Personalizing rehabilitation for individuals with musculoskeletal impairments: Feasibility of implementation of the Measures Associated to Prognostic (MAPS) tool.

INTRODUCTION: The Measures Associated to PrognoStic (MAPS) tool is a standardized questionnaire that integrates validated prognostic tools to detect the presence of biopsychosocial prognostic factors in patients consulting for musculoskeletal disorders. PURPOSE: The objectives were to assess the: 1) feasibility of implementation of the MAPS tool, 2) clinicians' acceptability of the dashboard, and 3) patients' acceptability of the MAPS tool. METHODS: Twenty physiotherapists and two occupational therapists from seven outpatient musculoskeletal clinics were recruited to implement the MAPS tool during a 3-month timeframe, where new patients completed the questionnaire upon initial assessment. The results were presented to the clinicians via a dashboard. Surveys and semi-structured interviews were conducted to measure feasibility and acceptability. RESULTS: Six out of 11 feasibility criteria (55%) and 21 out of 24 acceptability criteria (88%) reached the a priori threshold for success. The interviews allowed us to identify three main themes to facilitate implementation: 1) limiting the burden, 2) ensuring patients' understanding of the tool's purpose, and 3) integrating the dashboard as a clinical information tool. CONCLUSION: Our quantitative and qualitative results support the feasibility of implementation and acceptability of the MAPS tool pending minor adjustments. Depicting the patients' prognostic profile has the potential to help clinicians optimize their interventions for patients presenting with musculoskeletal disorders.

Establishing the prognostic profile of patients with work-related musculoskeletal disorders: Development and acceptability of the MAPS questionnaire.

PURPOSE: Work-related musculoskeletal disorders (WRMD) are the most common causes of disability worldwide and are associated with significant use of healthcare. One way to optimize the clinical outcomes of injured workers receiving rehabilitation is to identify and address individual prognostic factors (PF), which can facilitate the personalization of the treatment plan. As there is no pragmatic and systematic method to collect prognostic-related data, the purpose of the study was to develop and assess the acceptability of a set of questionnaires to establish the "prognostic profile" of workers with WRMD. METHODS: We utilized a multistep process to inform the acceptability of the Measures Associated to PrognoStic (MAPS) questionnaire. During STEP-1, a preliminary version of the was developed through a literature search followed by an expert consensus including a patient-advisor. During STEP-2, future users (rehabilitation professionals, healthcare administrators and compensation officers) were consulted through an online survey and were asked to rate the relevance of each content item; items that obtained ≥80% of "totally agree" answers were included. They were also asked to prioritize PF according to their usefulness for clinical decision-making, as well as perceived efficacy to enhance the treatment plan. RESULTS: The questionnaire was developed with three categories: the outcome predicted, the unique PF, and prognostic tools. Personal PF (i.e.: coping strategies, fear-avoidance beliefs), pain related PF (i.e.: pain intensity/severity, duration of pain), and work-related PF (i.e.: work physical demands, work accommodations) were identified to be totally relevant and included in the questionnaire. 84% of the respondents agreed that their patients could complete the MAPS questionnaire in their clinical setting, while 75% totally agreed that the questionnaire is useful to personalize rehabilitation interventions. CONCLUSION: The MAPS questionnaire was deemed acceptable to establish the "prognostic profile" of injured workers and help the clinicians in the treatment decision-making process.

Prognostic factors specific to work-related musculoskeletal disorders: An overview of recent systematic reviews.

PURPOSE: Work-related injuries affect a considerable number of people each year and represent a significant burden for society. To reduce this burden, optimizing rehabilitation care by integrating prognostic factors (PF) into the clinical decision-making process is a promising way to improve clinical outcomes. The aim of this study was to identify PF specific to work-related musculoskeletal disorders. METHODS: We performed an overview of systematic reviews reporting on PF that had the following outcomes of interest: Return to work, pain, disability, functional status, or poor outcomes. Each extracted PF was categorized according to its level of evidence (grade A or B) and whether it was modifiable or not. The risk of bias of each study was assessed with the ROBIS tool. RESULTS: We retrieved 757 citations from 3 databases. After removing 307 duplicates, 450 records were screened, and 20 studies were retained. We extracted a total of 20 PF with a Grade A recommendation, where 7 were deemed modifiable, 11 non-modifiable and 2 were index test. For example, return to work expectations, previous sick leave, delay in referral and pain intensity were found to be predictors of return-to-work outcomes. We also identified 17 PF with a Grade B recommendation, where 11 were deemed modifiable. For example, poor general health, negative recovery expectations, coping and fear-avoidance beliefs, pain severity, and particularly physical work were found to predict return to work outcomes. CONCLUSION: We found numerous modifiable PFs that can help clinicians personalize their treatment plan beyond diagnostic-related information for work-related musculoskeletal disorders.

Optimising management of low back pain through the pain and disability drivers management model: Findings from a pilot cluster nonrandomised controlled trial.

INTRODUCTION: Low back pain (LBP) remains the leading cause of disability. The Low Back Pain and Disability Drivers Management (PDDM) model aims to identify the domains driving pain and disability to guide clinical decisions. The objectives of this study were to determine the feasibility of conducting a pragmatic controlled trial of the PDDM model and to explore its effectiveness compared to clinical practice guidelines' recommendations for LBP management. METHODS: A pilot cluster nonrandomised controlled trial. Participants included physiotherapists and their patients aged 18 years or older presenting with a primary complaint of LBP. Primary outcomes were the feasibility of the trial design. Secondary exploratory analyses were conducted on LBP-related outcomes such as pain severity and interference at 12-week follow-up. RESULTS: Feasibility of study procedures were confirmed, recruitment exceeded our target number of participants, and the eligibility criteria were deemed suitable. Lost to follow-up at 12 weeks was higher than expected (43.0%) and physiotherapists' compliance rates to the study protocol was lower than our predefined threshold (75.0% vs. 57.5%). A total of 44 physiotherapists and 91 patients were recruited. Recommendations for a larger scale trial were formulated. The PDDM model group demonstrated slightly better improvements in all clinical outcome measures compared to the control group at 12 weeks. CONCLUSION: The findings support the feasibility of conducting such trial contingent upon a few recommendations to foster proper future planning to determine the effectiveness of the PDDM model. Our results provide preliminary evidence of the PDDM model effectiveness to optimise LBP management. CLINICAL TRIAL REGISTRATION: Clinicaltrial.gov, NCT04893369.

Self-management programs to ensure sustainable return to work following long-term sick leave due to low back pain: A sequential qualitative study.

BACKGROUND: Low back pain (LBP) is a prevalent condition frequently leading to disability. Research suggests that self-management (SM) programs for chronic LBP should include strategies to promote sustainable return to work. OBJECTIVES: This study aimed to 1) validate and prioritize the essential content elements of a SM program in light of the needs of workplace representatives, and 2) identify the main facilitators and barriers to be considered when developing and implementing a SM program delivered via information and communication technologies (ICT). METHODS: A sequential qualitative design was used. We recruited workplace representatives and potential future users of SM programs (union representatives and employers) and collected data through focus groups and nominal group techniques to validate the relevance of the different elements included into 3 broad categories (Understand, Learn, Apply), as well as to highlight potential barriers and facilitators. RESULTS: Eleven participants took part in this study. The content elements proposed in the scientific literature for SM programs were found to align with potential future users' needs, with participants ranking the same elements as those proposed in the literature as the most important across all categories. Although some barriers were identified, workplace representatives believed that ICT offer an appropriate strategy for delivering individualized SM programs to injured workers who have returned to work. CONCLUSION: Our study suggests that the elements identified in the scientific literature as essential components of SM programs designed to ensure a sustainable return to work for people with LBP are in line with the needs of future users.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination.

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation.

BACKGROUND: Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs. OBJECTIVES: The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice. METHODS: We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process. RESULTS: We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP. CONCLUSIONS: We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

Optimizing management of low back pain through the pain and disability drivers management model: A feasibility trial.

INTRODUCTION: Self-reported levels of disability in individuals with low back pain (LBP) have not improved in the last decade. A broader perspective and a more comprehensive management framework may improve disability outcomes. We recently developed and validated the Low Back Pain and Disability Drivers Management (PDDM) model, which aims to identify the domains driving pain and disability to guide clinical decisions. The objectives of this study were to determine the applicability of the PDDM model to a LBP population and the feasibility of conducting a pragmatic trial, as well as to explore clinicians' perceived acceptability of the PDDM model's use in clinical settings. METHODS: This study was an one-arm prospective feasibility trial. Participants included physiotherapists working with a population suffering from LBP and their patients aged 18 years or older presenting with a primary complaint of LBP that sought a new referral and deemed fit for rehabilitation from private and public clinical settings. Clinicians participated in a one-day workshop on the integration of the PDDM model into their clinical practice, and were asked to report various LBP-related outcomes via self-reported questionnaires (i.e., impact of pain on physical function, nervous system dysfunctions, cognitive-emotional factors, work disabilities) at baseline and at six-week follow-up. Physiotherapists' acceptability of the use of the PDDM model and appreciation of the training were assessed via semi-structured phone interviews. Analyses focused on a description of the model's applicability to a LBP population, feasibility outcomes and acceptability measures. RESULTS: Applicablity of the PDDM model was confirmed since it successfully established the profile of patients according to the elements of each categories, and each of the 5 domains of the model was represented among the study sample. Trial was deemed feasible contingent upon few modifications as our predefined success criteria for the feasibility outcomes were met but feasibility issues pertaining to data collection were highlighted. Twenty-four (24) clinicians and 61 patients were recruited within the study's timeframe. Patient's attrition rate (29%) and clinicians' compliance to the study protocol were adequate. Clinicians' perceived acceptability of the use of the model in clinical settings and their appreciation of the training and online resources were both positive. Recommendations to improve the model's integration in clinical practice, content of the workshop and feasibility of data collection methods were identified for future studies. A positive effect for all patients' reported outcome measures were also observed. All outcome measures except for the PainDetect questionnaire showed a statistically significant reduction post-intervention (p<0.05). CONCLUSION: These findings provide preliminary evidence of the potential of the PDDM model to optimize LBP management as well as conducting a future larger-scale pragmatic trial to determine its effectiveness. TRIAL REGISTRATION: Clinicaltrial.gov: NCT03949179.

Deciphering programs for optimal self-management of persistent musculoskeletal-related pain and disability - Clinical implications for PTs.

The prolonged disability associated with musculoskeletal (MSK) pain represents an enormous health burden, for individuals as well as society. Promoting pain and disability management for patients with persistent MSK-related conditions can be very challenging for rehabilitation professionals. These often-complex conditions require the adoption of a biopsychosocial perspective in order to assess and address a vast array of potential factors affecting the patient. Fortunately, a self-management (SM) approach has been deemed effective in enhancing patients' control over their symptoms and disabilities. However, given the many different existing SM approaches, rehabilitation professionals would benefit from a clearer definition of SM and a better understanding of the basics of a SM program in order to facilitate their patients' development of SM skills, as this can lead to better outcomes. This narrative review explores the various components of an intervention program intended to facilitate patients' SM of their symptoms and disabilities resulting from a persistent MSK condition. It does so by drawing on a body of published work on pain and disability management, conceptual frameworks underlying SM programs, essential skills associated with optimal SM, and examples from the persistent low back pain (LBP) literature.

A logic model for a self-management program designed to help workers with persistent and disabling low back pain stay at work.

BACKGROUND: Workers with persistent disabling low back pain (LBP) often encounter difficulty staying at work. Self-management (SM) programs can offer interesting avenues to help workers stay at work. OBJECTIVE: To establish the plausibility of a logic model operationalizing a SM program designed to help workers with persistent disabling LBP stay at work. METHODS: We used a qualitative design. A preliminary version of the logic model was developed based on the literature and McLaughlin et al.'s framework for logic models. Clinicians in work rehabilitation completed an online survey on the plausibility of the logic model and proposed modifications, which were discussed in a focus group. Thematic analyses were performed. RESULTS: Participants (n = 11) found the model plausible, contingent upon a few modifications. They raised the importance of making more explicit the margin of maneuver or "job leeway" for a worker who is trying to stay at work and suggested emphasizing a capability approach. Enhancing the workers' perceived self-efficacy and communication skills were deemed essential tasks of the model. CONCLUSION: A plausible logic model for a SM program designed for workers with disabling LBP stay at work was developed. The next step will be to assess its acceptability with potential users.

Driving the Musculoskeletal Diagnosis Train on the High-Value Track.

Clinicians who provide high-value musculoskeletal care offer evidence-based management that can improve pain, function, and quality of life. However, the current approach to improving outcomes emphasizes treatment strategies at the expense of accurate diagnosis. Guidelines rarely provide quality information on differential diagnosis and prognosis. The disconnect is worrying, because accurate diagnosis can lead to more appropriate care and improved patient outcomes. In this Viewpoint, we reflect on how the clinician can refine musculoskeletal diagnoses to provide high-value care. We (1) argue that the link between musculoskeletal diagnosis and patient outcomes must be strengthened, (2) introduce a diagnostic framework to help clinicians go beyond "special tests," and (3) present new methods for researchers to move forward from diagnostic accuracy studies. J Orthop Sports Phys Ther 2020;50(3):118-120. doi:10.2519/jospt.2020.0603.

Do experienced physiotherapists and final year physiotherapy trainees apply similar force during posterior-to-anterior lumbar mobilization techniques?

This study aims to quantify the force applied during posterior-to-anterior lumbar vertebrae mobilizations of different grades (I to IV) and compare that force between experienced physiotherapists and final year physiotherapy students. Four experienced physiotherapists and four final year physiotherapy students participated in this study along with five healthy asymptomatic individuals. A manual therapy table positioned over three force plates allowed for measurements of the force oscillation frequency and intensity applied during grade I, II, III and IV posterior-to-anterior (PA) mobilizations at two lumbar vertebral levels (L2 and L4). Mixed model ANOVAs were used to compare the force applied between the experienced physiotherapists and students, and between the various grades. The results showed that the mean oscillation frequency was similar between the groups for all grades. Grade I and grade IV PA mobilizations showed similar mean oscillation frequency as did grade II and III PA mobilizations. The minimum and maximum force applied was higher for the physiotherapists than for the students for all mobilization grades (p values < 0.05). Similar mean maximum force values were recorded for PA mobilizations between grade I and II and between grade III and grade IV. Grade III and IV PA mobilizations yielded higher mean maximum force values than those recorded during grade I and grade II PA mobilizations. The method used in this study allowed for quantification of the force applied during lumbar PA mobilizations. Experienced physiotherapists apply greater force than physiotherapy students across all grades, despite similar oscillation frequency.