Spinal degeneration and lumbar multifidus muscle quality may independently affect clinical outcomes in patients conservatively managed for low back or leg pain.

Few non-surgical, longitudinal studies have evaluated the relations between spinal degeneration, lumbar multifidus muscle (LMM) quality, and clinical outcomes. None have assessed the potential mediating role of the LMM between degenerative pathology and 12-month clinical outcomes. This prospective cohort study used baseline and 12-month follow-up data from 569 patients conservatively managed for low back or back-related leg pain to estimate the effects of aggregate degenerative lumbar MRI findings and LMM quality on 12-month low back and leg pain intensity (0-10) and disability (0-23) outcomes, and explored the mediating role of LMM quality between degenerative findings and 12-month clinical outcomes. Adjusted mixed effects generalized linear models separately estimated the effect of aggregate spinal pathology and LMM quality. Mediation models estimated the direct and indirect effects of pathology on leg pain, and pathology and LMM quality on leg pain, respectively. Multivariable analysis identified a leg pain rating change of 0.99 [0.14; 1.84] (unstandardized beta coefficients [95% CI]) in the presence of ≥ 4 pathologies, and a disability rating change of - 0.65 [- 0.14; - 1.16] for each 10% increase in muscle quality, but no effect on back pain intensity. Muscle quality had a non-significant mediating role (13.4%) between pathology and leg pain intensity. The number of different pathologies present demonstrated a small effect on 12-month leg pain intensity outcomes, while higher LMM quality had a direct effect on 12-month disability ratings but no mediating effect between pathology and leg pain. The relations between degenerative pathology, LMM quality, and pain-related outcomes appear complex and may include independent pathways.

Lumbar multifidus muscle morphology is associated with low back-related pain duration, disability, and leg pain: A cross-sectional study in secondary care.

BACKGROUND: Systematic reviews and studies exploring associations between morphologic change of paraspinal muscles and low back pain or related outcomes such as disability, radiculopathy, and physical workload, have reported conflicting results. This study explores the associations between lumbar multifidus muscle quality and clinical outcomes relating to low back pain. METHODS: Cross-sectional study of spinal clinic outpatients presenting with a primary complaint of low back and/or leg symptoms. Univariable and multivariable regression models were used to investigate associations between MRI-based multifidus muscle cross-sectional area at L4 and L5 and clinical outcomes for low back pain, leg pain, disability, restricted motion, and strenuous nature of work. Results were reported with ß-coefficients, odds ratios (OR), or incidence rate ratios (IRR) and their corresponding 95% confidence intervals, based on a 10% difference in muscle quality for each clinical variable. Multivariable analyses were adjusted for age, sex, and BMI. RESULTS: 875 patients [487 females; mean (SD) age: 43.6 (10.2) years] were included. In the multivariable analyses, muscle quality was significantly associated with disability (0-23 scale) [ß: -0.74, 95% CI: -1.14, -0.34], leg pain intensity (0-10 scale) [ß: -0.25, 95% CI: -0.46, -0.03], and current pain duration of more than 12 months [OR: 1.27, 95% CI: 1.03, 1.55]. No associations were found for low back pain intensity, morning stiffness, painful active range of motion, or work nature. CONCLUSIONS: Patients with higher lumbar multifidus muscle quality reported lower levels of low back pain-related disability and leg pain intensity, indicating that muscle quality may play a role in the etiology of lumbar spine disorders. However, the clinical importance of these associations is uncertain due to the low magnitude of identified associations. Future longitudinal studies are needed to understand the effect of lumbar multifidus muscle quality on lumbar-related pain and disability.

Spinal degeneration is associated with lumbar multifidus morphology in secondary care patients with low back or leg pain.

Associations between multifidus muscle morphology and degenerative pathologies have been implied in patients with non-specific low back pain, but it is unknown how these are influenced by pathology severity, number, or distribution. MRI measures of pure multifidus muscle cross-sectional area (CSA) were acquired from 522 patients presenting with low back and/or leg symptoms in an outpatient clinic. We explored cross-sectional associations between the presence, distribution, and/or severity of lumbar degenerative pathologies (individually and in aggregate) and muscle outcomes in multivariable analyses (beta coefficients [95% CI]). We identified associations between lower pure multifidus muscle CSA and disc degeneration (at two or more levels): - 4.51 [- 6.72; - 2.3], Modic 2 changes: - 4.06 [- 6.09; - 2.04], endplate defects: - 2.74 [- 4.58; - 0.91], facet arthrosis: - 4.02 [- 6.26; - 1.78], disc herniations: - 3.66 [- 5.8; - 1.52], and when > 5 pathologies were present: - 6.77 [- 9.76; - 3.77], with the last supporting a potential dose-response relationship between number of spinal pathologies and multifidus morphology. Our findings could hypothetically indicate that these spinal and muscle findings: (1) are part of the same degenerative process, (2) result from prior injury or other common antecedent events, or (3) have a directional relationship. Future longitudinal studies are needed to further examine the complex nature of these relationships.

The relationships between physical activity, lumbar multifidus muscle morphology, and low back pain from childhood to early adulthood: a 12-year longitudinal study.

We investigated the longitudinal associations between physical activity (PA), lumbar multifidus morphology, and impactful low back pain (LBP) in young people. Nine-year-old children were recruited from 25 primary schools and followed up at age 13, 16, and 21 years. We measured PA with accelerometers at age 9, 13, and 16; quantified patterns of lumbar multifidus intramuscular adipose tissue (IMAT) change from 13 to 16 years using magnetic resonance imaging; and recorded LBP and its impact with standardised questionnaires and interviews. Associations were examined with crude and adjusted logistic or multinomial models and reported with odds ratios (OR) or relative risk ratios (RRR). We included data from 364 children (mean[SD] age = 9.7[.4] years). PA behaviour was not associated with LBP. Having persistently high IMAT levels at age 13 and 16 was associated with greater odds of LBP (OR[95% CI] = 2.98[1.17 to 7.58]). Increased time in moderate and vigorous intensity PA was associated with a lower risk of higher IMAT patterns (RRR[95% CI] = .67[.46 to .96] to .74[.55 to 1.00]). All associations became non-significant after adjusting for sex and body mass index (BMI). Future studies investigating the relationships between PA behaviour, lumbar multifidus IMAT, and impactful LBP should account for potential confounding by sex and BMI.

Using Intervention Mapping to Develop a Decision Support System-Based Smartphone App (selfBACK) to Support Self-management of Nonspecific Low Back Pain: Development and Usability Study.

BACKGROUND: International guidelines consistently endorse the promotion of self-management for people with low back pain (LBP); however, implementation of these guidelines remains a challenge. Digital health interventions, such as those that can be provided by smartphone apps, have been proposed as a promising mode of supporting self-management in people with chronic conditions, including LBP. However, the evidence base for digital health interventions to support self-management of LBP is weak, and detailed descriptions and documentation of the interventions are lacking. Structured intervention mapping (IM) constitutes a 6-step process that can be used to guide the development of complex interventions. OBJECTIVE: The aim of this paper is to describe the IM process for designing and creating an app-based intervention designed to support self-management of nonspecific LBP to reduce pain-related disability. METHODS: The first 5 steps of the IM process were systematically applied. The core processes included literature reviews, brainstorming and group discussions, and the inclusion of stakeholders and representatives from the target population. Over a period of >2 years, the intervention content and the technical features of delivery were created, tested, and revised through user tests, feasibility studies, and a pilot study. RESULTS: A behavioral outcome was identified as a proxy for reaching the overall program goal, that is, increased use of evidence-based self-management strategies. Physical exercises, education, and physical activity were the main components of the self-management intervention and were designed and produced to be delivered via a smartphone app. All intervention content was theoretically underpinned by the behavior change theory and the normalization process theory. CONCLUSIONS: We describe a detailed example of the application of the IM approach for the development of a theory-driven, complex, and digital intervention designed to support self-management of LBP. This description provides transparency in the developmental process of the intervention and can be a possible blueprint for designing and creating future digital health interventions for self-management.

Motor performance and back pain in children and adolescents: A systematic review.

BACKGROUND AND OBJECTIVE: Motor performance during childhood and adolescence is recognized as a relevant determinant of present and future health, but its effects on back pain (BP) remain unclear. In this systematic review, we aimed to identify the association between motor performance and BP in children and adolescents. DATABASES AND DATA TREATMENT: A literature search was performed in the MEDLINE, Scopus, Embase, SPORTDiscus and CINAHL databases. We included cross-sectional, cohort, case-control and controlled clinical trials (data from control groups). The inclusion criteria were as follows: (a) participants aged 6-19 years; (b) assessment motor performance components; (c) assessment of BP and (d) reported measures of association. The risk of bias was assessed by the Downs and Black instrument and the quality of evidence by the grading of recommendations, assessment, development and evaluation (GRADE). RESULTS: A total of 2360 articles were identified, 25 of which were included in our systematic review. Of the 25 studies, 19 were evaluated as having a low risk of bias. GRADE indicated that 20 studies presented low or very low quality. Most of the studies evaluated flexibility (n = 16), muscle endurance (n = 18) and muscle strength (n = 9). Aerobic capacity, balance and speed were also examined in some studies (n < 5). Overall, motor performance (flexibility, muscle endurance, muscle strength, aerobic capacity, balance and speed) was not associated with BP. Most of the results were inconsistent because of the lack of studies, risk of bias and low quality of evidence. Only trunk extensor muscle endurance was associated with decreased BP with moderate quality of the supporting evidence. Prospective studies with a low risk of bias are warranted to further clarify this relationship in childhood and adolescence and findings may support more targeted and effective health promotion interventions. SIGNIFICANCE: This systematic review shows that motor performance (flexibility, muscle endurance, muscle strength, aerobic capacity, balance and speed) was not associated with BP in children and adolescents. Most of the results were inconsistent because of the lack of studies, risk of bias and low quality of evidence. Only trunk extensor muscle endurance was associated with decreased BP with moderate quality of supporting evidence.

'When the picture does not really tell the story'- A qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain.

OBJECTIVES: To explore the magnetic resonance imaging (MRI) feedback report as a health care encounter for generating shared diagnostic meaning. METHODS: An exploratory, qualitative case study was conducted using video observation of the MRI report of findings, individual face-to-face and telephonic interviews. RESULTS: From fourteen distinct encounters, three key themes emerged, these being: 'a powerful shared experience, 'a legacy of biomedical thinking' and 'clinical practice quandaries'. Generally speaking, the MRI encounter was observed to be both an effective and satisfying method for developing shared diagnostic meaning. However, in instances where a structure-based diagnosis could not be reasonably established, clinicians experienced doubts in what to present in a 'soft report'. A feature of these was the communication of speculative causal feedback, based on non-visualised structures and/or incidental findings observed. CONCLUSION: Shared diagnostic meaning can result from a 'soft' MRI report of findings. However, the emergence of diagnostic closure is not guaranteed. Further exploration of this phenomenon in the context of shared decision making and the therapeutic alliance is warranted. PRACTICE IMPLICATIONS: Pre-feedback peer conferences might be considered in order to standardise the information communicated to patients. Clinicians might also consider limiting the MRI scan as a visual aid in 'soft' reports.

Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain-Related Disability: A selfBACK Randomized Clinical Trial.

Importance: Lower back pain (LBP) is a prevalent and challenging condition in primary care. The effectiveness of an individually tailored self-management support tool delivered via a smartphone app has not been rigorously tested. Objective: To investigate the effectiveness of selfBACK, an evidence-based, individually tailored self-management support system delivered through an app as an adjunct to usual care for adults with LBP-related disability. Design, Setting, and Participants: This randomized clinical trial with an intention-to-treat data analysis enrolled eligible individuals who sought care for LBP in a primary care or an outpatient spine clinic in Denmark and Norway from March 8 to December 14, 2019. Participants were 18 years or older, had nonspecific LBP, scored 6 points or higher on the Roland-Morris Disability Questionnaire (RMDQ), and had a smartphone and access to email. Interventions: The selfBACK app provided weekly recommendations for physical activity, strength and flexibility exercises, and daily educational messages. Self-management recommendations were tailored to participant characteristics and symptoms. Usual care included advice or treatment offered to participants by their clinician. Main Outcomes and Measures: Primary outcome was the mean difference in RMDQ scores between the intervention group and control group at 3 months. Secondary outcomes included average and worst LBP intensity levels in the preceding week as measured on the numerical rating scale, ability to cope as assessed with the Pain Self-Efficacy Questionnaire, fear-avoidance belief as assessed by the Fear-Avoidance Beliefs Questionnaire, cognitive and emotional representations of illness as assessed by the Brief Illness Perception Questionnaire, health-related quality of life as assessed by the EuroQol-5 Dimension questionnaire, physical activity level as assessed by the Saltin-Grimby Physical Activity Level Scale, and overall improvement as assessed by the Global Perceived Effect scale. Outcomes were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months. Results: A total of 461 participants were included in the analysis; the population had a mean [SD] age of 47.5 [14.7] years and included 255 women (55%). Of these participants, 232 were randomized to the intervention group and 229 to the control group. By the 3-month follow-up, 399 participants (87%) had completed the trial. The adjusted mean difference in RMDQ score between the 2 groups at 3 months was 0.79 (95% CI, 0.06-1.51; P = .03), favoring the selfBACK intervention. The percentage of participants who reported a score improvement of at least 4 points on the RMDQ was 52% in the intervention group vs 39% in the control group (adjusted odds ratio, 1.76; 95% CI, 1.15-2.70; P = .01). Conclusions and Relevance: Among adults who sought care for LBP in a primary care or an outpatient spine clinic, those who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months. The improvement in pain-related disability was small and of uncertain clinical significance. Process evaluation may provide insights into refining the selfBACK app to increase its effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT03798288.

Self-management at the core of back pain care: 10 key points for clinicians.

BACKGROUND: A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain. OBJECTIVE: In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain. DISCUSSION: People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

Motor performance and back pain in children and adolescents: a systematic review and meta-analysis protocol.

BACKGROUND: The relationship between motor performance and back pain in children and adolescents remains unclear. This article describes the protocol for a systematic review to summarize the knowledge about the association between motor performance, such as agility, flexibility, balance, strength, muscle endurance, and cardiorespiratory fitness, and back pain. Thus, our aim is to identify the influence of motor performance on back pain among children and adolescents. METHODS: Two independent researchers will search MEDLINE, Scopus, Embase, SPORTDiscus, and CINAHL databases, with no period or language restrictions. We will include cross-sectional, cohort, case-control, and controlled clinical trial studies based on the following criteria: (a) participants from 6 to 19 years of age, (b) assessment of motor performance, (c) assessment of back pain, and (d) report measures of associations between motor performance and back pain. Study quality and risk of bias will be assessed using an adapted version of the Downs and Black instrument. Grading of Recommendations, Assessment, Development, and Evaluations will be used to assess the strength of the body of evidence. Meta-analyses of association measures will be performed for each type of motor performance, separately for different study types. The results will be reported using forest to show the pooled effect of findings and funnel plots to assess precision of the data. If studies are not homogeneous, results from the meta-analyses will not be reported. Associations will then be synthesized descriptively using a pragmatic approach. DISCUSSION: This systematic review will provide critical insights into the association between motor performance and back pain among children and adolescents; this information may help support clinical practice guidelines as well as public health programs. ETHICS AND DISSEMINATION: Protocol was written according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178496.

Discriminative and convergent validity of strain elastography for detecting tendinopathy within the supraspinatus tendon: a cross-sectional study.

BACKGROUND: We aimed to explore the discriminative validity of ultrasound strain elastography (SEL) between patients with painful supraspinatus tendinopathy and healthy control shoulders, as well as the associations between SEL and magnetic resonance imaging (MRI), conventional ultrasound (tendon thickness), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). METHODS: Thirty patients with shoulder pain and MRI-verified supraspinatus tendinopathy and 30 healthy control shoulders (no pain) were examined using SEL, MRI, and conventional ultrasound of the supraspinatus tendon. SEL variables included raw data, ratios between the deltoid muscle and supraspinatus tendon (deltoid ratio), color rating, and presence of red/yellow lesions (middle, worst part, and total tendon). RESULTS: Statistically significant increases in odds ratios for being symptomatic (increased softening) were seen for all raw data variables, corresponding to 3.978 (95% confidence interval [CI], 1.414-11.197) for middle, 4.602 (95% CI, 1.536-13.788) for worst, and 4.865 (95% CI, 1.406-16.836) for total tendon, and 1.260 (95% CI, 1.027-1.545) for the deltoid ratio (worst), adjusted for sex and body mass index (BMI). Tendon thickness was not associated with SEL; however, significantly positive associations were found between raw data variables and MRI (ß ≥ 0.58, P < .01), and positive associations were found between raw data variables and the DASH score (ß = 0.01, P ≤ .04), adjusted for sex and BMI. CONCLUSIONS: Raw data variables and the deltoid ratio (worst) discriminated between patients with painful supraspinatus tendinopathy and healthy control shoulders when adjusted for sex and BMI. Associations were statistically significant for raw data variables and MRI or DASH score when adjusted for sex and BMI. Further studies are needed to understand SEL and the role of sex and BMI, including the responsiveness of SEL.

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population.

BACKGROUND: Lumbar disc degeneration seen on magnetic resonance imaging (MRI) is defined as loss of signal intensity and/or disc height, alone or in combination with other MRI findings. The MRI findings and thresholds used to define disc degeneration vary in the literature, and their associations with low back pain (LBP) remain uncertain. OBJECTIVE: To explore how various thresholds of lumbar disc degeneration alter the association between disc degeneration and self-reported LBP. METHODS: An exploratory, cross-sectional cohort study of a general population. Participants in the cohort 'Backs-on-Funen' had MRI scans and completed questionnaires about LBP at ages 41, 45 and 49 years. The MRI variables, signal intensity (Grades 0-3) and disc height (Grades 0-3), were dichotomised at different thresholds. Logistic regression analyses were used to determine associations. Arbitrarily, a difference in odds ratio (OR) of > 0.5 between thresholds was considered clinically relevant. Receiver Operating Characteristic curves were used to investigate differences between diagnostic values at each threshold. RESULTS: At age 41, the difference in ORs between signal loss and LBP exceeded 0.5 between the thresholds of ≥2 (OR = 2.02) and = 3 (OR = 2.57). Difference in area under the curves (AUC) was statistically significant (p = 0.02). At ages 45 and 49, the difference in ORs exceeded 0.5 between the thresholds of ≥2 and = 3, but the differences between AUC were not statistically significant. At age 41, the difference in ORs between disc height loss and LBP at the thresholds of ≥1 (OR = 1.44) and ≥ 2 (OR = 2.53) exceeded 0.5. Differences in AUC were statistically significant (p = 0.004). At age 49, differences in ORs exceeded 0.5 (OR = 2.49 at the ≥1 threshold, 1.84 at ≥2 and 0.89 at =3). Differences between AUC were not statistically significant. CONCLUSION: The results suggest that the thresholds used to define the presence of lumbar disc degeneration influence how strongly it is associated with LBP. Thresholds at more severe grades of disc signal and disc height loss were more strongly associated with LBP at age 41, but thresholds at moderate grades of disc degeneration were most strongly associated with LBP at ages 45 and 49.

Cognitive Functional Therapy for People with Nonspecific Persistent Low Back Pain in a Secondary Care Setting-A Propensity Matched, Case-Control Feasibility Study.

BACKGROUND: Effective, inexpensive, and low-risk interventions are needed for patients with nonspecific persistent low back pain (NS-PLBP) who are unresponsive to primary care interventions. Cognitive functional therapy (CFT) is a multidimensional behavioral self-management approach that has demonstrated promising results in primary care and has not been tested in secondary care. OBJECTIVE: To investigate the effect of CFT and compare it with usual care for patients with NS-PLBP. DESIGN: Case-control study. SETTING: A secondary care spine center. SUBJECTS: Thirty-nine patients received a CFT intervention and were matched using propensity scoring to 185 control patients receiving usual care. METHODS: The primary outcome was Roland Morris Disability Questionnaire (0-100 scale) score. Group-level differences at six- and 12-month follow-up were estimated using mixed-effects linear regression. RESULTS: At six-month follow-up, a statistically significant and clinically relevant difference in disability favored the CFT group (-20.7, 95% confidence interval [CI] = -27.2 to -14.2, P < 0.001). Significant differences also occurred for LBP and leg pain, fear, anxiety, and catastrophizing in favor of CFT. At 12-month follow-up, the difference in disability was smaller and no longer statistically significant (-8.1, 95% CI = -17.4 to 1.2, P = 0.086). Differences in leg pain intensity and fear remained significantly in favor of CFT. Treatment satisfaction was significantly higher in the CFT group at six- (93% vs 66%) and 12-month (84% vs 52%) follow-up. CONCLUSIONS: These findings support that CFT is beneficial for patients with NS-PLBP who are unresponsive to primary care interventions. Subsequent randomized controlled trials could incorporate booster sessions, which may result in larger effects at 12-month follow-up.

The Interexaminer Reproducibility and Prevalence of Lumbar and Gluteal Myofascial Trigger Points in Patients With Radiating Low Back Pain.

OBJECTIVE: To determine the interexaminer reproducibility for judging the presence, number, and location of leg-pain referring myofascial trigger points, and their prevalence in patients with low back pain with and without concomitant leg pain referral. DESIGN: An interexaminer reproducibility study. SETTING: An outpatient public Hospital Spine Centre in Southern Denmark. PARTICIPANTS: Examiners: experienced examiners (N=2), a chiropractor and a physiotherapist, respectively. Subjects: a case mix of patients with low back pain (N=32) with and without leg pain referral. INTERVENTIONS: A standardized palpation examination protocol of 4 bilateral lumbosacral muscles performed by each examiner. MAIN OUTCOME MEASURES: Reproducibility on presence (measured in Cohen's κ), number (difference and limits of agreement), location (distance between matching marks placed by examiners), and prevalence of myofascial trigger points. RESULTS: Kappa values of the examined muscles were as follows: quadratus lumborum (κ=0.42), gluteus medius (κ=0.83), gluteus minimus (κ=0.74), and piriformis (κ=0.62), with a mean of all examined muscles of kappa=0.66, assessed as substantial agreement. The mean difference in number of trigger points was 0.8, with limits of agreement ranging from -6.4 to 4.9. Mean distance between trigger point locations was 12.9 mm, with 57% only being identified by a single examiner. The prevalence of trigger points was 82.7%, highest in the gluteal region of the painful side. CONCLUSIONS: Inadequate standardization and multiple trigger point sites complicate interexaminer reproducibility on location and number of patients with low back pain and leg pain referral. Nevertheless, substantial interexaminer reproducibility for the trigger point presence appears achievable. Implemented routinely, this relatively simple clinical evaluation procedure could meaningfully enhance diagnostic triage and eventual management.

Strain Elastography and Tendon Response to an Exercise Program in Patients With Supraspinatus Tendinopathy: An Exploratory Study.

BACKGROUND: Shoulder pain is common, with a lifetime prevalence of up to 67%. Evidence is conflicting in relation to imaging findings and pain in the shoulder. Sonoelastography can be used to estimate tissue stiffness and may be a clinically relevant technique for diagnosing and monitoring tendon healing. PURPOSE: To evaluate changes in supraspinatus tendon stiffness using strain elastography (SEL) and associations with changes in patient-reported outcomes, supraspinatus tendon thickness, and grade of tendinopathy after 12 weeks of unilateral shoulder exercises in patients with supraspinatus tendinopathy. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 23 patients with unilateral clinical supraspinatus tendinopathy performed 12 weeks of "standard care" exercises. At baseline and follow-up, supraspinatus tendon stiffness was measured bilaterally using SEL and compared with tendinopathy grading on magnetic resonance imaging scans and tendon thickness measured using conventional ultrasound. Patient-reported outcome measures included physical function and symptoms from the Disabilities of the Arm, Shoulder and Hand questionnaire and pain rating (visual analog scale). RESULTS: No significant changes in SEL within or between groups (asymptomatic vs symptomatic tendon) were seen. All patient-reported outcomes showed significant improvement from baseline to follow-up, but with no change in tendinopathy grading and tendon thickness. No significant differences in the proportion of patients changing above the minimal detectable change in SEL and PROM were seen, except for discomfort while sleeping. CONCLUSION: Despite no significant within-group or between-group changes in SEL, significant improvements were found in patient-reported outcomes. An acceptable agreement between patients changing above the minimal detectable change in SEL and patient-reported outcome measure was seen. Further studies should explore the use of SEL to detect changes after tendon repair and long-term training potentially in subgroups of different tendinopathy phases. CLINICAL RELEVANCE: In the short term, structural changes in supraspinatus tendons could not be visualized using SEL, indicating that a longer time span should be expected in order to observe structural changes, which should be considered before return to sports. Subgrouping based on stage of tendinopathy may also be important in order to evaluate changes over time with SEL among patients with supraspinatus tendinopathy. REGISTRATION: NCT03425357 (ClinicalTrials.gov identifier).

An App-Delivered Self-Management Program for People With Low Back Pain: Protocol for the selfBACK Randomized Controlled Trial.

BACKGROUND: Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP. OBJECTIVE: The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP. METHODS: This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months. RESULTS: The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020. CONCLUSIONS: This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions. TRIAL REGISTRATION: ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14720.

Electronic measures of movement impairment, repositioning, and posture in people with and without neck pain-a systematic review.

BACKGROUND: Neck pain is a major public health problem. Our objective was to describe differences in measures of movement and posture between people with and without neck pain. METHODS: PubMed and Embase were searched before 15 February 2019 for studies comparing people with neck pain with controls using electronic measurements of neck movement and/or posture. Data were extracted on participants, device, test methods, active range of motion (RoM) and quality of motion, joint positioning sense, and posture. Study quality was assessed using the quality assessment of studies of diagnostic accuracy included in systematic reviews (QUADAS) and Guidelines for Reporting Reliability and Agreement Studies (GRRAS) guidelines. RESULTS: Thirty-six studies were included: 24 studies included measurement of active RoM, 15 quality of motion, 12 joint positioning sense, and 5 cervical spine posture. Measurements and test methods were heterogeneous. The reporting of study populations and methods were poor, whereas devices and statistics were well described. All studies on RoM showed reduced active RoM in people with neck pain when compared with controls, 5 of 10 studies reported reduced movement speed for people with neck pain, and 5 of 9 studies reported significantly greater joint positioning error for people with neck pain compared with controls. Due to heterogeneous test parameters and methods, no conclusion regarding differences in conjunct motion, tracking a motion pattern, and measures of posture could be drawn. CONCLUSIONS: People with neck pain appear to have reduced active RoM, movement speed, and head repositioning accuracy when compared with controls. However, quality of reviewed studies was low and better descriptions of participants and methods are required before firm conclusions can be drawn.

GLA:D® Back: group-based patient education integrated with exercises to support self-management of persistent back pain - feasibility of implementing standardised care by a course for clinicians.

BACKGROUND: Clinical guidelines for management of low back pain (LBP) are not routinely implemented in practice, and guidelines rarely offer tools for implementation. Therefore, we developed GLA:D® Back, a standardised intervention of patient education and supervised exercises. This pilot study tested the feasibility of implementing GLA:D Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors. It should further inform the planning of an implementation-effectiveness study using a pre-post group design alongside nation-wide implementation. METHODS: Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption and through focus group interviews and a feedback meeting. Patient-level data, including pain, disability, and pain enablement, were collected from (1) LBP patients visiting the clinics during a pre-specified 2-week period 2 months prior to clinicians attending the GLA:D Back course (n = 84), (2) LBP patients consulting during a 2-week period 2 months after the course (n = 77), and (3) those enrolled in GLA:D Back during 4 months after implementation (n = 89). Patient data were collected at baseline and at 4 months. RESULTS: Clinicians' evaluations of the course were positive and resulted in several modifications. The clinical intervention was adopted by all test sites. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (73% > 3 months) and most had been treated for more than 4 weeks at inclusion. Patients in GLA:D Back were more often retired (30% vs. 16% before implementation) and at high risk of poor prognosis (25% vs. 13%). Procedures for data collection were feasible, and outcomes after implementation, especially with GLA:D Back, were as good as or better than before implementation. Recruiting patients and achieving comparable pre- and post-groups was difficult. CONCLUSIONS: Implementation of the GLA:D Back clinical intervention in Danish primary care physiotherapy and chiropractic clinics was feasible through a 2-day clinician course. Both clinicians and patients were satisfied with the programme, and patient-reported outcomes were slightly better than outcomes in patients registered before implementation. It was not deemed possible to conduct an implementation-effectiveness trial as part of a nation-wide implementation.

Ultrasonic strain elastography for detecting abnormalities in the supraspinatus tendon: an intra- and inter-rater reliability study.

OBJECTIVES: The reliability of ultrasonic strain elastography (SEL) used to detect abnormalities in the supraspinatus tendon is unclear. Thus, the aim of this study was to investigate the reliability of SEL in the supraspinatus tendon. DESIGN: An intra-rater and inter-rater reliability study. SETTING: A single-centre study conducted at the University of Southern Denmark. PARTICIPANTS: Twenty participants with shoulder pain and MRI-verified supraspinatus tendinosis and 20 asymptomatic participants (no MRI). PRIMARY AND SECONDARY OUTCOME MEASURES: Raw values (RAW) and ratios (deltoid muscle (DELT) and gel pad (GEL) as reference tissues) were calculated and mean values of measurements from three regions of the supraspinatus tendon were reported. Colour scale ratings and number of yellow/red lesions from the three areas were also included. RESULTS: Intra-rater reliability showed intraclass correlation coefficients (ICCs) for RAW, DELT and GEL: 0.97 (minimal detectable change (MDC): 0.28 (6.36% of the mean)), 0.89 (MDC: 2.91 (20.37%)) and 0.73 (MDC: 1.61 (58.82%)), respectively. The ICCs for inter-rater reliability were 0.89 (MDC: 0.47 (10.53%)), 0.78 (MDC: 3.69 (25.51%)) and 0.70 (MDC: 1.75 (62.63%)), respectively.For colour scale ratings, intra-rater reliability (linear weighted kappa) ranged from 0.76 to 0.79, with the inter-rater reliability from 0.71 to 0.81. For the number of lesions, intra-rater reliability ranged from 0.40 to 0.82 and inter-rater reliability from 0.24 to 0.67. CONCLUSIONS: Intra-rater and inter-rater reliability were excellent for raw values and for ratios with deltoid muscle as the reference tissue, and good for ratios with gel pad as the reference tissue. The reliability of colour scale ratings was substantial-to-almost perfect, and for the number of lesions fair-to-almost perfect.Although high reliability was found, validity and responsiveness of these elastographic methods needs further investigation. ETHICS APPROVAL: The study protocol was approved by the Ethics Committee for the Region of South Denmark (S-20160115) and reported to the Danish Data Protection Agency (2014-41-3266).