Effects of transcutaneous electrical nerve stimulation on pain, function, and descending inhibition in people with non-specific chronic low-back pain: a study protocol for a randomized crossover trial.

BACKGROUND: Low back pain (LBP) is a significant public health problem, is very prevalent, and is often characterized by the persistence of symptoms. Transcutaneous electrical nerve stimulation (TENS) may benefit people with chronic LBP because it can activate descending inhibitory pathways and inhibit central excitability. However, previous studies that have investigated the effects of TENS on pain in people with LBP have failed to use proper intensities of current, and the timing of the assessment of pain was not performed during the peak of the analgesic response or functional activities. Therefore, the present study aims to assess the effects of TENS on measures of pain, function, and descending inhibition using the maximal tolerable intensity of TENS in participants with LBP. METHODS/DESIGN: This study will be a randomized crossover trial. The participants for this study will be recruited from various places, including the University of Hartford, physical therapy clinics, and local businesses in the Hartford area, as well as online websites geared towards clinical trial recruitment. A total of 34 participants will receive all three treatments: active TENS, placebo TENS, and no treatment control. The treatment order will be randomized using a website-based randomization tool. For active TENS, a modulating frequency of 2-125 Hz will be applied with a variable pulse duration and maximal tolerable intensity for 30 min. The TENS will be left on for post-treatment testing to assess the effects during its maximally effective period for a total of 50 to 60 min. Furthermore, the intensity may be turned down if muscle twitching is present to ensure blinding of the evaluator. For placebo TENS, the unit will deliver current for 45 s, ramping to 0 in the last 15 s. The primary outcome will be pain intensity at rest and with movement, determined using the numerical pain rating scale. The secondary outcomes will be pressure pain threshold, heat pain threshold, temporal summation of pain, conditioned pain modulation, sit-to-stand test, and repeated trunk flexion. The assessments will be performed immediately before and after treatment. Statistical analysis of the data obtained will consider a significance level of p < 0.05. DISCUSSION: This study will provide evidence concerning the effects and mechanisms of TENS treatment in participants with chronic non-specific low back pain. The outcomes, including pain, function, and descending inhibition, will help us gain a greater understanding of how TENS can be used for these participants. TRIAL REGISTRATION: ClinicalTrials.gov NCT05812885. Registered on 24th May 2023.

Effects of different treatments on pain, functional disability, position sense and range of motion in elite bodybuilders with chronic low back pain.

Back pain is one of the major global challenges and is one of the most prevalent musculoskeletal disorders occurring in 80% of people at least once in their lifetime. Therefore, the need to find appropriate treatment methods for this issue is very important. The objective is to examine the short-term and acute effects of a treatment session with dry needling, massage therapy, stretching exercises and Kinesio tape on pain, functional disability, position sense and range of motion in elite bodybuilders with non-specific chronic low back pain. The sample of this quasi-experimental study consisted of 48 bodybuilders with non-specific chronic low back pain (all male, mean age = 25.96 ± 2.18 years; mean weight = 74.45 ± 4.51 kg; mean height = 173.88 ± 3.74 cm; mean BMI = 24.60 ± 0.74 kg/m2) who randomly were placed in 4 dry needling, massage therapy, stretching exercises and Kinesio tape groups. The duration of each intervention was 30 min. The dependent variables in this study included the massage range of motion, position sense tests and visual pain scale that were taken separately from each subject in pretest, posttest (acute effect) and follow-up test (72 h after posttest; short-term effect). The results of a 4 (groups) × 3 (time) the mixed ANOVAs showed that pain in the short-term phase was significantly lower in the dry needling group than in the stretching and massage groups (P < 0.05). Also in the acute effect phase, the flexion range of motion was significantly lower in the dry needling group than in the massage group (P < 0.05). Furthermore, the two groups of stretching and massage exercises showed significantly greater range of motion (P < 0.05). Other comparisons were not significant (P > 0.05). The findings of the study showed that both massage and stretching treatment have higher acute effects, while dry needling treatment was more effective in follow up. On the other hand, these findings show that these treatment methods can have immediate and lasting positive effects in improving the performance in elite bodybuilders with non-specific chronic low back pain.

Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial.

OBJECTIVE: The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. DESIGN: A benchmarking controlled trial design was used. SUBJECTS/PATIENTS: Three primary healthcare areas and 654 low back pain patients with or without sciatica. METHODS: Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. RESULTS: No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003).  Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.

Exploring the body surface temperature of the lumbosacral region and relevant back-shu points in patients with lumbar disc herniation induced low back pain based on infrared thermography. / åŸºäºŽçº¢å¤–çƒ­æˆåƒæŠ€æœ¯æŽ¢è®¨è °æ¤Žé—´ç›˜çªå‡ºç—‡è °ç—›æ‚£è€ è °éª¶éƒ¨åŠç›¸å ³èƒŒä¿žç©´è¡¨çš®æ¸©åº¦.

OBJECTIVES: To observe the body surface temperature of the lumbosacral region and relevant back-shu points in patients with lumbar disc herniation (LDH) induced low back pain utilizing infrared thermography, and to explore the functional attribute changes of acupoints under pathological conditions. METHODS: A total of 50 patients with LDH induced low back pain were included as the observation group, and 45 healthy subjects were included as the control group. Using infrared thermography, the body surface temperature of the lumbosacral region and bilateral Sanjiaoshu (BL 22), Shenshu (BL 23), Qihaishu (BL 24), Dachangshu (BL 25), Guanyuanshu (BL 26), Xiaochangshu (BL 27), and Pangguangshu (BL 28) was measured in both groups. The temperature difference values between the bilateral lumbosacral regions and back-shu points of the two groups were calculated. Additionally, the body surface temperature of the affected and healthy sides of the lumbosacral region and relevant back-shu points was compared in the observation group. RESULTS: Compared with the control group, the body surface temperature of the lumbosacral region and the bilateral temperature difference values of the lumbosacral regions were increased in the observation group (P<0.001). The body surface temperature difference values of bilateral Shenshu (BL 23), Qihaishu (BL 24), Dachangshu (BL 25), Guanyuanshu (BL 26) and Xiaochangshu (BL 27) in the observation group were higher than those in the control group (P<0.05, P<0.01, P<0.001). In the observation group, the body surface temperature of the affected side of the lumbosacral region as well as Shenshu (BL 23) and Dachangshu (BL 25) was elevated compared with that of healthy side (P<0.001). CONCLUSIONS: The patients with LDH induced low back pain have imbalanced and asymmetrical distribution of body surface temperature in the lumbosacral region and related back-shu points, Shenshu (BL 23) and Dachangshu (BL 25) have the relative specificity.

Chronic Low Back Pain in Adults: Evaluation and Management.

Chronic low back pain, defined as lumbar pain persisting for 12 weeks or more, occurs in about 13% of U.S. adults. Patients with chronic low back pain should have a history and physical examination to identify red flags that may indicate serious conditions that warrant immediate intervention or yellow flags (i.e., psychological, environmental, and social factors) that indicate risk of disability. The examination should include an evaluation for radicular symptoms. Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy. Patients should avoid bed rest. Nonpharmacologic treatment is first-line management and may include therapies with varying evidence of support, such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy. Pharmacologic interventions are second-line treatment. Nonsteroidal anti-inflammatory drugs are the initial medication of choice; duloxetine may also be beneficial. Evidence is inconclusive to recommend the use of benzodiazepines, muscle relaxants, antidepressants, corticosteroids, insomnia agents, anticonvulsants, cannabis, acetaminophen, or long-term opioids. Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain. Most patients with chronic low back pain will not require surgery; evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk. Physicians should consider prevention of chronic low back pain when patients present with acute back pain. Screening tools are available to predict the progression from acute to chronic low back pain, and targeted treatment strategies are beneficial for preventing progression.

A Study of 60 Patients with Low Back Pain to Compare Outcomes Following Magnetotherapy, Ultrasound, Laser, and Electrotherapy with and without Lumbosacral Kinesiotherapy.

BACKGROUND This study of 60 patients with low back pain (LBP) aimed to compare outcomes following magnetotherapy, ultrasound therapy, laser therapy, and electrotherapy, with and without lumbosacral kinesiotherapy, and used the Roland-Morris Disability Questionnaire (RMDQ) and the Oswestry Low Back Pain Disability Questionnaire (OLBPDQ). This was a randomized actively controlled intervention trial of adding kinesiotherapy to a standard physiotherapy for LBP. MATERIAL AND METHODS The research included 60 participants with a diagnosis of chronic non-specific lumbar pain syndrome (CNSLPS) (mean±SD age 58.3±15.4 years, 37 women) LBP randomly assigned (1: 1) to 2 treatment groups. In Group 1, 30 patients were treated with magnetotherapy, ultrasound therapy, laser therapy, and electrotherapy. In Group 2, 30 patients received the same treatments as in Group 1, and also performed kinesiotherapy exercises affecting the lumbosacral spine and adjacent muscles. At baseline and at the end of the study, all participants completed the RMDQ and the OLBPDQ. RESULTS Both groups had significant improvement after therapy. Repeated-measures ANOVA indicated that at the end of treatment there was significantly greater progress and symptom reduction (P<0.001) in Group 2. Patients in Group 2 had a pain reduction of 52.5%, while Group 1 had 25.4% pain reduction (P=0.009). CONCLUSIONS For treatment of disability caused by CNSLPS, physical therapy combined with kinesiotherapy should be a treatment of choice.

Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study.

BACKGROUND: This study evaluates the feasibility of a nine-month advanced quality-improvement program aimed at enhancing the quality of care provided by primary care physical therapists in the Netherlands. The evaluation is based on routinely collected health outcomes of patients with nonspecific low back pain, assessing three feasibility domains: (1) appropriateness, feasibility, and acceptability for quality-improvement purposes; (2) impact on clinical performance; and (3) impact on learning and behavioral change. METHODS: A mixed-methods quality-improvement study using a concurrent triangulation design was conducted in primary care physical therapist practice. Feedback reports on the processes and outcomes of care, peer assessment, and self-assessment were used in a Plan-Do-Study-Act cycle based on self-selected goals. The program's appropriateness, feasibility, and acceptability, as well as the impact on clinical performance, were evaluated using the Intervention Appropriate Measure, Feasibility Intervention Measure, Acceptability Intervention Measure (for these three measure, possible scores range from 4 to 20), and with a self-assessment of clinical performance (scored 0-10), respectively. The impact on learning and behavioral change was evaluated qualitatively with a directed content analysis. RESULTS: Ten physical therapists from two practices participated in this study. They rated the program with a mean of 16.5 (SD 1.9) for appropriateness, 17.1 (SD 2.2) for feasibility, and 16.4 (SD 1.5) for acceptability. Participants gave their development in clinical performance a mean score of 6.7 (SD 1.8). Participants became aware of the potential value of using outcome data and gained insight into their own routines and motivations. They changed their data collection routines, implemented data in their routine practice, and explored the impact on their clinical behavior. CONCLUSIONS: This explorative study demonstrated that a quality-improvement program, using health outcomes from a national registry, is judged to be feasible. IMPACT STATEMENT: This study provides preliminary evidence on how physical therapists may use health outcomes to improve their quality, which can be further used in initiatives to improve outcome-based care in primary physical therapy.

The Fremantle Back Awareness Questionnaire: cross-cultural adaptation, reliability, and validity of the Italian version in people with chronic low back pain.

BACKGROUND AND AIM: There is evidence to suggest that assessing back-specific altered self-perception may be useful when seeking to understand and manage low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is a patient-reported measure of back-specific body perception that has never been adapted and psychometrically analysed in Italian. Hence, the objectives of this research were to cross-culturally adapt and validate the Italian version of this outcome measure (namely, the FreBAQ-I), to make it available for use with Italians suffering from chronic LBP. METHODS: The FreBAQ-I was developed by forward and backward translation, review by a committee skilled in patient-reported measures and test of the pre-final version to assess its clarity, acceptability, and relevance. The statistical analyses examined: structural validity based on Rasch analysis; hypotheses testing by investigating correlations of the FreBAQ-I with the Roland Morris Disability Questionnaire (RMDQ), a pain intensity numerical rating scale (PI-NRS), the Pain Catastrophising Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) (Pearson's correlations); reliability by internal consistency (Cronbach's alpha) and test-retest repeatability (intraclass correlation coefficient, ICC (2,1)); and measurement error by determining the minimum detectable change (MDC). After the development of a consensus-based translation of the FreBAQ-I, the new outcome measure was delivered to 100 people with chronic LBP. RESULTS: Rasch analysis confirmed the substantial unidimensionality and the structural validity of the FreBAQ-I. Hypothesis testing was considered good as at least 75% of the hypotheses were confirmed; correlations: RMDQ (r = 0.35), PI-NRS (r = 0.25), PCS (r = 0.41) and TSK (r = 0.38). Internal consistency was acceptable (alpha = 0.82) and test-retest repeatability was excellent (ICC (2,1) = 0.88, 95% CI: 0.83, 0.92). The MDC95 corresponded to 6.7 scale points. CONCLUSION: The FreBAQ-I was found to be a unidimensional, valid, and reliable outcome measure in Italians with chronic LBP. Its application is advised for clinical and research use within the Italian speaking community.

The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial.

BACKGROUND: Chronic low back pain (CLBP) is a significant problem affecting millions of people worldwide. Three widely implemented psychological techniques used for CLBP management are cognitive therapy (CT), mindfulness meditation (MM), and behavioral activation (BA). This study aimed to evaluate the relative immediate (pre- to post-treatment) and longer term (pre-treatment to 3- and 6-month follow-ups) effects of group, videoconference-delivered CT, BA, and MM for CLBP. METHODS: This is a secondary analysis of a three-arm, randomized clinical trial comparing the effects of three active treatments-CT, BA, and MM-with no inert control condition. Participants were N = 302 adults with CLBP, who were randomized to condition. The primary outcome was pain interference, and other secondary outcomes were also examined. The primary study end-point was post-treatment. Intent-to-treat analyses were undertaken for each time point, with the means of the changes in outcomes compared among the three groups using an analysis of variance (ANOVA). Effect sizes and confidence intervals are also reported. RESULTS: Medium-to-large effect size reductions in pain interference were found within BA, CT, and MM (ds from - .71 to - 1.00), with gains maintained at both follow-up time points. Effect sizes were generally small to medium for secondary outcomes for all three conditions (ds from - .20 to - .71). No significant between-group differences in means or changes in outcomes were found at any time point, except for change in sleep disturbance from pre- to post-treatment, improving more in BA than MM (d = - .49). CONCLUSIONS: The findings from this trial, one of the largest telehealth trials of psychological treatments to date, critically determined that group, videoconference-delivered CT, BA, and MM are effective for CLBP and can be implemented in clinical practice to improve treatment access. The pattern of results demonstrated similar improvements across treatments and outcome domains, with effect sizes consistent with those observed in prior research testing in-person delivered and multi-modal psychological pain treatments. Thus, internet treatment delivery represents a tool to scale up access to evidence-based chronic pain treatments and to overcome widespread disparities in healthcare. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03687762.

Lumbar intervertebral disc degeneration in low back pain.

Intervertebral disc degeneration is characterized by deterioration in structural support that is potentially followed by stimulated neuronal ingrowth, and dysfunction of cellular physiology in the disc. Discogenic low back pain originates from nociceptors within the intervertebral disc or the cartilage endplate. This narrative review examines the mechanisms of disc degeneration, the association between degeneration and pain, and the current diagnosis and treatment of discogenic low back pain. Mechanisms of disc degeneration include dysregulated homeostasis of the extracellular matrix of the disc, altered spine mechanics, DNA damage, oxidative stress, perturbed cell signaling pathways, and cellular senescence. Although disc degeneration is more common in individuals with low back pain than in asymptomatic ones, degeneration occurs in a large proportion of asymptomatic individuals. Therefore, degeneration itself is not sufficient to trigger low back pain. Imaging and discography are common diagnostic tools of discogenic low back pain but have limited validity to diagnose discogenic pain. Most of current treatments options are not specific to discogenic pain but are unspecific treatments of low back pain of any origin. There is an urgent need to clarify and distinguish the molecular mechanisms of discogenic pain from mechanisms of disc degeneration that are not involved in nociception. Future research should make use of current methods to study molecular mechanisms of human pain in comprehensively and quantitatively phenotyped patients with low back pain, with the objective to identify molecular triggers of discogenic pain and determine the relationship between molecular mechanisms, pain, and patient-relevant outcomes.

Clinical Outcome for Lumbar Disc Herniation Treatment with Intradiscal Oxygen-ozone Therapy.

BACKGROUND: Low back pain due to disc herniation is a common problem causing frequent hospital visits and loss of working days with major socio-economic impact. Conservative treatments like analgesics, physiotherapy do not work in all patients. Surgical treatment has been the mainstay of treatment when indicated but is associated with anesthetic and surgical complications. Intradiscal oxygen-ozone chemonucleolysis is a minimally invasive procedure done under local anesthesia and has promising role in shrinking the bulged disc and reducing nerve root compression and related symptoms. This retrospective study was done to see how intradiscal oxygen-ozone chemonucleolysis reduces pain severity in patients with discogenic low back pain. METHODS: Retrospective data were retrieved of those patients who underwent fluoroscopy guided intradiscal oxygen-ozone chemonucleolysis with 5-6 ml of an O2-O3 mixture (concentration of 30 microgram/ml) during a period of two years in Nepal pain care and research center. Numerical pain scale (NRS) at various follow ups were compared to preprocedural NRS. RESULTS: Preprocedural NRS was 8± 13. NRS at three hours, one week, one month, three months and six months were 2± 13 (73 percent reduction), 2± 53 (68 percent reduction), 2± 27 (72 percent reduction), 1± 08 (77 percent reduction) and 1± 67 (79 percent reduction) respectively. CONCLUSIONS: Intradiscal oxygen-ozone chemonucleolysis can be a useful modality of treatment for discogenic low back pain in patients who fail to respond to conservative management and in whom surgery is not indicated.

The changes of blood-based inflammatory biomarkers after non-pharmacologic interventions for chronic low back pain: a systematic review.

BACKGROUND: Chronic low back pain (CLBP) is a prevalent and debilitating condition, leading to significant challenges to both patients and the governmental healthcare system. Non-pharmacologic interventions have received increasing attention as potential strategies to alleviate chronic low back pain and improve patient outcomes. The aim of this systematic review was to comprehensively assess the changes in blood inflammatory biomarkers after non-pharmacologic interventions for CLBP patients, thus trying to understand the complex interactions between non-pharmacologic interventions and inflammatory biomarker changes in CLBP. METHODS: A thorough search (from January 1st, 2002 to October 5th, 2022) of PubMed, Medline (platform Web of Science), and the Cochrane Library (platform Wiley Online Library) were conducted, and inclusion criteria as well as exclusion criteria were refined to selection of the studies. Rigorous assessments of study quality were performed using RoB 2 from Cochrane or an adaptation of the Downs and Black checklist. Data synthesis includes alterations in inflammatory biomarkers after various non-pharmacologic interventions, including exercise, acupressure, neuro-emotional technique, and other modalities. RESULTS: Thirteen primary studies were included in this systematic review, eight randomized controlled trials, one quasi-randomized trial, and four before-after studies. The interventions studied consisted of osteopathic manual treatment (one study), spinal manipulative therapy (SMT) (three studies), exercise (two studies), yoga (two studies) and acupressure (two studies), neuro-emotional technique (one study), mindfulness-based (one study) and balneotherapy study (one study). Four studies reported some changes in the inflammatory biomarkers compared to the control group. Decreased tumor necrosis factor-alpha (TNF-α) after osteopathic manual treatment (OMT), neuro-emotional technique (NET), and yoga. Decreased interleukin (IL)-1, IL-6, IL-10, and c-reactive protein (CRP) after NET, and increased IL-4 after acupressure. Another five studies found changes in inflammatory biomarkers through pre- and post-intervention comparisons, indicating improvement outcomes after intervention. Increased IL-10 after balneotherapy; decreased TNF-α, IL-1ß, IL-8, Interferon-gamma, interferon-γ-induced protein 10-γ-induced protein 10 after exercise; decreased IL-6 after exercise and SMT; decreased CRP and chemokine ligand 3 after SMT. CONCLUSION: Results suggest a moderation of inflammatory biomarkers due to different non-pharmacologic interventions for CLBP, generally resulting in decreased pro-inflammatory markers such as TNF-α and IL-6 as well as increased anti-inflammatory markers such as IL-4, thus revealing the inhibition of inflammatory processes by different non-pharmacologic interventions. However, a limited number of high-quality studies evaluating similar interventions and similar biomarkers limits the conclusion of this review.

A qualitative study exploring the ritual-like activity and therapeutic relationship between Pilates teachers and clients with persistent low back pain.

BACKGROUND AND PURPOSE: Pilates is a commonly recommended exercise modality for the management of persistent low back pain. Whilst guidelines recommend the use of exercise for low back pain, research suggests that no one exercise is superior, creating a question over the mechanism of effect. The patient-practitioner relationship may be important in managing low back pain; however, the relationship between Pilates teachers and clients is not well understood. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain, explore key influences on the relationship, and ascertain the nature of the relationship. METHOD: We conducted a qualitative, ethnographically-informed study at eight sites in the South of England, observing 24 Pilates sessions and interviewing 9 Pilates teachers and 10 clients with persistent low back pain. Fieldnotes and interview transcripts were analysed thematically. RESULTS: The findings demonstrate a complex, multi-faceted interaction that occurs during Pilates sessions, grounded within certain health perceptions, and predicated on expectations of individuality, choice and expertise. A key finding reveals the perceived importance of mastery of prescribed movements with control and precision, in which clients particularly value the authority of the teacher in a directive learning environment. CONCLUSION: We contend that the role of the Pilates teacher in this study facilitated the alleviation of clients' distress through the application of ritual-like Pilates activity. We conclude that the relationship between Pilates teachers and clients with persistent low back pain may be considered a therapeutic relationship.

Effect of aerobic exercises on patients with chronic mechanical low back pain: A randomized controlled clinical trial.

BACKGROUND: Chronic mechanical low back pain (CMLBP) is one of the most prevalent and costly disorders. Determining its most effective treatment approach is a priority for researchers. PURPOSE: To examine the effects of including aerobic exercise within a conventional therapy regimen for young adults with CMLBP. METHODS: Fifty CMLBP patients (22 males and 28 females) were randomly and equally assigned to one of two groups to receive the prescribed treatment for 8 weeks. The control group received the traditional program only (infrared, ultrasound, burst TENS, and exercises); for the experimental group, an aerobic training program using a stationary bicycle was added. Back pain intensity was the primary outcome. Secondary outcomes included the Oswestry disability index, back extensor endurance measured by the Sorensen test, and physical performance indicated by the back performance scale and the 6-min walk test. A Two-way MANOVA was used for data analysis. RESULTS: Multivariate tests revealed statistically significant effects of group (p = 0.002, partial η2 = 0.182), time (p < 0.001, partial η2 = 0.928), and group-by-time interaction (p = 0.01, partial η2 = 0.149). Univariate group-by-time interactions were significant for back disability (p = 0.043), extensor endurance (p = 0.023) and results of the 6-min walk test (p = 0.023) showing greater improvement in the experimental group. However, back pain intensity and the back performance scale revealed no significant group-by-time interactions. Within-group comparisons were significant for all measured variables in both groups (p < 0.001). CONCLUSION: Although a traditional program of infrared, ultrasound, TENS, and exercises is beneficial for CMLBP treatment, adding aerobic exercises to the program leads to more beneficial outcomes.

Development and pilot of equine facilitated physical therapy outcome measure tool for chronic low back pain patients.

Equine Facilitated Physical Therapy (EFPT) lacks consistent documentation due to being an unconventional physical therapy treatment to chronic low back pain patients (LBP) and lacking rehabilitation outcome measure tools for a stable (equestrian) environment. The objectives were to develop an online evaluation tool as well as to define inter- and intra-rater reliability to validate the outcome measurement tool "Evaluation of maintaining sitting position (on a horse) and walking (short distances)" designed for LBP patients in EFPT". A total of 48 movement related functions (n = 48), were derived from the International Classification of Functioning (ICF) and organized to an online evaluation tool. Depending on the state of validation two to six (2-6) raters scored randomized patient (n = 22) video material, recorded during a 12-week EFPT intervention, with the designed tool. Inter-rater agreement level between the experts reached good (α = 87) reliability for the scoring of the items and calculated per patient excellent (α = 100). Intra-rater reliability reached good (α = 87) and per patient good (α = 80) repeatability. For the healthy adults the reliability between raters reached acceptable (α = 72) levels and per rated excellent (α = 100). The developed assessment tool was found satisfactory to fulfil the requirement for the therapeutic practice. With the use of the tool physical therapist may detect postural changes for LBP patients as outcome report in EFPT. The tool may be used to identify treatment progress and to help design home exercises. The created tool will help to collect similar outcome measures from LBP patients in EFPT and to validate the treatment within industry.

Factors associated with return to play following conservative treatment for lumbar spondylolysis among young athletes: A retrospective case series using structural equation modeling.

INTRODUCTION: Lumbar spondylolysis is the most common underlying cause of lower back pain (LBP) in young athletes. Conservative treatment methods are often used to reduce pain and promote healing. Several parameters may affect the duration of conservative treatment, such as the time to return to play (RTP), patient behavior, and physical parameters; however, no study has comprehensively assessed the factors that affect the time to RTP. OBJECTIVES: This study aimed to determine the factors associated with the time required for RTP among young athletes with early-stage spondylolysis receiving conservative treatment using structural equation modeling (SEM). METHODS: In this retrospective case series, 137 young athletes (128 males and 9 females, aged 9-18 years) with early-stage lumbar spondylolysis were enrolled. All patients were examined using plain radiography and magnetic resonance imaging and treated conservatively (sports cessation, wearing a corset, therapeutic exercises, and low-intensity pulsed ultrasound radiation). SEM was used to investigate the factors affecting the time to RTP in these patients. RESULTS: The final model included the following factors: spondylolysis laterality, symptom duration, lower-extremity flexibility, treatment interval, patient adherence, and residual LBP. SEM revealed that patient adherence to physician orders (p < 0.01), treatment interval (p < 0.001), and spondylolysis laterality (p < 0.001) contributed directly to shortened RTP. CONCLUSION: Patient adherence is essential for reducing the time to RTP among young athletes receiving conservative treatment for early-stage spondylolysis.

Translation, validity and reliability of the pain attitudes and beliefs scale for physiotherapists in French.

BACKGROUND: The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) questionnaire evaluates manual therapists' biomedical and biopsychosocial beliefs regarding the management of chronic low back pain. Its usage in clinical settings is an important step in the implementation of national guidelines and policies to improve patient management. OBJECTIVES: The objective of this study was to translate the PABS-PT questionnaire into French, to adapt it culturally, and to conduct a psychometric analysis. DESIGN: Qualitative and cross-sectional study. METHOD: The translation process followed published guidelines with cross-cultural validation by an expert committee. We followed a forward and backward translation procedure and an expert committee, including the original author of the questionnaire and a linguistics expert ensuring good cultural adaptation, issued a finalised version. Psychometric analysis of the French version of the questionnaire was conducted among 390 French manual therapists in two phases. The first phase evaluated structural validity as well as external validity compared with the TSK and BBQ questionnaires. Then, reliability and scalability were analysed. The second phase evaluated test-retest reproducibility by sending the same questionnaire 3 months later. RESULTS: The validity study revealed three subscales: the classic biomedical subscale and two subscales for biopsychosocial beliefs (aetiology of pain and physical activity). With 21 items in total for the PABS-PT-FR, the structural validity scores were good (BM: alpha = 0.82, H = 0.38; Physical Activity: alpha = 0.62, H = 0.32; Aetiology of Pain: alpha = 0.55, H = 0.29). CONCLUSIONS: This study provides a validated tool to assess French physiotherapists' and, more generally, healthcare providers' beliefs about chronic low back pain, with a new insight into the BPS subscale internal construct.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial.

INTRODUCTION: Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS: NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION: This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER: ACTRN12623001000695.