered to increase patients' feelings of anger, loneliness, hopelessness and vulnerability. Moreover, such approaches are counterintuitive to both recovery-orientated and trauma-informed practice.Our project, based in a male 15-bed secure forensic ward, aimed to reduce the duration (outcome measure) and frequency (balancing measure) of the use of seclusion by 10% over 6 months. Following the analysis of our local data systems and feedback from both patients and staff, we identified the high levels of use of seclusion, and reluctance to terminate it. These included a lack of awareness of the effective and appropriate use of such a facility, a hesitancy to use de-escalation techniques and an over-reliance on multidisciplinary team and consultant decision making.We subsequently designed and implemented three tests of change which reviewed seclusion processes, enhanced de-escalation skills and improved decision making. Our tests of change were applied over a 6-month period. During this period, we surpassed our original target of a reduction of frequency and duration by 10% and achieved a 33% reduction overall. Patients reported feeling safer on the ward, and the team reported improvements in relationships with patients.Our project highlights the importance of relational security within the secure setting and provides a template for other wards wishing to reduce the frequency and duration of seclusions.

Development of low back pain curriculum content standards for entry-level clinical training.

BACKGROUND: The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs. METHODS: The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group. RESULTS: Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described. CONCLUSION: We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

Identification and characterization of calreticulin as a novel plasminogen receptor.

Calreticulin (CRT) was originally identified as a key calcium-binding protein of the endoplasmic reticulum. Subsequently, CRT was shown to possess multiple intracellular functions, including roles in calcium homeostasis and protein folding. Recently, several extracellular functions have been identified for CRT, including roles in cancer cell invasion and phagocytosis of apoptotic and cancer cells by macrophages. In the current report, we uncover a novel function for extracellular CRT and report that CRT functions as a plasminogen-binding receptor that regulates the conversion of plasminogen to plasmin. We show that human recombinant or bovine tissue-derived CRT dramatically stimulated the conversion of plasminogen to plasmin by tissue plasminogen activator or urokinase-type plasminogen activator. Surface plasmon resonance analysis revealed that CRT-bound plasminogen (KD = 1.8 µM) with moderate affinity. Plasminogen binding and activation by CRT were inhibited by ε-aminocaproic acid, suggesting that an internal lysine residue of CRT interacts with plasminogen. We subsequently show that clinically relevant CRT variants (lacking four or eight lysines in carboxyl-terminal region) exhibited decreased plasminogen activation. Furthermore, CRT-deficient fibroblasts generated 90% less plasmin and CRT-depleted MDA MB 231 cells also demonstrated a significant reduction in plasmin generation. Moreover, treatment of fibroblasts with mitoxantrone dramatically stimulated plasmin generation by WT but not CRT-deficient fibroblasts. Our results suggest that CRT is an important cellular plasminogen regulatory protein. Given that CRT can empower cells with plasmin proteolytic activity, this discovery may provide new mechanistic insight into the established role of CRT in cancer.

How Movement Is Assessed Matters. Changes in Forward Bending During Cognitive Functional Therapy Treatment for People With Chronic Low Back Pain.

OBJECTIVE: To investigate forward bending range of motion (ROM) and velocity in patients with low back pain who were receiving Cognitive Functional Therapy and determine (1) the amount and timing of change occurring at the trunk and pelvis (global angles), and lumbar spine (intersensor angle), and (2a) differences in changes between participants with and without sensor biofeedback, and (2b) participants with and without baseline movement limitation. DESIGN: Observational study. METHODS: Two hundred sixty-one participants attended Cognitive Functional Therapy treatment and wore sensors at the T12 and S2 spine levels while performing forward bending. Measures included ROM and velocity from both sensors, and the intersensor angle. Regression models estimated changes over time. Time-group interactions tested participants who were subgrouped by treatment and baseline movement. RESULTS: During the 90-day evaluation period, most change occurred in the first 21 days. Changes in ROM observed at T12 (3.3°, 95% CI: 1.0°, 5.5°; P = .001) and S2 (3.3°, 95% CI: 1.2°, 5.4°; P = .002) were similar. Intersensor angle remained similar (0.2°, 95% CI: -2.0°, -1.6°; P = .81). Velocity measured at T12 and S2, and the intersensor angle increased 8.5°/s (95% CI: 6.7°/s, 10.3°/s; P<.0001), 5.3°/s (95% CI: 4.0°/s, 6.5°/s; P<.0001), and 3.4°/s (95% CI: 2.4°/s, 4.5°/s; P<.0001), respectively, for 0 to 21 days. There were minimal differences in participants who received biofeedback. Larger increases occurred in participants with restricted ROM and slower velocity at baseline. CONCLUSION: During 0 to 21 days, we observed changes at the trunk and pelvis (especially in people with reduced ROM), and velocity changes across all measures (especially in people with baseline movement limitations). Biofeedback did not augment the changes. When targeting forward bending in people with low back pain, clinicians should monitor changes in velocity and global ROM. J Orthop Sports Phys Ther 2024;54(3):1-13. Epub 19 December 2023. doi:10.2519/jospt.2023.12023.

Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis.

Background: Adverse childhood experiences (ACEs) have been shown to negatively affect health in adulthood. Estimates of associations between ACEs and chronic painful conditions are lacking.Objectives: This systematic review and meta-analysis aimed to evaluate associations between exposure to ACEs and chronic pain and pain-related disability in adults.Methods: We searched 10 electronic databases from inception to February 2023. We included observational studies assessing associations between direct ACEs (childhood sexual, physical, emotional abuse, or neglect) alone or in combination with indirect ACEs (witnessing domestic violence, household mental illness), and adult chronic pain (≥3 months duration) and pain-related disability (daily activities limited by chronic pain). Pairs of reviewers independently extracted data and assessed study risks of bias. Random-effect models were used to calculate pooled adjusted odds ratios [aOR]. Tau square [T2], 95% prediction intervals [95%PI] and I2 expressed the amount of heterogeneity, and meta-regressions and subgroup meta-analyses investigated sources of heterogeneity (PROSPERO: CRD42020150230).Results: We identified 85 studies including 826,452 adults of which 57 studies were included in meta-analyses. Study quality was generally good or fair (n = 70). The odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (aOR, 1.45, 95%CI, 1.38-1.53). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (aOR, 1.50, 95CI, 1.39-1.64) and pain-related disability (1.46, 95CI, 1.03-2.08) during adulthood. Exposure to any ACEs alone or combined with indirect ACEs significantly increase the odds of adult chronic painful conditions (aOR, 1.53, 95%CI, 1.42-1.65) and pain-related disability (aOR, 1.29; 95%CI, 1.01-1.66). The risk of chronic pain in adulthood significantly increased from one ACE (aOR, 1.29, 95%CI, 1.22-1.37) to four or more ACEs (1.95, 95%CI, 1.73-2.19).Conclusions: Single and cumulative ACEs are significantly associated with reporting of chronic pain and pain-related disability as an adult.

Previous meta-analyses highlighted the negative impact of adverse childhood experiences on physical, psychological, and behavioural health across the lifespan.We found exposure to any direct adverse childhood experience, i.e. childhood sexual, physical, emotional abuse, or neglect alone or combined, increased the risk of reporting chronic pain and pain-related disability in adulthood.The risk of reporting chronic painful disorders increased with increasing numbers of adverse childhood experiences.

A review of patient recruitment in randomised controlled trials of preoperative exercise.

BACKGROUND: Randomised controlled trials (RCTs) are considered the gold standard design to determine the effectiveness of an intervention, as the only method of decreasing section bias and minimising random error. However, participant recruitment to randomised controlled trials is a major challenge, with many trials failing to recruit the targeted sample size accordingly to the planned protocol. Thus, the aim of this review is to detail the recruitment challenges of preoperative exercise clinical trials. METHODS: A comprehensive search was performed on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED and PsycINFO from inception to July 2021. Randomised controlled trials investigating the effectiveness of preoperative exercise on postoperative complication and/or length of hospital stay in adult cancer patients were included. Main outcomes included recruitment rate, retention rate, number of days needed to screen and recruit one patient and trial recruitment duration. Descriptive statistics were used to summarise outcomes of interest. RESULTS: A total of 27 trials were identified, including 3656 patients screened (N = 21) and 1414 randomised (median recruitment rate (interquartile range) = 53.6% (25.2%-67.6%), N = 21). The sample size of the included trials ranged from 19 to 270 (median = 48.0; interquartile range = 40.0-85.0) and the duration of trial recruitment ranged from 3 to 50 months (median = 19.0 months; interquartile range = 10.5-34.0). Overall, a median of 3.6 days was needed to screen one patient, whereas 13.7 days were needed to randomise one participant. Over the trials duration, the median dropout rate was 7.9%. Variations in recruitment outcomes were observed across trials of different cancer types but were not statistically significant. CONCLUSION: The recruitment of participants to preoperative exercise randomised controlled trials is challenging, but patient retention appears to be less of a problem. Future trials investigating the effectiveness of a preoperative exercise programme following cancer surgery should consider the time taken to recruit patients. Strategies associated with improved recruitment should be investigated in future studies.

Test procedures and positive diagnostic criteria of the upper limb tension tests differ: a systematic review of the DiTA database.

BACKGROUND: The validity of the ULTT is unclear, due to heterogeneity of test procedures and variability in the definition of a positive test OBJECTIVE: To evaluate test procedures and positive diagnostic criteria for the upper limb tension test (ULTT) in diagnostic test accuracy studies. METHODS: A systematic review of diagnostic accuracy studies was performed. We conducted a search of the DiTA (Diagnostic Test Accuracy) database and selected primary studies evaluating the diagnostic accuracy of the ULTT. We assessed risk of bias, performed data extraction on study characteristics, test procedures, and positive diagnostic criteria, and performed a descriptive analysis. RESULTS: We included nine studies (681 participants), four diagnosing people with cervical radiculopathy (CR), four diagnosing people with carpal tunnel syndrome (CTS), and one included both CR and CTS. The risk of bias varied between 2 and 6 out of 6 positive items. Eight studies reported on the ULTT1 (median nerve). Overall, all studies clearly described their test procedures and positive diagnostic criteria although the order of movements and the diagnostic criteria between studies varied. We suggest a more standardised test procedure for the ULTT1 to consist of: 1) stabilising the shoulder in abduction, 2) extending the wrist/fingers, 3) supinating the forearm, 4) externally rotating the shoulder, 5) extending the elbow, and finally 6) performed structural differentiation by side bending (lateral flexion) of the neck. This proposed test procedure should reproduce the symptoms and enables the clinician to evaluate whether symptoms increase/decrease when stressing or relaxing the nerves. CONCLUSION: Based on our findings we proposed a more standardised test procedure for the ULTT1 with accompanying positive diagnostic criteria to facilitate homogeneity in future diagnostic accuracy studies of the ULTT.

Development of normalized quantitative measures of lumbar disc degeneration.

Background: Lumbar disc degeneration (DD) is widely regarded as a likely contributor to low back pain (LBP), but the association between DD and LBP is relatively weak. No known studies have normalized quantitative measures of DD severity relative to multiple variables such as age, height, and disc level. This study developed normalized quantitative measures (z-scores) of disc signal intensity (DSI) and disc height (DH) to rate relative severity of DD. Methods: Raw (unnormalized) quantitative measures of DSI and DH alongside potential normalization variables were acquired from MRI scans and clinical data of 76 patients. The associations between the raw quantitative measures and potential normalization variables were investigated to develop the normalized quantitative measures (z-scores) of DSI and DH. Construct validity was assessed by comparing the normalized measures to an experienced radiologist's subjective measures of relative severity of DSI and DH loss. Results: CSF signal intensity, age, and disc level were significantly associated with raw DSI (R 2 = 0.06, 0.25, and 0.09, respectively). Lumbar height and disc level were significantly associated with raw DH (R 2 = 0.13 and 0.31). Normalizing DSI and DH by these variables resulted in stronger relationships (R 2 = 0.39 and 0.37) than raw DSI and DH (R 2 = 0.24 and 0.31) with the radiologist's subjective measures. Normalized DSI and DH were both normally distributed (p = 0.32 and 0.12). Conclusions: Construct validity and the distributions suggested that normalized quantitative measures of DSI and DH are better than existing measures of DSI and DH at rating relative DD severity. Determining whether normalized quantitative measures are more predictive of clinical outcomes is important future research.

A NRF2 inhibitor selectively sensitizes KEAP1 mutant tumor cells to cisplatin and gefitinib by restoring NRF2-inhibitory function of KEAP1 mutants.

NRF2 (nuclear factor erythroid 2-related factor 2) is a master regulator of protective responses in healthy tissues. However, when it is active in tumor cells, it can result in drug resistance. KEAP1, the endogenous NRF2 inhibitor, binds NRF2 and redirects it to proteasomal degradation, so the KEAP1/NRF2 interaction is critical for maintaining NRF2 at a basal level. A number of clinically relevant KEAP1 mutations were shown to disrupt this critical KEAP1/NRF2 interaction, leading to elevated NRF2 levels and drug resistance. Here, we describe a small-molecule NRF2 inhibitor, R16, that selectively binds KEAP1 mutants and restores their NRF2-inhibitory function by repairing the disrupted KEAP1/NRF2 interactions. R16 substantially sensitizes KEAP1-mutated tumor cells to cisplatin and gefitinib, but does not do so for wild-type KEAP1 cells, and sensitizes KEAP1 G333C-mutated xenograft to cisplatin. We developed a BRET2-based biosensor system to detect the KEAP1/NRF2 interaction and classify KEAP1 mutations. This strategy would identify drug-resistant KEAP1 somatic mutations in clinical molecular profiling of tumors.

Red flags to screen for vertebral fracture in people presenting with low back pain.

BACKGROUND: Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture. OBJECTIVES: To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture). SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022. SELECTION CRITERIA: We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool. MAIN RESULTS: This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96). AUTHORS' CONCLUSIONS: The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

What Factors Do Clinicians, Coaches, and Athletes Perceive Are Associated With Recovery From Low Back Pain in Elite Athletes? A Concept Mapping Study.

OBJECTIVE: Identify factors that elite sport clinicians, coaches, and athletes perceive are associated with low back pain (LBP) recovery. DESIGN: Concept mapping methodology. METHOD: Participants brainstormed, sorted (thematically), and rated (5-point Likert scales: importance and feasibility) statements in response to the prompt, "What factors are associated with the recovery of an elite athlete from low back pain?" Data cleaning, analysis (multidimensional scaling, hierarchical cluster analysis, and descriptive statistics), and visual representation (cluster map and Go-Zone graph) were conducted following concept mapping guidelines. RESULTS: Participants (brainstorming, n = 56; sorting, n = 34; and rating, n = 33) comprised 75% clinicians, 15% coaches, and 10% athletes and represented 13 countries and 17 sports. Eighty-two unique and relevant statements were brainstormed. Sorting resulted in 6 LBP recovery-related themes: (1) coach and clinician relationships, (2) inter-disciplinary team factors, (3) athlete psychological factors, (4) athlete rehabilitation journey, (5) athlete non-modifiable risk factors, and (6) athlete physical factors. Participants rated important recovery factors as follows: athlete empowerment and psychology, coach-athlete and athlete-clinician relationships, care team communication, return-to-sport planning, and identifying red flags. CONCLUSION: Factors perceived as important to LBP recovery in elite athletes align with the biopsychosocial model of community LBP management. Clinicians should consider that an athlete's psychology, relationships, care team communication, and rehabilitation plan may be as important to their LBP recovery as the formulation of a diagnosis or the medications or exercises prescribed. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub 10 August 2023. doi:10.2519/jospt.2023.11982.

Single-group studies in leading physical therapy journals commonly make inappropriate conclusions regarding treatment effect modifiers. A systematic review.

BACKGROUND: Characteristics that identify patients who respond differently to certain interventions are called treatment effect modifiers. Some studies inappropriately report the presence of treatment effect modifiers without adequate study designs. OBJECTIVES: To evaluate what proportion of single-group studies published in leading physical therapy journals inappropriately report treatment effect modifiers, and to assess whether the proportion varies over time or between journals. METHODS: A systematic review was conducted of studies published in eight leading physical therapy journals since 2000. Eligible studies were single-group studies (e.g., cohort study or secondary analysis of treatment arm of randomised controlled trial) that investigated any condition, treatment or outcome. Studies that suggested participants with certain baseline characteristics responded better/or worse to the treatment, were considered to have reported inappropriately. Studies reporting that participants with certain baseline characteristics had improved outcomes but did not state it was due to the treatment were considered to have reported appropriately. The proportion of inappropriate reporting was compared over time and between journals. RESULTS: Of the 145 included studies, 73 (50.3%) were categorised as inappropriately reporting treatment effect modifiers. The proportion of inappropriate reporting was highest in the most recent period, 2018 - 2022 (59.6%) and 2006 - 2011 (55.6%). The proportion of inappropriate reporting varied substantially between journals from 0% (Journal of Physiotherapy) to 91.7% (Journal of Neurologic Physical Therapy). CONCLUSIONS: A large proportion (50.3%) of single-arm studies in leading physical therapy journals inappropriately report treatment effect modifiers. This inappropriate reporting risks misleading clinicians when selecting interventions for individual patients.

Physiotherapists should apply health coaching techniques and incorporate accountability to foster adherence to a walking program for low back pain: a qualitative study.

QUESTIONS: What motivates individuals to start a walking program for the prevention of low back pain? What strategies optimise short-term and long-term adherence to a walking program? What strategies can physiotherapists incorporate into clinical practice to facilitate commencement of and adherence to a walking program? DESIGN: Qualitative study. PARTICIPANTS: Twenty-two adults recently recovered from an episode of non-specific low back pain who participated in a 6-month, progressive and individualised walking program that was prescribed by a physiotherapist trained in health coaching. METHODS: Semi-structured focus groups conducted online following completion of the walking program. Interview questions explored: primary motivations for starting a walking program, identification of which elements were useful in optimising adherence to the program, and identification of the barriers to and facilitators of engagement with the program. Audio recordings were transcribed and thematic analysis was conducted. RESULTS: Three major themes were identified. Theme one identified that strong motivators to start a walking program were anticipated improvements in low back pain management and the added general health benefits of a more active lifestyle. Theme two identified that fear of high-impact exercises led to avoidance; however, walking was considered a safe exercise option. Theme three identified accountability, enjoyment of exercise and health benefits were critical to adherence. CONCLUSION: Participants recently recovered from low back pain reflected positively on a physiotherapist-prescribed walking program. Participants described what elements of the program were crucial to starting exercise and optimising adherence. These findings have informed a list of practical recommendations for physiotherapists to improve patient commencement and adherence to exercise.

Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial.

BACKGROUND: Low back pain is the leading cause of years lived with disability globally, but most interventions have only short-lasting, small to moderate effects. Cognitive functional therapy (CFT) is an individualised approach that targets unhelpful pain-related cognitions, emotions, and behaviours that contribute to pain and disability. Movement sensor biofeedback might enhance treatment effects. We aimed to compare the effectiveness and economic efficiency of CFT, delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling low back pain. METHODS: RESTORE was a randomised, controlled, three-arm, parallel group, phase 3 trial, done in 20 primary care physiotherapy clinics in Australia. We recruited adults (aged ≥18 years) with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation. Exclusion criteria were serious spinal pathology (eg, fracture, infection, or cancer), any medical condition that prevented being physically active, being pregnant or having given birth within the previous 3 months, inadequate English literacy for the study's questionnaires and instructions, a skin allergy to hypoallergenic tape adhesives, surgery scheduled within 3 months, or an unwillingness to travel to trial sites. Participants were randomly assigned (1:1:1) via a centralised adaptive schedule to usual care, CFT only, or CFT plus biofeedback. The primary clinical outcome was activity limitation at 13 weeks, self-reported by participants using the 24-point Roland Morris Disability Questionnaire. The primary economic outcome was quality-adjusted life-years (QALYs). Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001396213. FINDINGS: Between Oct 23, 2018 and Aug 3, 2020, we assessed 1011 patients for eligibility. After excluding 519 (51·3%) ineligible patients, we randomly assigned 492 (48·7%) participants; 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedback mean difference -4·6 [-5·8 to -3·3]) for activity limitation at 13 weeks (primary endpoint). Effect sizes were similar at 52 weeks. Both interventions were also more effective than usual care for QALYs, and much less costly in terms of societal costs (direct and indirect costs and productivity losses; -AU$5276 [-10 529 to -24) and -8211 (-12 923 to -3500). INTERPRETATION: CFT can produce large and sustained improvements for people with chronic disabling low back pain at considerably lower societal cost than that of usual care. FUNDING: Australian National Health and Medical Research Council and Curtin University.

Feasibility, Reliability, and Safety of Remote Five Times Sit to Stand Test in Patients with Gastrointestinal Cancer.

Background: To determine the feasibility, reliability, and safety of the remote five times sit to stand test (5STS) test in patients with gastrointestinal cancer. Methods: Consecutive adult patients undergoing surgical treatment for lower gastrointestinal cancer at a major referral hospital in Sydney between July and November 2022 were included. Participants completed the 5STS test both face-to-face and remotely, with the order randomised. Outcomes included measures of feasibility, reliability, and safety. Results: Of fifty-five patients identified, seventeen (30.9%) were not interested, one (1.8%) had no internet coverage, and thirty-seven (67.3%) consented and completed both 5STS tests. The mean (SD) time taken to complete the face-to-face and remote 5STS tests was 9.1 (2.4) and 9.5 (2.3) seconds, respectively. Remote collection by telehealth was feasible, with only two participants (5.4%) having connectivity issues at the start of the remote assessment, but not interfering with the tests. The remote 5STS test showed excellent reliability (ICC = 0.957), with limits of agreement within acceptable ranges and no significant systematic errors observed. No adverse events were observed within either test environment. Conclusions: Remote 5STS for the assessment of functional lower extremity strength in gastrointestinal cancer patients is feasible, reliable, and safe, and can be used in clinical and research settings.

Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review.

Background: The accuracy of diagnostic tests available in primary care to identify the disc, sacroiliac joint, and facet joint as the source of low back pain is uncertain. Methods: Systematic review of diagnostic tests available in primary care. MEDLINE, CINAHL, and EMBASE were searched between March 2006 and 25th January 2023. Pairs of reviewers independently screened all studies, extracted data, and assessed risk of bias using QUADAS-2. Pooling was performed for homogenous studies. Positive likelihood ratios (+LR) ≥2 and negative likelihood ratios (-LR) ≤0.5 were considered informative. This review is registered with PROSPERO (CRD42020169828). Findings: We included 62 studies: 35 investigated the disc, 14 the facet joint, 11 the sacroiliac joint, and 2 investigated all three structures in patients with persistent low back pain. For risk of bias, the domain 'reference standard' scored worst, however approximately half the studies were of low risk of bias for every other domain. For the disc, pooling demonstrated MRI findings of disc degeneration and annular fissure resulted in informative +LRs: 2.53 (95% CI: 1.57-4.07) and 2.88 (95% CI: 2.02-4.10) and -LRs: 0.15 (95% CI: 0.09-0.24) and 0.24 (95% CI: 0.10-0.55) respectively. Pooled results for Modic type 1, Modic type 2, and HIZ on MRI, and centralisation phenomenon yielded informative +LRs: 10.00 (95% CI: 4.20-23.82), 8.03 (95% CI: 3.23-19.97), 3.10 (95% CI: 2.27-4.25), and 3.06 (95% CI: 1.44-6.50) respectively, but uninformative -LRs: 0.84 (95% CI: 0.74-0.96), 0.88 (95% CI: 0.80-0.96), 0.61 (95% CI: 0.48-0.77), and 0.66 (95% CI: 0.52-0.84) respectively. For the facet joint, pooling demonstrated facet joint uptake on SPECT resulted in informative +LRs: 2.80 (95% CI: 1.82-4.31) and -LRs: 0.44 (95% CI: 0.25-0.77). For the sacroiliac joint, a combination of pain provocation tests and absence of midline low back pain resulted in informative +LRs of 2.41 (95% CI: 1.89-3.07) and 2.44 (95% CI: 1.50-3.98) and -LRs of 0.35 (95% CI: 0.12-1.01) and 0.31 (95% CI: 0.21-0.47) respectively. Radionuclide imaging yielded an informative +LR 7.33 (95% CI: 1.42-37.80) but an uninformative -LR 0.74 (95% CI: 0.41-1.34). Interpretation: There are informative diagnostic tests for the disc, sacroiliac joint, and facet joint (only one test). The evidence suggests a diagnosis may be possible for some patients with low back pain, potentially guiding targeted and specific treatment approaches. Funding: There was no funding for this study.

Some magnetic resonance imaging findings may predict future low back pain and disability: a systematic review.

QUESTIONS: Do magnetic resonance imaging (MRI) findings predict future low back pain (LBP), associated disability and global recovery in people with current LBP? Do MRI findings predict these outcomes in people with no current LBP? Do MRI findings predict these outcomes in a mixed sample of people with and without current LBP? DESIGN: This review is an update of a previous systematic review investigating the relationship between lumbar spine MRI findings and future LBP. PARTICIPANTS: People with or without LBP with lumbar MRI scans. OUTCOME MEASURES: MRI findings, pain and disability. RESULTS: Of the included studies, 28 reported on participants with current LBP, eight reported on participants with no LBP and four reported on a mixed sample. Most results were based on single studies and did not demonstrate clear relationships between MRI findings and future LBP. In populations with current LBP, pooling demonstrated that the presence of Modic type 1 changes alone or Modic type 1 and 2 changes were associated with slightly worse pain or disability outcomes in the short term, and the presence of disc degeneration was associated with worse pain and disability outcomes in the long term. In populations with current LBP, pooling demonstrated no evidence of an association between the presence of nerve root compression and disability outcomes in the short term, and no evidence of an association between the presence of disc height reduction, disc herniation, spinal stenosis, high-intensity zone and clinical outcomes in the long term. In populations with no LBP, pooling demonstrated that the presence of disc degeneration may increase the likelihood of experiencing pain in the long term. In mixed populations, no pooling was possible; however, single studies demonstrated that Modic type 1, 2 or 3 changes and disc herniation were each associated with worse pain in the long term. CONCLUSIONS: The results suggest that some MRI findings may have weak associations with future LBP; however, larger high-quality studies are needed to resolve uncertainty. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021252919.

Effectiveness and cost-effectiveness of a progressive, individualised walking and education program for prevention of low back pain recurrence in adults: statistical analysis plan for the WalkBack randomised controlled trial.

BACKGROUND: Exercise for the prevention of low back pain recurrences is recommended, but under-researched. The effectiveness and cost-effectiveness of a walking program for preventing low back pain recurrence remains unknown. This a priori statistical analysis plan describes the methods of analysis for the WalkBack trial. METHODS: WalkBack is a prospectively registered, pragmatic, randomised controlled trial. The aim is to investigate the effectiveness and cost-effectiveness of a 6-month progressive and individualised walking and education program (intervention) for the prevention of low back pain recurrences, compared to a no-treatment control group. The primary outcome is days to the first recurrence of an episode of activity-limiting low back pain. Key secondary outcomes include days to any recurrence of low back pain, days to a care-seeking recurrence of low back pain, disability level, health-related quality of life, costs associated with low back pain and adverse events. All participants will be followed for a minimum of 12 months. Analysis will follow the intention-to-treat principle. Cox regression is planned to assess the effects for the outcomes of time to activity-limiting, minimal and care-seeking recurrence. Hazard ratios and median survival times with 95% confidence intervals will be calculated. The effect of the intervention on continuous outcomes will be estimated with repeated-measure linear mixed models. An economic evaluation will be performed from the societal perspective for recurrence prevented (yes/no) and quality-adjusted life years. The proportion of adverse events between groups will be compared using Fisher's exact test. DISCUSSION: The WalkBack trial will provide evidence on the effectiveness and cost-effectiveness of a walking intervention to prevent low back pain recurrences. This statistical analysis plan provides transparency on the analysis of the trial. TRIAL REGISTRATION: WalkBack - Effectiveness and cost-effectiveness of a progressive individualised walking and education program for the prevention of a recurrence of low back pain. ACTRN12619001134112 . Date Registered: 14/08/2019.