Patient and Staff Insights on Digital Care Pathways for Patients With Low Back Pain in the Emergency Department: A Qualitative Study.

BACKGROUND: Back pain is a huge global problem. For some people, the pain is so severe that they feel the need to present to an emergency department (ED). Our aim was to explore patient and staff perspectives for the development of a digital care pathway (DCP) for people with back pain who have presented to ED, including acceptability, barriers and facilitators. METHODS: We used a descriptive phenomenology approach using semi-structured interviews with patient and staff participants at a tertiary hospital. Interviews were transcribed and data codes were developed using inductive thematic analysis. Themes were discussed between researchers until consensus was achieved. RESULTS: A total of 16 interviews were carried out, half of which involved patient participants. We identified three major themes: (i) expectations and experiences of staff and patients with low back pain in ED; (ii) a digital care pathway can empower patients and support clinicians in providing care; and (iii) acceptability, barriers, facilitators and recommendations of engaging with a DCP to track the trajectory of back pain. Each theme was further categorised into subthemes. CONCLUSION: Introducing a DCP was perceived as acceptable and beneficial by patients and staff. Both groups were aware of the potential participant burden if surveys were too long. Introducing a DCP could be a valuable adjunct to current management care models, providing a standardised source of education with the potential for individualised tracking and monitoring. The design and development of a DCP will need to consider reported facilitators and address perceived barriers for engagement. PATIENT OR PUBLIC CONTRIBUTION: This project sought insights from patients and staff about a digital care pathway. This forms the first step of patient and consumer consultation before implementing a digital care pathway. All consumers were offered the opportunity to review their responses and our interpretation.

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

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

BackTrAC: A Digital Care Pathway for People Presenting to Emergency with Lower Back Pain. A Development and Feasibility Study Protocol.

OBJECTIVES: Back pain is a prevalent condition that affects 1 in 6 Australians at any time, with high associated health care costs. To date, there is limited information relating to symptom severity and recovery trajectory in people with back pain who present to the emergency department for care. A digital care pathway (DCP) can track patient outcomes following presentation with back pain. The primary aim of this protocol is to outline the co-development, implementation, and evaluation of a DCP for back pain patients who present to the emergency department. METHODS: The primary aim will be addressed in 3 overlapping phases: Phase 1 (co-design) will include interviews with back pain patients and health care professionals from the Northern Hospital Emergency Department. Interview findings will inform education resources featured on the DCP and establish questionnaire content and frequency acceptability. Phase 2 (implementation) will include the rollout of the DCP and tracking of patient-reported outcome measures, which will be collected over 12 weeks. Phase 3 (evaluation) will include interviews with a subset of back pain patients who have participated in Phase 2 to evaluate the acceptability of the DCP and the barriers and facilitators of using the DCP. ETHICS AND DISSEMINATION: This project has been approved via the National Health and Medical Research Council of Australia's National Mutual Acceptance Scheme by St Vincent's Hospital Human Ethics Committee (2022/PID06476), La Trobe University Research Governance (HEC#206/22), and Northern Health Research Governance (NH-2023-372687). We plan to publish the findings in a peer-reviewed journal and present them at conferences.

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

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

Effectiveness of Early Postpartum Rectus Abdominis versus Transversus Abdominis Training in Patients with Diastasis of the Rectus Abdominis Muscles: A Pilot Randomized Controlled Trial.

Purpose: To determine feasibility of a randomized controlled trial (RCT) comparing postpartum rectus abdominis training with transversus abdominis training in reducing the inter-recti distance in patients with diastasis of the rectus abdominis muscles (DRAM). Method: A pilot, randomized controlled trial with longitudinal assessment following vaginal delivery at 6 and 12 weeks postpartum was completed. Forty-four women with DRAM (inter-recti distance of ≥ 30mm as measured by digital calipers) were recruited from a regional public hospital in Australia. The standard treatment group (n = 21) was provided with a 5-second transversus abdominis activation exercise in crook lying. The experimental group (n = 23) was provided with a 1-second rectus abdominis crunch exercise. Dosage was between 1-10 repetitions at baseline and between 1-20 at 6 weeks, twice a day, at least 5 days per week, prescribed depending on individual participant ability. The primary outcome measure was inter-recti distance. Feasibility measures were recruitment rate, loss to follow-up, adverse events, and exercise adherence. Results: The rectus abdominis group achieved greater reduction of the inter-recti distance at 6 weeks (at and below the umbilicus) and 12 weeks (above, below, and at the umbilicus). Recruitment rate was acceptable (45%) and there were no adverse events, but loss to follow-up was high due to COVID-19 impacts and participants did not return exercise adherence diaries. Conclusion: Prescription of rectus abdominis exercise during the early postpartum period following vaginal delivery resulted in a greater reduction of the inter-recti distance at 6 and 12 weeks when compared with transversus abdominis exercise. This pilot trial was impacted by high loss to follow up due to COVID-19 restrictions, but feasibility was otherwise acceptable. The findings of the study will inform future fully powered trials comparing these two exercise types in postpartum women with DRAM.

Objectif : déterminer la faisabilité d'une étude randomisée et contrôlée pour comparer l'entraînement des grands droits à l'entraînement des muscles transverses afin de réduire la distance intermusculaire chez les patientes ayant une diastase des grands droits (DGD). Méthodologie : étude pilote randomisée et contrôlée comportant une évaluation longitudinale six et 12 semaines après un accouchement vaginal. Au total, 44 femmes ayant une DGD (distance intermusculaire d'au moins 30 mm, mesurée à l'aide d'une règle à coulisse numérique) ont été recrutées dans un hôpital régional public de l'Australie. Le groupe sous traitement standard (n = 21) a reçu un exercice d'activation des muscles transverses de cinq secondes en position allongée sur le dos, les genoux pliés. Le groupe expérimental (n = 23) a reçu un exercice de demi-redressement assis des grands droits d'une seconde. La posologie de une à dix répétitions pour commencer et de une à 20 répétitions deux fois par jour la sixième semaine, au moins cinq jours par semaine, dépendait de la capacité de chaque participante. La mesure d'issue primaire était la distance entre les muscles. Les mesures de faisabilité étaient le taux de recrutement, la perte au suivi, les événements indésirables et l'adhésion aux exercices. Résultats : le groupe d'exercices des grands droits a réduit davantage la distance entre les muscles au bout de six semaines (à l'ombilic et sous l'ombilic) et de 12 semaines (au-dessus et au-dessous de l'ombilic et à l'ombilic). Le taux de recrutement était acceptable (45 %) et il n'y avait pas d'événements indésirables, mais la perte au suivi était élevée à cause des conséquences de la COVID-19, et les participantes n'ont pas remis leur journal d'adhésion aux exercices. Conclusion : la prescription d'exercices des grands droits au début de la période postnatale après un accouchement vaginal favorisait une plus grande réduction de la distance entre les grands droits au bout de six et 12 semaines que les exercices des muscles transverses. L'étude pilote a été touchée par une forte perte au suivi à cause des restrictions liées à la COVID-19, mais la faisabilité était autrement acceptable. Les résultats de l'étude éclaireront de futures études comportant un plein échantillonnage pour comparer deux types d'exercices postnatals chez des femmes présentant une diastase des grands droits.

A pilot randomised trial comparing individualised physiotherapy versus shockwave therapy for proximal hamstring tendinopathy: a protocol.

PURPOSE: Proximal hamstring tendinopathy (PHT) presents as localised lower buttock pain with tasks such as squatting and sitting. It is a condition that occurs at all ages and levels of sporting participation and can cause disability with sport, work, and activities of daily living. This paper details a pilot trial protocol for investigating the effectiveness of individualised physiotherapy compared to extracorporeal shockwave therapy (ESWT) on pain and strength in people with PHT. METHODS: The study is an assessor-blinded, pilot randomised controlled trial (RCT). One hundred participants with PHT will be recruited from the local community and sporting clubs. Participants will be randomised to receive six sessions of either individualised physiotherapy or ESWT, with both groups also receiving standardised education and advice. Primary outcomes will be global rating of change on a 7-point Likert scale, and the Victorian Institute of Sport-Hamstring (VISA-H) scale, measured at 0, 4, 12, 26 and 52 weeks. Secondary outcomes will include sitting tolerance, the modified Physical Activity Level Scale, eccentric hamstring strength, modified Tampa scale for kinesiophobia, the Örebro Musculoskeletal Pain Screening Questionnaire Short Form (ÖMPSQ-SF), Numerical Pain Rating Scale (NPRS) for average and worst pain, participant adherence, the Pain Catastrophizing scale, satisfaction scores, and quality of life. Data will be analysed on an intention to treat basis, with between-group effects estimated using linear mixed models for continuous data and Mann Whitney U tests for ordinal data. CONCLUSIONS: This pilot RCT will compare individualised physiotherapy versus ESWT for PHT. The trial will determine feasibility and estimated treatment effects to inform a definitive trial in the future. TRIAL REGISTRATION: The trial has been prospectively registered with the Australia & New Zealand Clinical Trials Registry (ACTRN12621000846820), registered 1 July 2021, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373085.

Does the Addition of Whole-Body Vibration Training Improve Postural Stability and Lower Limb Strength During Rehabilitation Following Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis.

OBJECTIVES: To investigate whether the addition of whole-body vibration therapy to standard rehabilitation improves postural stability and lower limb strength following anterior cruciate ligament (ACL) reconstruction. DATA SOURCES: A computer-based literature search of MEDLINE, AMED, SPORTDiscus, Embase, CINAHL, CENTRAL, and Physiotherapy Evidence Database (PEDro) included studies up to October 2019. MAIN RESULTS: Seven randomised controlled trials of moderate-to-high methodological quality involving 244 participants were included. Meta-analysis found statistically significant improvements in medial-lateral stability [standardized mean difference (SMD) = 0.50; 95% confidence interval (CI), 0.12-0.88] and overall stability (SMD = 0.60; 95% CI, 0.14-1.06) favoring whole-body vibration therapy, but effects were not significant for quadriceps strength (SMD = 0.24; 95% CI, -0.65 to 1.13), hamstring strength (SMD = 0.84; 95% CI, -0.05 to 1.72), lower limb strength (SMD = 0.76; 95% CI, -0.16 to 1.67), or anterior-posterior stability (SMD = 0.19; 95% CI, -0.39 to 0.76). CONCLUSIONS: The addition of whole-body vibration therapy to standard postoperative rehabilitation following ACL reconstruction does not appear to significantly improve lower limb strength and anterior-posterior stability but may improve medial-lateral and overall postural stability. We found small sample sizes in all included trials, statistical heterogeneity, and methodological quality concerns, including publication bias, suggesting that larger high-quality trials are likely to be influential in this field. Registration: PROSPERO 155531.

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

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

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

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

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

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

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

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

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

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

Classroom Movement Breaks Reduce Sedentary Behavior and Increase Concentration, Alertness and Enjoyment during University Classes: A Mixed-Methods Feasibility Study.

This mixed-methods study aimed to determine the feasibility of incorporating movement breaks into university classes in terms of acceptability (disruption, engagement, satisfaction), practicality (ease of scheduling and conducting breaks) and efficacy (sedentary time, concentration, alertness, enjoyment). Movement breaks of five to 10 min duration were scheduled after 20 min of sedentary time during 2-h classes. Classes without movement breaks were used as a comparison. Data were collected using surveys, objective physical activity monitoring and focus group interviews of students (n = 85) and tutors (n = 6). Descriptive statistics (quantitative data) and independent coding and thematic analysis (qualitative data) were completed. Students (mean age 23 ± 2 years, 69% female) actively engaged in movement breaks with no adverse events. Movement breaks were perceived to be beneficial for concentration, engagement and productivity. Timing of the break was perceived to be important to enhance the benefit and reduce disruption. Students preferred outdoor or competitive movement breaks. Students spent 13 min less time sitting (95%CI 10 to 17), took 834 more steps (95%CI 675 to 994) and had higher levels of concentration, alertness and enjoyment (p < 0.001) in classes with movement breaks compared to classes without. Classroom movement breaks are feasible and may be considered for incorporation into university classes to reduce sedentary behaviour and increase physical activity, alertness, concentration and enjoyment.

Randomised, cross-over trial on the effect of isotonic and isometric exercise on pain and strength in proximal hamstring tendinopathy: trial protocol.

BACKGROUND: Proximal hamstring tendinopathy (PHT) is a condition that occurs at all ages and levels of sporting participation. Presenting as localised lower buttock pain with tasks such as squatting and sitting, it can cause disability with sport, work and other activities of daily living. Recent research has investigated the effect of isometric exercise on pain and strength with a range of tendinopathies but there are no published studies on PHT. This protocol paper details a study investigating the effectiveness of isometric compared with isotonic exercise on pain and strength in people with PHT. METHODS/DESIGN: The study is a prospective, cross-over randomised controlled trial (RCT). Twenty participants with PHT, recruited from the local community and sporting clubs will be recruited for the study. Participants will receive one session of isotonic hamstring strength exercises and one session of isometric hamstring exercise, with random allocation to the order of intervention.Primary outcomes will be hamstring strength measured with a dynamometer and pain with a functional task, assessed immediately following and 45 min after intervention. A secondary outcome will be pain with sitting assessed 24 hours after intervention.The effect of isotonic versus isometric exercise on hamstring pain and strength will be determined using a repeated measures linear mixed model. Further analyses will determine the proportion of patients with clinically important pain and strength improvements, using relative risks, χ2 testing and number needed to treat. DISCUSSION: This RCT protocol will investigate the effect of isometric compared with isotonic exercise for PHT.

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

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

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

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

Randomized Trial of General Strength and Conditioning Versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcomes.

Exercise and spinal manipulative therapy are commonly used for the treatment of chronic low back pain (CLBP) in Australia. Reduction in pain intensity is a common outcome; however, it is only one measure of intervention efficacy in clinical practice. Therefore, we evaluated the effectiveness of two common clinical interventions on physical and self-report measures in CLBP. Participants were randomized to a 6­month intervention of general strength and conditioning (GSC; n = 20; up to 52 sessions) or motor control exercise plus manual therapy (MCMT; n =20; up to 12 sessions). Pain intensity was measured at baseline and fortnightly throughout the intervention. Trunk extension and flexion endurance, leg muscle strength and endurance, paraspinal muscle volume, cardio­respiratory fitness and self-report measures of kinesiophobia, disability and quality of life were assessed at baseline and 3- and 6-month follow-up. Pain intensity differed favoring MCMT between-groups at week 14 and 16 of treatment (both, p = 0.003), but not at 6-month follow­up. Both GSC (mean change (95%CI): -10.7 (-18.7, -2.8) mm; p = 0.008) and MCMT (-19.2 (-28.1, -10.3) mm; p < 0.001) had within-group reductions in pain intensity at six months, but did not achieve clinically meaningful thresholds (20mm) within- or between­group. At 6-month follow-up, GSC increased trunk extension (mean difference (95% CI): 81.8 (34.8, 128.8) s; p = 0.004) and flexion endurance (51.5 (20.5, 82.6) s; p = 0.004), as well as leg muscle strength (24.7 (3.4, 46.0) kg; p = 0.001) and endurance (9.1 (1.7, 16.4) reps; p = 0.015) compared to MCMT. GSC reduced disability (-5.7 (­11.2, -0.2) pts; p = 0.041) and kinesiophobia (-6.6 (-9.9, -3.2) pts; p < 0.001) compared to MCMT at 6­month follow-up. Multifidus volume increased within-group for GSC (p = 0.003), but not MCMT or between-groups. No other between-group changes were observed at six months. Overall, GSC improved trunk endurance, leg muscle strength and endurance, self-report disability and kinesiophobia compared to MCMT at six months. These results show that GSC may provide a more diverse range of treatment effects compared to MCMT.

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

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

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

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