SPINE20 recommendations 2022: spine care-working together to recover stronger.

PURPOSE: Globally, spine disorders are the leading cause of disability, affecting more than half a billion individuals. However, less than 50% of G20 countries specifically identify spine health within their public policy priorities. Therefore, it is crucial to raise awareness among policy makers of the disabling effect of spine disorders and their impact on the economic welfare of G20 nations. In 2019, SPINE20 was established as the leading advocacy group to bring global attention to spine disorders. METHODS: Recommendations were developed through two Delphi methods with international and multi-professional panels. RESULTS: In 2022, seven recommendations were delivered to the leaders of G20 countries, urging them to: Develop action plans to provide universal access to evidence-based spine care that incorporates the needs of minorities and vulnerable populations. Invest in the development of sustainable human resource capacity, through multisectoral and inter-professional competency-based education and training to promote evidence-based approaches to spine care, and to build an appropriate healthcare working environment that optimizes the delivery of safe health services. Develop policies using the best available evidence to properly manage spine disorders and to prolong functional healthy life expectancy in the era of an aging population. Create a competent workforce and improve the healthcare infrastructure/facilities including equipment to provide evidence-based inter-professional rehabilitation services to patients with spinal cord injury throughout their continuum of care. Build collaborative and innovative translational research capacity within national, regional, and global healthcare systems for state-of-the-art and cost-effective spine care across the healthcare continuum ensuring equality, diversity, and inclusion of all stakeholders. Develop international consensus statements on patient outcomes and how they can be used to define and develop pathways for value-based care. Recognize that intervening on determinants of health including physical activity, nutrition, physical and psychosocial workplace environment, and smoking-free lifestyle can reduce the burden of spine disabilities and improve the health status and wellness of the population. At the third SPINE20 summit 2022 which took place in Bali, Indonesia, in August 2022, 17 associations endorsed its recommendations. CONCLUSION: SPINE20 advocacy efforts focus on developing public policy recommendations to improve the health, welfare, and wellness of all who suffer from spinal pain and disability. We propose that focusing on facilitating access to systems that prioritize value-based care delivered by a competent healthcare workforce will reduce disability and improve the productivity of the G20 nations.

SPINE20 recommendations 2021: spine care for people's health and prosperity.

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

Obesity is associated with more disability at presentation and after treatment in low back pain but not in neck pain: findings from the OIOC registry.

BACKGROUND: The influence on the treatment response in patients with low back pain (LBP) and neck pain (NP) is unknown. The aim of the study was to investigate the influence of body weight in patients with low back pain (LBP) and neck pain (NP) on baseline and end of treatment disability. METHODS: Cross-sectional analysis of baseline factors. Longitudinal analysis of prospectively collected patient information at an outpatient physical therapy registry (data from June 2010 to December 2012). WHO-BMI classification was used: underweight, lean, overweight, obesity class I, obesity class II and III. The influence of body weight and a predefined set of confounders was analyzed by multiple regression models. RESULTS: In LBP, disability increased with increasing BMI [lean = reference, obesity class I Beta 5.41 (95 % CI 0.75; 10.07), obesity class II-III Beta 7.58 (95 % CI 2.13; 13.03)]. Compared to lean patients, disability after treatment improved in overweight subjects [Beta -3.90 (95 % CI -7.4; -0.41)] but not in subjects with obesity class II-III [Beta 3.43 (95 % CI -3.81; 10.68)]. There were insufficient patients in the sample with severe obesity and therefore this trend has to be confirmed. The likelihood for meaningful important change (MID) was similar in all BMI subgroups. For patients with NP, BMI was not associated with baseline disability, and did not predict end of treatment disability or the likelihood of a MID. These findings must be interpreted with caution as BMI subgroups did not meet the required sample size. CONCLUSION: Overweight and obesity are associated with higher levels of disability before treatment in LBP patients, but not in NP. In severely obese patients class II-III with LBP the rate of MID was lowest indicating that these patients experienced the least treatment response compared to the other groups. Further studies should address the impact of severe obesity on the prognosis of LBP. In patients with LBP, severe obesity may be an important factor to consider during the physical therapy treatment. In particular, combined treatment strategies combining weight management, cardiovascular fitness, and low back pain rehabilitation should be investigated.

Does Coordinated, Multidisciplinary Treatment Limit Medical Disability and Attrition Related to Spine Conditions in the US Navy?

BACKGROUND: Musculoskeletal conditions account for the largest proportion of cases resulting in early separation from the US Navy. This study evaluates the impact of the Spine Team, a multidisciplinary care group that included physicians, physical therapists, and a clinical psychologist, for the treatment of active-duty service members with work-disabling, nonspecific low back pain at the Naval Medical Center, Portsmouth, VA, USA. We compared the impact of the introduction of the Spine Team in limiting disability and attrition from work-disabling spine conditions with the experience of the Naval Medical Center, San Diego, CA, USA, where there is no comparable spine team. QUESTIONS/PURPOSES: Is a multidisciplinary spine team effective in limiting disability and attrition related to work-disabling spine conditions as compared with the current standard of care for US military active-duty service members? METHODS: This is a retrospective, pre-/post-study with a separate, concurrent control group using administratively collected data from two large military medical centers during the period 2007 to 2009. In this study, disability is expressed as the proportion of active-duty service members seeking treatment for a work-disabling spine condition that results in the assignment of a first-career limited-duty status. Attrition is expressed as the proportion of individuals assigned a first-career limited-duty status for a work-disabling spine condition who were referred to a Physical Evaluation Board. We analyzed 667 individuals assigned a first-career limited-duty for a work-disabling spine condition between 2007 and 2009 who received care at the Naval Medical Center Portsmouth or Naval Medical Center San Diego. RESULTS: Rates of first-career limited-duty assignments for spine conditions decreased from 2007 to 2009 at both sites, but limited-duty rates decreased to a greater extent at the intervention site (Naval Medical Center Portsmouth; from 8.5 per 100 spine cases in 2007 to 5.1 per 100 cases in 2009, p < 0.001) as compared with the control site (Naval Medical Center San Diego; 16.0 per 100 spine cases in 2007 and 14.1 per 100 cases in 2009, p = 0.38) after the Spine Team was implemented in 2008. The risk of disability was lower at Naval Medical Center Portsmouth as compared with Naval Medical Center San Diego for each of the 3 years studied (in 2007, the relative risk was 0.53 [95% confidence limit {CL}, 0.42-0.68; p < 0.001]) indicating a protective effect of Naval Medical Center Portsmouth in limiting disability (in 2008, it was 0.58 [95% CL, 0.45-0.73; p < 0.001] and in 2009 0.34 [95% CL, 0.27-0.47; p < 0.001]); the relative risk improved in 2009 after the introduction of the Spine Team at Naval Medical Center Portsmouth. There were no differences observed in rates of attrition from the period before the introduction of the Spine Team to after at Naval Medical Center Portsmouth, and no overall differences could be statistically detected between the two sites. CONCLUSIONS: This study provides suggestive evidence that a multi-disciplinary Spine Team may be effective in limiting disability. No conclusion can be drawn about the Spine Team's effectiveness in limiting attrition. Additional study is warranted to examine the effect of the timing of the introduction of multidisciplinary care for work-disabling spine conditions. LEVEL OF EVIDENCE: Level III, therapeutic study.

What do older adults want from spine care?

Introduction: Older adults comprise a large portion of back pain (BP) sufferers but are under-represented in the literature. Patients over age 65 present with different clinical characteristics and psychosocial needs than younger patients. Therefore, recommended patient-centered outcomes for BP may not be relevant to older patients. Research question: What treatment outcomes are most important to adults over 65 years of age? Materials and methods: We queried older adults seeking treatment for BP using qualitative methods. Participants were asked about their goals and expectations of treatment in an audio-taped interview. Audiotapes were transcribed, coded and analyzed by the investigators. Using thematic analysis, main themes and constructs were extracted and interpreted by the investigators. From there we were able to generate hypotheses about what older patients want from spine treatment. Results: For all participants, age played a role in their treatment goals as a moderator or motivator. They were most concerned with returning to usual activities and preventing further physical limitations to maintain independence. Goals that reflect important outcomes such as increasing walking tolerance and improving balance were of particular importance. Confidence in the provider acted as a facilitator of goals. Discussion and conclusion: Unlike their younger cohorts, they did not emphasize work-related outcomes and pain relief. These findings can be tested in future quantitative studies and will help to develop protocols for outcomes assessment in older adults. This study is a first step towards understanding and improving the quality of care for older patients with back pain.

Protocol for the Implementation of Psychologically Informed Physical Therapy to Prevent Chronification in Service Members With Musculoskeletal Disorders.

INTRODUCTION: Musculoskeletal disorders (MSDs) are a primary cause of separation and long-term disability in active duty service members (ADSMs). Psychologically informed physical therapy (PiPT) is designed to identify and address modifiable psychological risk factors early in an MSD episode and has been proven effective in preventing chronicity in civilian populations. We developed a course to train military physical therapy (PT) personnel in PiPT for treating ADSM with MSD. This study tests the feasibility and effectiveness of our training. OBJECTIVE: Establish the feasibility of implementing PiPT and its effectiveness in the U.S. military. MATERIALS AND METHODS: An observational, prospective, comparative cohort study will test implementation and effectiveness. First, we will observe clinical outcomes in a cohort of ADSM with MSD receiving usual PT care at a military outpatient PT clinic. Next, we will train all PT staff in PiPT. Finally, PiPT will be implemented in a second cohort of ADSM. Data will be collected from each cohort at pre-treatment, fourth PT visit, 6 months post enrollment, and 12 months post enrollment. The primary outcomes are pain interference and psychological risk for chronicity. RESULTS AND CONCLUSIONS: Data collection is ongoing. Findings will identify the factors associated with PiPT outcomes in ADSM, inform the implementation of PiPT across health care settings, and allow us to document the prevalence of risk factors for chronicity in ADSM. Findings can help to prevent chronification from MSD, thereby reducing lost man-hours and enhancing military readiness, contribute to the development of a highly skilled workforce for the provision of health services to ADSM, and enhance the efficiency of health care delivery through optimal allocation of PT resources, resulting in significant cost savings for the military.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Implementation of a multidisciplinary program for active duty personnel seeking care for low back pain in a U.S. Navy Medical Center: a feasibility study.

The aim of the pilot study was to evaluate a multidisciplinary program for nonspecific low back pain (NSLBP) at a major U.S. Navy base. In this single blinded randomized clinical trial, subjects were drawn from a larger, prospective cohort of active duty service members seeking care for NSLBP pain at a U.S. Navy Branch Medical Clinic. Outcome measures included return to work, self-reported pain, function, and psychological distress. Subjects were randomly allocated to one of two study arms: a multidisciplinary reconditioning program or the current standard of care for low back pain. The intervention lasted 4 weeks with a 12-week follow-up. Thirty-three subjects were enrolled. Subjects allocated to multidisciplinary care reported significantly lower perceived disability (p = 0.014) and less pain than those allocated to usual care at the end of the intervention period. All subjects returned to their usual duty following the conclusion of the intervention. The implementation of the intervention program was successful. Subjects in the multidisciplinary program showed a clinically significant improvement in the perception of disability compared to the usual care group. This is an important finding since perception of disability is associated with long-term functional outcome.

Incidence and Mechanisms of Musculoskeletal Injuries in Deployed Navy Active Duty Service Members Aboard Two U.S. Navy Air Craft Carriers.

INTRODUCTION: This brief report describes the number and nature of cases of musculoskeletal pain and injury among sailors and marines presenting to the ship's physical therapist during recent, respective deployments of two U.S. Navy aircraft carriers. MATERIALS AND METHODS: The case definition for this study was cases of work-limiting medical complaints involving the musculoskeletal system presenting, or referred, to the ship's physical therapy services for evaluation and treatment. The population for this study was drawn from ship's company from two Nimitz class carriers on their respective deployments. Potential subjects were recruited at their index visit for their complaint. Participants completed a survey of their symptoms while at the ship's medical department. Data for analysis consist of counts of cases, body part affected, self-reported mechanism of injury, age, and gender of the subject. Data were analyzed by generating descriptive tables. RESULTS: One hundred ninety-seven cases were captured across the two carriers. Injury to the low back was the most frequent (34%), followed by shoulder (25%) and knee (15%). Twenty one cases (11%) were reported to be exacerbation of previous injuries and the rest new injuries. Of the 176 new injury cases, 93 (53%) were of an insidious onset and the remainder had a specific, identifiable onset. Of the 82 cases with a specific identifiable onset, 38 cases (46%) occurred during participation in sport and exercise activity on board ship, and the remainder of the cases occurred during the performance of duty-related work. None of the cases required evacuation off of the ship. CONCLUSION: Care should be used interpreting the results since participants were volunteers and a small proportion of eligible subjects chose not to participate in the study. Nevertheless, our data are generally consistent with other studies of musculoskeletal injury on board U.S. Navy ships and are useful for health care planning purposes and for planning for future studies that may take place on board U.S. Navy vessels. The novel and important finding of this study suggests that sports and exercise activity on board ship may warrant a new area of attention for safety.

Both positive and negative beliefs are important in patients with spine pain: findings from the Occupational and Industrial Orthopaedic Center registry.

BACKGROUND CONTEXT: Negative beliefs are known to influence treatment outcome in patients with spine pain (SP). The impact of positive beliefs is less clear. PURPOSE: We aimed to assess the influence of positive and negative beliefs on baseline and treatment responses in patients with SP. STUDY DESIGN/SETTING: A retrospective cross-sectional and longitudinal analysis of prospectively collected data of outpatient physical therapy patients with SP was carried out. Questionnaires administered before and during treatment included the STarT Back distress scale (negative beliefs), and expectation and self-efficacy questions (positive beliefs). PATIENT SAMPLE: Patients with SP with a baseline assessment and follow-up assessment comprised the study sample. OUTCOME MEASURE: Perceived disability was measured using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). A clinical meaningful change (minimum clinically important difference [MCID]) was defined as decrease in ODI or NDI of ≥30%. METHODS: We used the Akaike Information Criterion from the first imputed dataset of the prediction model to select predictor variables. Prediction models were fitted to the outcome variables. RESULTS: In the cross-sectional analysis, 1,695 low back pain (LBP) episodes and 487 neck pain (NP) episodes were analyzed. STarT Back Screening Tool (SBST)-distress was positively associated with perceived disability in both LBP (beta 2.31, 95% confidence interval [CI] 1.75-2.88) and NP (beta 2.57, 95% CI 1.47-3.67). Lower self-efficacy was negatively associated with more perceived disability for LBP (beta 0.50, 95% CI 0.29-0.72) but not for NP, whereas less positive expectations was associated with more perceived disability in NP (beta 0.57, 95% CI 0.02-1.12) but not in LBP. In the longitudinal analysis, 607 LBP episodes (36%) and 176 (36%) NP episodes were included. SBST-distress did not predict treatment outcome in spine patients. In LBP, patients with a lower positive expectation were less likely to experience an MCID in perceived disability (odds ratio [OR] per point increase 0.89, 95% CI 0.83-0.96), and there was a similar trend in NP (OR per point increase 0.90, 95% CI 0.79-1.03). In patients with LBP, lower self-efficacy at baseline was associated with a higher likelihood that an MCID was achieved (OR per point increase 1.09, 95% CI 1.01-1.19). In NP, self-efficacy was not included in the final model. CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability. However, in this study, only positive beliefs were associated with treatment outcome.

Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries.

This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment.

Self-care techniques for acute episodes of low back pain.

Guidelines recommend minimal medical intervention for acute non-specific low back pain. However, patients often request strategies to reduce symptoms and recover quickly. Self-care techniques that do not contradict current evidence-based recommendations may be suggested. Self-care techniques can reduce costs and iatrogenic complications that can occur with medical treatment. They may also increase the patient's perception of control and improve long-term outcome. A shift in paradigm for the health care provider and the patient is required for self-care to be successful. These issues, as well as self-care approaches such as medication, exercises, modalities and mind-body techniques are discussed. Practice points for each approach are given.

Measures for low back pain: a proposal for clinical use.

Low back pain represents a serious public health problem. Therefore, great efforts have been made in order to improve and assess the efficacy of its treatment. Reports in international literature have presented important studies concerning instruments to assess pain and functional incapacity in patients with low back pain. This study presents a clinical protocol which was developed by a multidisciplinary team. This protocol consists of the evaluation and distribution of pain, The Spitzer Quality of Life, The Oswestry Low Back Pain Disability Questionnaire, and The Center for Epidemiological Studies Depression Scale. Instruments must be urgently developed or adapted in order to be used according to the Brazilian reality.

Factors predicting clinical outcome 12 and 36 months after an exercise intervention for recurrent low-back pain.

PURPOSE: The aim of this cohort study was to identify early predictive factors for a poor outcome of disability and pain 12- and 36-months after an intervention in patients with recurrent low-back pain, currently at work. METHOD: Seventy-one patients with recurrent low-back pain, all at work, seeking care in a primary health care setting were included. Predictive indicators including demographic data and health-related variables were derived from questionnaires pre- and post intervention over eight weeks. The dependent outcome variables were perceived disability and present pain at 12- and 36-months. RESULTS: Multivariate regression analyses show that early data on poor self-efficacy for physical activity, greater disability, and higher level of pain-ratings emerged as independent predictors of a poor outcome of disability at 12 and 36 months. Higher ratings of pain and poor self-efficacy appeared again as independent predictors of a poor outcome of pain at the 12-month follow-up. Pain frequency ratings predicted a poor outcome of pain at 36 months. CONCLUSIONS: Our results suggest that ratings of poor self-efficacy for physical activity, greater disability, and pain-ratings, are the most consistent independent predictors of long-term poor outcome of disability and pain. This indicates the importance of screening for such factors to optimize the management of low-back pain. However, larger studies in similar patient populations are needed to confirm these results.

Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain.

BACKGROUND CONTEXT: Musculoskeletal disorders of the spine in the US military account for the single largest proportion of the absence of sickness causes leading to early termination. We explored if selected psychological and physical factors were associated with poor outcome after episodes of low back pain (LBP). PURPOSE: To identify clinical, demographic, and psychological factors predictive of work duty status after a complaint of LBP. STUDY DESIGN: A prospective clinical cohort of US Navy personnel treated for LBP. PATIENT SAMPLE: Eligible cases were active duty US Navy or Marine Corps personnel presenting to an emergency clinic or primary care clinic with a complaint of LBP, where the index episode of LBP was no more than 12 weeks duration before enrollment. OUTCOME MEASURES: The subject's work status (full duty, light duty, sick in quarters [SIQ], limited duty, or medically released to full duty) was abstracted from the subject's electronic medical record at approximately 4 weeks and then again 12 weeks after study enrollment. Work status in this study population is assigned by a Navy health-care provider at the time of a clinical visit and based on the health-care provider's determination of medical fitness for duty. This study collapsed work status into two groups, "full duty" (consisting of "full duty" and "medically released to full duty") and "not at full duty" (consisting of "light duty," "SIQ," and "limited duty"). METHODS: Volunteers completed a baseline questionnaire consisting of recommended well-validated measures, including attitudes and beliefs about LBP and work (Fear-Avoidance Beliefs Questionnaire [FABQ] and the Tampa Scale of Kinesiophobia), distress (the Pain Catastrophizing Scale), clinical depression (The Center for Epidemiologic Studies Depression scale), a numeric pain intensity scale, self-perceived disability (Oswestry Disability Index), and general health status (12-Item Short Form Health Survey). Navy health-care providers conducted a back pain-specific medical evaluation. Associations are expressed as multivariate-adjusted prevalence ratios (PRs) estimated using Poisson regression. RESULTS: Two hundred fifty-three participants were enrolled. Work status outcome was collected for 239 participants. Predictors of "not at full duty" at 4 weeks after enrollment included having back pain for 4 weeks or less before study enrollment (PR, 2.69; 95% CI, 1.21-5.97) and increased FABQ Work subscale score (PR, 1.05; 95% CI, 1.01-1.08). The sole predictor of work status at 12 weeks after enrollment was increased FABQ Physical Activity (FABQ Physical) subscale score (PR=1.14; 95% CI, 1.00-1.30). CONCLUSIONS: The findings that fear-avoidance beliefs were predictive of subsequent work status among active duty service personnel in this study population (after adjusting for clinical, demographic, and psychological covariates) suggest the clinical utility of addressing these factors during treatment of back pain episodes in the military. These findings reflect the important role that psychological factors may play in the return to work process in an active duty military population.

Work retention and nonspecific low back pain.

STUDY DESIGN: A cohort study of patients with nonspecific low back pain (LBP) participated in a 4-week multidisciplinary rehabilitation program. OBJECTIVE: To identify factors that predict work retention 24 months after treatment in patients with nonspecific LBP. SUMMARY OF BACKGROUND DATA: There is evidence that select physical, psychologic, and psychosocial factors are related to positive outcome for work-related nonspecific LBP. However, there is very little information related to work retention following an episode of nonspecific LBP. This is an exploratory study to identify select physical and psychosocial factors related to work retention. METHODS: Patients who returned to work after treatment (n = 67) were followed for 2 years. Physical baseline measures included tests of flexibility, strength, and functional capacity. Psychosocial baseline measures were The Symptoms Checklist 90-R, The Pain Beliefs and Perceptions Inventory, The Oswestry Scale of perceived disability, The Work Stress Inventory, and The Quality of Life Scale. All physical parameters, perceived disability, and quality of life were tested before and after treatment. The dependent variable, work retention, was defined as the number of days that the subject worked during the 2-year follow-up period. Survival analysis was used to establish the predictive model. RESULT: The average time out of work before treatment was 9 months (standard deviation 12.8) for 67 subjects (mean age 40 years [standard deviation 9.6]), including 18 females and 49 males. There were 18 participants (25%) that had interruption of work retention at follow-up. Average work retention was 362 days (range 47-682). Variables that reached a P value of <0.10 in the bivariate analysis were included in the multivariate analysis. They were trunk flexion (hazard ratio [HR = 2.4], 95% confidence interval [CI] 1.24-4.38; P = 0.01), trunk extension (HR = 2.1, 95% CI 1.02-4.16; P = 0.04), the somatization scale from the Symptom Checklist 90 revised (HR = 2.0, 95% CI 1.03-4.05; P = 0.04), and the obsessive-compulsiveness scale from the Symptom Checklist 90 revised (HR = 0.4, 95% CI 0.12-1.15; P = 0.09). Results showed that post-test trunk flexion, somatization, and obsessive compulsiveness predicted work retention (final trunk flexion HR = 2.5 [95% CI 1.26-4.79; P = 0.01], somatization scale HR = 2.5 [95% CI 1.25-4.93; P = 0.01], and obsessive compulsion HR = 0.2 [95% CI 0.07-0.77; P = 0.02]). CONCLUSION: Psychosocial and physical factors are associated with work retention for patients with nonspecific LBP. The predictive value of certain constructs may vary with the time when they are assessed and how outcome is operationalized. Further studies are needed to confirm these findings.

Predictors of compliance with short-term treatment among patients with back pain.

OBJECTIVE: Great efforts have been made to find effective treatments for back pain. Nevertheless, the effectiveness of a particular treatment can depend on patient compliance. The objective of this study was to prospectively investigate whether patients' demographic factors, clinical factors, external barriers in following the treatment, and perceptions of disability, quality of life, depression, and control over health were predictive of compliance with a physical therapy program carried out with patients with low back pain. METHODS: This was an exploratory prospective cohort study that was carried out in New York City during 1999. All study participants answered a questionnaire at the initial clinical evaluation by a physical therapist and were followed during the treatment. The study assessed compliance with the three treatment regimens that were prescribed for every patient: attending scheduled physical therapy sessions, following a program of home exercises, and watching back-education videotapes. Depending on the individual patient, the planned treatment program could last from 2 to 6 weeks. The study employed a battery of instruments to measure patient characteristics that included perceived functional limitations, perceived quality of life, depression, and their beliefs about their health. Student's t tests and chi-square tests were used to determine if non- and low-compliant patients differed significantly from high-compliant patients. Logistic regression was used to estimate adjusted odds ratios expressing the association of selected variables with compliance. RESULTS: We found that 51% of the patients were either noncompliant or low-compliant overall with the low back pain treatment program. There were differences in compliance behavior among the three treatment regimens, with compliance being highest for watching the back-education videotapes and lowest for doing the home exercises. Poor compliance overall was positively associated with the expectation of barriers in following the proposed treatment, with comorbidity, and with longer duration of treatment in this program. CONCLUSIONS: The findings of our study indicate that patient compliance with back pain treatment is a serious and complex problem. Nevertheless, while this study was only an exploratory one, we believe that the results of this study can be used by care providers to identify patients likely to become noncompliant and also by researchers to plan specific studies on the effectiveness of treatment programs for patients with low back pain.

Measures for low back pain: a proposal for clinical use

Low back pain represents a serious public health problem. Therefore, great efforts have been made in order to improve and assess the efficacy of its treatment. Reports in international literature have presented important studies concerning instruments to assess pain and functional incapacity in patients with low back pain. This study presents a clinical protocol which was developed by a multidisciplinary team. This protocol consists of the evaluation and distribution of pain, The Spitzer Quality of Life, The Oswestry Low Back Pain Disability Questionnaire, and The Center for Epidemiological Studies Depression Scale. Instruments must be urgently developed or adapted in order to be used according to the Brazilian reality.

Predictors of compliance with short-term treatment among patients with back pain / Factores predictivos del cumplimiento del tratamiento a corto plazo en pacientes con lumbalgia

Objective. Great efforts have been made to find effective treatments for back pain. Nevertheless, the effectiveness of a particular treatment can depend on patient compliance. The objective of this study was to prospectively investigate whether patients' demographic factors, clinical factors, external barriers in following the treatment, and perceptions of disability, quality of life, depression, and control over health were predictive of compliance with a physical therapy program carried out with patients with low back pain. Methods. This was an exploratory prospective cohort study that was carried out in New York City during 1999. All study participants answered a questionnaire at the initial clinical evaluation by a physical therapist and were followed during the treatment. The study assessed compliance with the three treatment regimens that were prescribed for every patient: attending scheduled physical therapy sessions, following a program of home exercises, and watching back-education videotapes. Depending on the individual patient, the planned treatment program could last from 2 to 6 weeks. The study employed a battery of instruments to measure patient characteristics that included perceived functional limitations, perceived quality of life, depression, and their beliefs about their health. Student's t tests and chi-square tests were used to determine if non- and low-compliant patients differed significantly from high-compliant patients. Logistic regression was used to estimate adjusted odds ratios expressing the association of selected variables with compliance. Results. We found that 51% of the patients were either noncompliant or low-compliant overall with the low back pain treatment program. There were differences in compliance behavior among the three treatment regimens, with compliance being highest for watching the back-education videotapes and lowest for doing the home exercises. Poor compliance overall was positively associated with the expectation of barriers in following the proposed treatment, with comorbidity, and with longer duration of treatment in this program. Conclusions. The findings of our study indicate that patient compliance with back pain treatment is a serious and complex problem. Nevertheless, while this study was only an exploratory one, we believe that the results of this study can be used by care providers to identify patients likely to become noncompliant and also by researchers to plan specific studies on the effectiveness of treatment programs for patients with low back pain

Objetivos. Aunque se han hecho grandes esfuerzos por encontrar tratamientos eficaces para las lumbalgias, la eficacia de las diferentes modalidades terapéuticas puede depender de su cumplimiento por parte del paciente. El objetivo de este estudio prospectivo consistió en investigar si las características demográficas del paciente, los factores clínicos, los obstáculos externos al cumplimiento del tratamiento y la percepción subjetiva de la discapacidad y la calidad de vida, la depresión y el control sobre la salud permiten predecir el cumplimiento de un programa fisioterapéutico para pacientes con lumbalgia. Métodos. El estudio, de cohorte, prospectivo y exploratorio, se realizó en la ciudad de Nueva York en 1999. Todos los participantes contestaron un cuestionario durante el examen clínico inicial, realizado por un fisioterapeuta, y fueron seguidos durante el tratamiento. Se investigó el cumplimiento de los tres regímenes terapéuticos prescritos a cada uno de los pacientes, que consistieron en asistir a sesiones programadas de fisioterapia, realizar un programa de ejercicios en su casa y visionar cintas de vídeo educativas sobre la espalda. Dependiendo de cada caso, el programa terapéutico planeado podía durar entre 2 y 6 semanas. Para caracterizar a los pacientes se empleó un conjunto de instrumentos que medían la limitación funcional subjetiva, la calidad de vida, la depresión y las creencias sobre su salud. Para detectar diferencias estadísticamente significativas entre los pacientes no cumplidores o con bajo cumplimiento y aquellos con alto cumplimiento se utilizaron las pruebas de la t de Student y de la 2. Las razones de probabilidades (odds ratios) ajustadas que expresaban la asociación entre determinadas variables y el cumplimiento se estimaron mediante regresión logística. Resultados. En términos generales, 51% de los pacientes incumplieron total o parcialmente el programa terapéutico. Hubo diferencias entre los tres regímenes en lo que se refiere a su cumplimiento; el mayor correspondió a los vídeos educativos y el menor al programa de ejercicios a realizar en casa. El bajo cumplimiento global se asoció de forma positiva a la previsión de obstáculos para seguir el tratamiento propuesto, a la comorbilidad y a la mayor duración del tratamiento. Conclusiones. Los resultados de este estudio indican que el cumplimiento de los tratamientos de la lumbalgia es un problema serio y complejo. Aunque solo se trató de un estudio exploratorio, los autores creen que sus resultados pueden servir a los profesionales de la salud para identificar a los pacientes con probabilidades de no cumplir el tratamiento, y a los investigadores para planear estudios específicos sobre la eficacia de los programas detratamiento de la lumbalgia.