Assessing the performance of AI chatbots in answering patients' common questions about low back pain.

OBJECTIVES: The aim of this study was to assess the accuracy and readability of the answers generated by large language model (LLM)-chatbots to common patient questions about low back pain (LBP). METHODS: This cross-sectional study analysed responses to 30 LBP-related questions, covering self-management, risk factors and treatment. The questions were developed by experienced clinicians and researchers and were piloted with a group of consumer representatives with lived experience of LBP. The inquiries were inputted in prompt form into ChatGPT 3.5, Bing, Bard (Gemini) and ChatGPT 4.0. Responses were evaluated in relation to their accuracy, readability and presence of disclaimers about health advice. The accuracy was assessed by comparing the recommendations generated with the main guidelines for LBP. The responses were analysed by two independent reviewers and classified as accurate, inaccurate or unclear. Readability was measured with the Flesch Reading Ease Score (FRES). RESULTS: Out of 120 responses yielding 1069 recommendations, 55.8% were accurate, 42.1% inaccurate and 1.9% unclear. Treatment and self-management domains showed the highest accuracy while risk factors had the most inaccuracies. Overall, LLM-chatbots provided answers that were 'reasonably difficult' to read, with a mean (SD) FRES score of 50.94 (3.06). Disclaimer about health advice was present around 70%-100% of the responses produced. CONCLUSIONS: The use of LLM-chatbots as tools for patient education and counselling in LBP shows promising but variable results. These chatbots generally provide moderately accurate recommendations. However, the accuracy may vary depending on the topic of each question. The reliability level of the answers was inadequate, potentially affecting the patient's ability to comprehend the information.

Clinical indicators to monitor health care in low back pain: a scoping review.

Clinical care indicators for low back pain can be used to monitor healthcare practices and consequently be used to evaluate success of strategies to improve care quality. The aim of this study was to identify the clinical care indicators that have been used to measure appropriateness of health care for patients with low back pain. We conducted a systematic search of five electronic databases and Google to identify clinical care indicators that have been used to measure any aspect of care for people with low back pain. Care indicators were narratively described according to their type (i.e. structure, process, or outcomes) and categorized by their purpose (e.g. to measure aspects related to assessment, imaging requests, treatment/prevention, and outcomes). A total of 3562 and 2180 records were retrieved from electronic databases and Google searches, respectively. We identified 280 indicators related to low back pain care from 40 documents and publications. Most quality indicators were process indicators (n = 213, 76%), followed by structure (n = 41, 15%) and outcome indicators (n = 26, 9%). The most common indicators were related to imaging requests (n = 41, 15%), referral to healthcare providers (n = 30, 11%), and shared decision-making (n = 21, 7%). Our review identified a range of clinical care indicators that have been used to measure the quality of health care for people with low back pain. Our findings will support a Delphi study to reach international consensus on what would be the most important and feasible indicators for a minimum dataset to be collected globally.

Clinical care standards for the management of low back pain: a scoping review.

The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.

Compared to what? An analysis of comparators in trials informing the National Institute of Clinical Excellence (NICE) low back pain guideline.

BACKGROUND: Low back pain (LBP) is the leading cause of disability globally. Clinical practice guidelines (CPGs) have been developed in hopes of encouraging evidence-based care for LBP. However, poor quality of trials that underpin CPGs can lead to misleading recommendations for LBP. OBJECTIVES: To categorize the comparator used in trials included in the National Institute of Clinical Excellence (NICE) LBP CPG and describe the proportion and association of suboptimal comparators with NICE recommendation. METHODS: We conducted a cross-sectional analysis to describe the proportion of trials included in the NICE LBP CPG that used a suboptimal comparator. If comparators used an ineffective treatment, a treatment of unknown effectiveness, or no or minimal treatment then they were considered suboptimal. RESULTS: We included 408 trials and analyzed 580 comparators used in the trials. 30.9% of the comparators used in the trials were suboptimal. Trials testing invasive treatments (32.4%) had the highest proportion of suboptimal comparators followed by non-surgical (32.3%) and pharmacological (19.0%) treatments. Trials using suboptimal treatments were less likely to have their treatment recommended (odds ratio: 0.68; 95% CI: 0.47, 0.98) for use by NICE. CONCLUSION: There is a concerning proportion of suboptimal comparators used in LBP trials that may be misleading CPG recommendations, funding allocation decisions, and ultimately clinical practice. Efforts to increase the use of optimal comparators in LBP trials are urgently needed to better understand what treatments should be recommended.

A content analysis of online information about the benefits and harms of spine surgery.

BACKGROUND: It is unknown whether online information about the benefits and harms of surgery contains an accurate description of evidence. OBJECTIVE: To describe the proportion of webpages containing information about surgery for spinal pain (decompression and fusion) that accurately described the evidence on the benefits of surgery, described harms, and provided quantitative estimates of these harms. METHODS: We performed a content analysis of webpages containing information about spine surgery. Two reviewers identified webpages and extracted data. Primary outcomes were the proportion of webpages that accurately described the evidence on the benefits, described harms, and provided quantitative estimates of these harms. RESULTS: We included 117 webpages. Only 29 (25%) webpages accurately described the evidence on the benefits of spine surgery, and more webpages on decompression accurately described the evidence compared to webpages on fusion (31% vs 15%, difference in proportions = 16%; 95% CI: 2%, 31%). Harms of surgery were described in most webpages (n = 76, 65%), but a much smaller proportion of webpages (n = 18, 15%) provided a quantitative estimate for the mentioned harms. CONCLUSIONS: Most webpages failed to accurately describe the benefits and harms of decompression and fusion surgeries for spinal pain. Unbiased consumer resources and educating the public on how to critically evaluate health claims are important steps to improve knowledge on the benefits and harms of spine surgery.

Meditation for adults with non-specific low back pain: a systematic review and meta-analysis.

OBJECTIVES: We aim to determine the effectiveness of meditation for adults with non-specific low back pain. METHODS: We searched PubMed, EMBASE, PEDro, Scopus, Web of Science, Cochrane Library, and PsycINFO databases for randomized controlled trials that investigated the effectiveness of meditation in adults with non-specific low back pain. Two reviewers rated risk of bias using the PEDro scale and the certainty of the evidence using the GRADE approach. Primary outcomes were pain intensity and disability. RESULTS: We included eight trials with a total of 1,234 participants. Moderate-certainty evidence shows that meditation is better than usual care for disability at short-term (SMD = -0.22; 95% CI = -0.42 to -0.02). We also found that meditation is better than usual care for pain intensity at long-term (SMD = -0.28; 95% CI = -0.54 to -0.02). There is no significant difference for pain intensity between meditation and minimal intervention or usual care at short and intermediate-term. We did not find differences between meditation and minimal intervention for disability at intermediate-term or usual care in any follow-up period. CONCLUSIONS: We found small effect sizes and moderate-certainty evidence that meditation is slightly better than minimal intervention in the short-term for disability. Low-certainty of evidence suggests that meditation is slightly better than usual care for pain in the long-term. Meditation appears to be safe with most trials reporting no serious adverse events.

A look into the challenges and complexities of managing low back pain in Mexico.

Low back pain is a global health problem. In Mexico it is one of the most common musculoskeletal conditions as well as the leading cause of disability. This review provides an overview of the challenges and complexities of managing low back pain in Mexico. It begins with an explanation of the Mexican healthcare system and an overview of the burden of low back pain. Usual care for low back pain in Mexico is then contrasted with recommended best practice care to highlight common evidence-practice gaps and drivers of poor care. Finally, solutions are proposed based on positive experiences from other countries. Delving into the Mexican health framework and the burden of low back pain will provide a better understanding of why it is important to pay attention to this musculoskeletal disorder. Potential steps required to reduce the burden are also outlined to benefit not only the people suffering from low back pain but also the Mexican economy and society.

TOPS - a randomized controlled trial of exercise and education to prevent recurrence of low back pain: statistical analysis plan.

BACKGROUND: This a priori statistical analysis plan describes the methods of analysis for the Trial Of Prevention Strategies for low back pain (TOPS). OBJECTIVES: TOPS aimed to investigate the effectiveness and cost-effectiveness of exercise and education classes compared with a minimal intervention control in preventing recurrence of low back pain (LBP) in people who have recently recovered from an episode of LBP. METHODS: TOPS is a superiority, pragmatic, parallel-group randomized controlled trial with allocation concealment, blinded outcome assessors, and intention-to-treat analysis. Participants were randomized to a physical therapist-led exercise and education program for 12 weeks or minimal intervention. The primary outcome was days to recurrence of an episode of LBP. The three key secondary outcomes were days to recurrence of an episode of LBP resulting in (1) activity limitation, (2) care seeking for LBP; and (3) work absence of at least 1 day. Differences in survival curves for the primary (days to recurrence) and secondary outcome (days to LBP with activity limitation, days to care seeking due to LBP, and days to work absence due to LBP) will be compared using Cox regression. Hazard ratios (HRs) and median survival times with 95% confidence intervals (CI) will be calculated. The number of adverse events, including serious adverse events will be reported and the proportion of adverse events between groups will be compared using a Chi-squared test. DISCUSSION: This paper will provide a detailed description of the planned analyses for the TOPS trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12615000939594).

Short-Term Effects of Different Rates of Thoracic Mobilization on Pressure Pain Thresholds in Asymptomatic Individuals: A Randomized Crossover Trial.

OBJECTIVE: The primary aim of this study was to determine the effects of different rates of thoracic spine passive accessory intervertebral mobilization (PAIVM) on pressure pain threshold (PPT) at T4. The secondary aim was to investigate the widespread effects of different rates of thoracic PAIVM. METHODS: Twenty asymptomatic participants were randomly assigned to 3 experimental conditions: posteroanterior rotatory thoracic PAIVM at 2 Hz, 0.5 Hz, and placebo. Each participant received all 3 experimental conditions in a random order with a washout period of at least 48 hours between each procedure. The PPT was measured in 3 different points: pre-treatment, immediately after, and 15 minutes after the treatment at C7 and T4 spinous process, first interossei dorsal on the right and left hands and tibial tuberosity bilaterally. A repeated-measures analysis of covariance adjusted by baseline values was used to assess between-group differences at each point. Pairwise comparisons were adjusted for multiple tests with a Bonferroni correction. A P value < .05 was considered significant. RESULTS: There was no between-group differences on PPT at T4 when comparing 0.5 Hz (mean difference -0.29; 95% CI -0.99 to 0.42; P = .999) or 2 Hz (mean difference -0.37; 95% CI -1.1 to 0.33; P = .528) to placebo. CONCLUSION: None of the mobilization techniques in this study (0.5 Hz, 2 Hz, and placebo) showed a significant change of PPT both locally and at distant sites at any point in asymptomatic participants.

Neurodynamic treatment for patients with nerve-related leg pain: Protocol for a randomized controlled trial.

OBJECTIVES: To investigate if neurodynamic treatment is more effective than advice to remain active in patients with nerve-related leg pain. DESIGN: Parallel-group randomized controlled trial blinded to the outcome assessor conducted in Porto Alegre, Brazil. PARTICIPANTS: Sixty patients recruited from the community and private practices. INTERVENTION: Patients will be randomly assigned to receive four sessions of neurodynamic treatment over two weeks comprising passive lumbar foramen opening and neurodynamic sliders plus home exercises or advice to remain active. MAIN OUTCOME MEASURES: Leg pain intensity, disability, low back pain intensity, functional ability, symptoms distribution and global impression of recovery will be assessed at two and four weeks after randomization. ANALYSIS: A linear mixed model will be employed for each outcome following intention to treat principles.

Global Postural Reeducation for patients with musculoskeletal conditions: a systematic review of randomized controlled trials.

OBJECTIVES: To systematically review randomized controlled trials that assessed the effects of Global Postural Reeducation (GPR) on patient-reported outcomes in conditions of the musculoskeletal system. METHOD: An electronic search of MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, and SciELO was performed from their inception to June 2015. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate risk of bias, and the quality of evidence was rated following the GRADE approach. There were no language restrictions. RESULTS: Eleven trials were included totaling 383 patients. Overall, the trials had high risk of bias. GPR was superior to no treatment but not to other forms of treatment for pain and disability. No placebo-controlled trials were found. CONCLUSION: GPR is not superior to other treatments; however, it is superior to no treatment. Due to the lack of studies, it is unknown if GPR is better than placebo. The quality of the available evidence ranges from low to very low, therefore future studies may change the effect estimates of GPR in musculoskeletal conditions.

Global Postural Reeducation for patients with musculoskeletal conditions: a systematic review of randomized controlled trials

ABSTRACT Objectives To systematically review randomized controlled trials that assessed the effects of Global Postural Reeducation (GPR) on patient-reported outcomes in conditions of the musculoskeletal system. Method An electronic search of MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, and SciELO was performed from their inception to June 2015. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate risk of bias, and the quality of evidence was rated following the GRADE approach. There were no language restrictions. Results Eleven trials were included totaling 383 patients. Overall, the trials had high risk of bias. GPR was superior to no treatment but not to other forms of treatment for pain and disability. No placebo-controlled trials were found. Conclusion GPR is not superior to other treatments; however, it is superior to no treatment. Due to the lack of studies, it is unknown if GPR is better than placebo. The quality of the available evidence ranges from low to very low, therefore future studies may change the effect estimates of GPR in musculoskeletal conditions.