Emergency department length of stay and re-presentation rates in patients with low back pain: A medical record review study.

BACKGROUND: Low back pain (LBP) is ranked in the top 10 conditions presenting to emergency departments (ED) in Australia. We aimed to investigate ED re-presentation rates and length of stay (LOS) of patients with LBP, including associated factors. METHODS: We reviewed medical records of three EDs in Sydney, Australia from January 2016 to October 2021. The primary outcome was the proportion of episodes of non-serious LBP with at least one re-presentation within 12 months. Secondary outcomes were re-presentation rates within 3-days, 1-week, 1-month, 3-months, 6-months, and mean LOS. Multivariable logistic regression analyses were performed to investigate the associated factors with re-presentation and prolonged stay (>4 h) and reported as adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). RESULTS: Of 8289 episodes of non-serious LBP, 7.7% included at least one re-presentation within 12 months. There were only 14 re-presentations (0.2%) where the diagnosis changed from non-serious LBP at the index visit to serious spinal pathology at the repeat visit. The overall mean LOS was 4.1 h, and 26.9% of patients stayed in the ED for >4 h. Those who received opioids (aOR: 1.31; 95% CI: 1.08-1.59) were more likely to re-present. In contrast, patients receiving imaging were less likely to re-present (aOR: 0.78, 95% CI: 0.65-0.94). Receiving imaging (aOR: 2.83; 95% CI: 2.56-3.13) and opioids (aOR: 1.64; 95% CI: 1.47-1.82) increased the odds of prolonged stay. CONCLUSION: A re-presentation within 12 months occurs in 7.7% of episodes of LBP in ED. Over one-quarter of patients stayed longer than 4 h.

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.

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.

Association of Musculoskeletal Pain With Sedentary Behavior in Public School Teachers: The Role of Habitual Physical Activity.

BACKGROUND: Sedentary behavior has been associated with musculoskeletal pain in school teachers. However, our hypothesis is that physical activity practice could mitigate this association. AIM: The aim of this study was to investigate the relationship of musculoskeletal pain with high screen-based sedentary behavior among public school teachers and whether physical activity could mitigate this relationship. METHOD: A sample of 246 teachers from 13 public schools were assessed (45.0 ± 10.4 years, 76.0% of women). Musculoskeletal pain was assessed using the Nordic Musculoskeletal Questionnaire, screen-based sedentary behavior was measured considering the sum of screen time in television, computer, and smartphone/tablet, and physical activity using the Baecke habitual physical activity questionnaire. Binary logistic regression was used to verify the associations between high screen-based sedentary behavior and musculoskeletal pain in school teachers (Model 1-unadjusted; Model 2-adjusted by age, sex, and socioeconomic status; Model 3-variables of Model 2 + adjusted by physical activity). RESULTS: High screen-based sedentary behavior was associated with pain in neck (odds ratio = 2.09; 95%confidence interval = 1.08-4.04), upper back (odds ratio = 2.21; 95%confidence interval = 1.07-4.56), and low back (odds ratio = 1.91; 95%confidence interval = 1.00-3.65). However, after inserting the variables, including physical activity, these associations were mitigated. CONCLUSIONS: High screen-based sedentary behavior was associated with musculoskeletal pain in public school teachers. However, this relationship was mitigated after the inclusion of confounding variables, including physical activity.

Do Patients with Acute Low Back Pain in Emergency Departments Have More Severe Symptoms than Those in General Practice? ASystematic Review with Meta-Analysis.

INTRODUCTION: There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those who are seen in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice vs those presenting to emergency departments. METHODS: Electronic searches were conducted in MEDLINE, EMBASE, and CINAHL from database inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0-100 scale were the primary outcomes. Risk of bias was evaluated with a validated tool for observational studies, and the overall quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis with random effects and meta-regression were used to test for differences between the two settings. RESULTS: We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice, with a mean difference of 17.3 points (95% confidence interval: 8.8 to 25.9 on a 0-100 scale). Similarly, there was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7; 95% confidence interval: 4.6 to 38.7 on a 0-100 scale). CONCLUSION: Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice.

Relationship of sleep quality with screen-based sedentary time and physical activity in adolescents - the moderating effect of body mass index.

OBJECTIVE: To analyze the association of sleep quality with reported screen-based sedentary time and reported physical activity, among overweight adolescents. METHODS: Adolescents aged 10 to 17 years enrolled in public and private schools were included. Data collection was carried out during the school semesters of 2014-2015 and participants who did not participate in all evaluations were excluded. Sleep quality and physical activity were assessed by validated questionnaires. Screen-based sedentary time was assessed by self-reported mean daily hours spent on television, computer, smartphone/tablet, and videogames. Body mass index was objectively measured and adolescents were classified into normal weight and overweight according to cutoff points for age and sex. Multiple linear regression models adjusted by covariates (age, sex, ethnicity, and socioeconomic status) were used to analyze the relationship between variables. RESULTS: A total of 1008 adolescents were assessed, with a mean age of 13.2 ± 2.4 years and a mean body mass index of 20.4 ± 4.3 kg/m2. Overweight was observed in 28.0% of sample, while 53.0% reported non-white ethnicity. Self-reported screen-based sedentary time was significantly related to poor sleep quality in adolescents (ß = 0.116, p = 0.005), remaining significant only in those who were normal weight (ß = 0.101, p = 0.007) in sensitivity analysis. Self-reported physical activity showed no relationship with sleep quality in both normal weight and overweight adolescents. CONCLUSION: Self-reported screen-based sedentary time was associated with poor sleep quality in adolescents, mainly among those with normal weight. The time spent on screen-based sedentary activities can impair sleep quality even in normal weight adolescents.

Effectiveness of brief patient information materials for promoting correct beliefs about imaging and inevitable consequences of low back pain: A randomised controlled trial.

OBJECTIVE: To investigate what format for providing patient information (i.e. written summary, infographic or video animation) is most effective for promoting correct beliefs about imaging and inevitable consequences of low back pain (LBP). DESIGN: Randomised controlled trial. SETTING/PATIENTS: One hundred and fifty-nine patients with non-specific LBP were recruited from outpatient physiotherapy clinics. INTERVENTION: Participants were randomised to receive patient information in one of three formats: video animation, infographic or written summary. Patients were allowed to read or watch the materials for up to 20 min. MEASUREMENTS: Outcome were assessed before and immediately after the intervention. The primary outcome was the Back Beliefs Questionnaire. The secondary outcome was beliefs about imaging for LBP assessed by two questions. RESULTS: All 159 patients completed the study. Our findings revealed no difference between groups for the Back Beliefs Questionnaire. Correct beliefs about imaging were more likely with the infographic than the video animation (Question 1- Odds Ratio [OR] = 3.9, 95% confidence interval [CI]: 1.7, 8.7; Question 2- OR = 6.8, 95%CI: 2.7, 17.2) and more likely with the written summary than the video animation (Question 1- OR = 3.3, 95%CI: 1.5, 7.4; Question 2- OR = 3.7, 95%CI: 1.6, 8.5). No difference between infographic and written summary formats were reported for the questions assessing LBP imaging beliefs. CONCLUSION: The three materials were equally effective in improving patient's general beliefs about LBP care. However, the traditional written summary or infographic formats were more effective than the video animation format for improving beliefs about imaging for LBP.

Clinical course of patients with low back pain following an emergency department presentation: a systematic review and meta-analysis.

INTRODUCTION: Low back pain, and especially non-specific low back pain, is a common cause of presentation to the emergency department (ED). Although these patients typically report relatively high pain intensity, the clinical course of their pain and disability remains unclear. Our objective was to review the literature and describe the clinical course of non-specific low back pain after an ED visit. METHODS: Electronic searches were conducted using MEDLINE, CINAHL and EMBASE from inception to March 2019. We screened for cohort studies or randomised trials investigating pain or disability in patients with non-specific low back pain presenting to EDs. We excluded studies that enrolled participants with minimal pain or disability scores at baseline. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias and quality of evidence. Estimates of pain and disability were converted to a common 0-100 scale. We estimated pooled means and 95% CIs of pain and disability as a function of time since ED presentation. RESULTS: Eight studies (nine publications) with a total of 1994 patients provided moderate overall quality evidence of the expected clinical course of low back pain after an ED visit. Seven of the eight studies were assessed to have a low risk of bias. At the time of the ED presentation, the pooled estimate of the mean pain score on a 0-100 scale was 71.0 (95% CI 64.2-77.9). This reduced to 46.1 (95% CI 37.2-55.0) after 1 day, 41.8 (95% CI 34.7 to 49.0) after 1 week and 13.5 (95% CI 5.8-21.3) after 26 weeks. The course of disability followed a similar pattern. CONCLUSIONS: Patients presenting to EDs with non-specific low back pain experience rapid reductions in pain intensity, but on average symptoms persisted 6 months later. This review can be used to educate patients so they can have realistic expectations of their recovery.

Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials.

BACKGROUND: Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit. METHODS: Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (≥18 years) with non-specific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence. RESULTS: Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30 min (mean difference (MD) -15.0, 95% confidence interval (CI) -21.0 to -9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD -15.7, 95% CI -19.8 to -11.6) and intravenous morphine (MD -11.4, 95% CI -21.6 to -1.2) were both superior to placebo at 30 min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95% CI -0.71 to 18.7) or sciatica (MD -6.8, 95% CI -24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating non-pharmacological treatments (low quality evidence). CONCLUSION: Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.

Characteristics Associated With People With Chronic Low Back Pain Meeting Physical Activity Guidelines and Recommendations for Sedentary Behavior: A Cross-Sectional Study.

OBJECTIVE: The purpose of this study was to identify factors associated with meeting physical activity guidelines and sedentary recommendations in people with chronic low back pain (LBP). METHODS: This was a cross-sectional study including 171 people with chronic LBP. Trained assessors collected information regarding demographic, anthropometric, and clinical data. Physical activity levels and sedentary time were objectively measured using a tri-axial accelerometer. Participants were classified as being physically active (ie, performing at least 150 minutes of moderate or 75 minutes of vigorous physical activity per week) and sedentary (ie, more than 8 hours of time spent in sedentary activities per day). Multivariable logistic regression analyses were used to determine the association of being physically active or sedentary with the range of demographic, anthropometric and clinical variables. RESULTS: Our results showed that although lower body mass index (odds ratio [OR] = 0.91; 95% CI: 0.85-0.98) and higher self-reported levels of leisure time physical activity (OR = 3.46; 95% CI: 1.94-6.15) were associated with being physically active, lower self-reported levels of physical activity at work (OR = 0.56; 95% CI: 0.39-0.81) was associated with being sedentary. CONCLUSION: Our findings showed that, in people with LBP, lower body mass index and higher levels of leisure time physical activity may be important factors for identifying those physically active. In contrast, lower levels of physical activity at work may be considered when identifying sedentary people with LBP. Future studies should consider these factors when designing interventions aiming to promote physical activity and decrease sedentary behavior in this population.

Co-occurrence of Chronic Musculoskeletal Pain and Cardiovascular Diseases: A Systematic Review with Meta-analysis.

OBJECTIVE: To determine the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain. DESIGN: Systematic review with meta-analysis. METHODS: A comprehensive search was performed in five electronic databases. Population-based studies reporting the prevalence of cardiovascular diseases in adults stratified by chronic musculoskeletal pain status were considered eligible. Two independent reviewers performed the screening of the records following the inclusion criteria, extracted data, and evaluated the risk of bias of the included studies using an assessment tool of risk of bias for observational studies. In addition, we assessed the overall quality of evidence using an adaptation of the GRADE approach for prognosis. RESULTS: Twenty studies were included in this review. There was high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91, 95% confidence interval = 1.64-2.21). CONCLUSIONS: Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Future studies are still warranted to better understand the association between chronic musculoskeletal pain and the specific types of cardiovascular diseases.

Epidural corticosteroid injections for lumbosacral radicular pain.

BACKGROUND: Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES: To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS: We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA: We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS: Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS: We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS: This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.

Effects of active video games on children and adolescents: A systematic review with meta-analysis.

OBJECTIVE: To investigate the effectiveness of active video games (AVGs) on obesity-related outcomes and physical activity levels in children and adolescents. DESIGN: Systematic review with meta-analysis. METHODS: Literature search was performed in five electronic databases and the main clinical trials registries. Randomized controlled trials investigating the effect of AVGs compared with no/minimal intervention on obesity-related outcomes (body mass index [BMI], body weight, body fat, and waist circumference) and physical activity levels of children and adolescents were eligible. Two independent reviewers extracted the data of each included study. PEDro scale was used to assess risk of bias and GRADE approach to evaluate overall quality of evidence. Pooled estimates were obtained using random effect models. RESULTS: Twelve studies were considered eligible for this review. Included studies mostly reported outcome data at short-term (less or equal than three months) and intermediate-term follow-up (more than 3 months, but <12 months). AVGs were more effective than no/minimal intervention in reducing BMI/zBMI at short-term (SMD = -0.34; 95% CI: -0.62 to -0.05) and intermediate-term follow-up (SMD = -0.36; 95% CI: -0.01 to -0.71). In addition, AVGs were more effective in reducing body weight compared with no/minimal intervention at intermediate-term follow-up (SMD = -0.25; 95% CI: -0.46 to -0.04). Regarding physical activity levels, AVGs were not more effective compared with minimal intervention at short-term and intermediate-term follow-up. CONCLUSIONS: Our review identified that AVGs were better than minimal intervention in reducing BMI and body weight, but not for increasing physical activity in young people.

Defining and measuring imaging appropriateness in low back pain studies: a scoping review.

PURPOSE: Patients with low back pain (LBP) rarely have serious underlying pathology but frequently undergo inappropriate imaging. A range of guidelines and red flag features are utilised to characterise appropriate imaging. This scoping review explores how LBP imaging appropriateness is determined and calculated in studies of primary care practice. METHODS: This scoping review builds upon a previous meta-analysis, incorporating articles identified that were published since 2014, with an updated search to capture articles published since the original search. Electronic databases were searched, and citation lists of included papers were reviewed. Inclusion criteria were studies assessing adult LBP imaging appropriateness in a primary care setting. Twenty-three eligible studies were identified. RESULTS: A range of red flag features were utilised to determine imaging appropriateness. Most studies considered appropriateness in a binary manner, by the presence of any red flag feature. Ten guidelines were referenced, with 7/23 (30%) included studies amending or not referencing any guideline. The method for calculating the proportion of inappropriate imaging varied. Ten per cent of the studies used the total number of patients presenting with LBP as the denominator, suggesting most studies overestimated the rate of inappropriate imaging, and did not capture where imaging is not performed for clinically suspicious LBP. CONCLUSION: Greater clarity is needed on how we define and measure imaging appropriateness for LBP, which also accounts for the problem of failing to image when indicated. An internationally agreed methodology for imaging appropriateness studies would ultimately lead to an improvement in the care delivered to patients. These slides can be retrieved under Electronic Supplementary Material.

Association Between Clinical Tests Related to Motor Control Dysfunction and Changes in Pain and Disability After Lumbar Stabilization Exercises in Individuals With Chronic Low Back Pain.

OBJECTIVE: To investigate whether clinical tests used to detect motor control dysfunction can predict improvements in pain and disability in patients with chronic nonspecific low back pain (LBP) who have undergone an 8-week lumbar stabilization exercise program. STUDY DESIGN: A prospective cohort study. SETTING: Outpatient physical therapy university clinic. PARTICIPANTS: Seventy people with chronic nonspecific LBP were recruited, and 64 completed the exercise program (N=64). INTERVENTIONS: The lumbar stabilization program was provided twice a week for 8 weeks. MAIN OUTCOME MEASURES: Pain intensity (11-point numerical rating scale) and disability (Roland Morris Disability Questionnaire) and clinical tests, such as the Deep Muscle Contraction (DMC) scale, Clinical Test of Thoracolumbar Dissociation (CTTD), and Passive Lumbar Extension (PLE) test. Univariate and multivariate linear regression models were used in the prediction analysis. RESULTS: Mean changes in pain intensity and disability following the 8-week stabilization program were -3.8 (95% confidence interval [CI], -3.2 to -4.4) and -7.4 (95% CI, -6.3 to -8.5), respectively. Clinical test scores taken at baseline did not predict changes in pain and disability at 8-week follow-up. CONCLUSION: Our findings revealed that the DMC scale, CTTD, PLE test, clinical tests used to assess motor control dysfunction, do not predict improvements in pain and disability in patients with chronic nonspecific LBP following an 8-week lumbar stabilization exercise program.

Association of perceived physical overload at work with pain and disability in patients with chronic non-specific low back pain: a 6-month longitudinal study.

BACKGROUND: Physical overload at work has been described as a risk factor for the development of low back pain. However, few studies have investigated the prognostic value of perceived physical overload at work in patients with chronic low back pain. OBJECTIVE: To investigate the association of perceived physical overload at work with pain and disability over a period of 6 months in patients with chronic non-specific low back pain. METHODS: Patients with chronic LBP seeking physiotherapy care were considered eligible. Clinical data collected were: pain intensity, disability, fear of movement, depression and perceived physical overload at work. Linear regression analyses were used to investigate the association of perceived physical workload at work at baseline with pain intensity and disability at 6-month follow-up. The total score and the score for each category of the physical overload at work questionnaire were analyzed separately. RESULTS: Ninety-two patients with chronic low back pain were included in the analysis. The subcategories of the physical overload questionnaire were not significantly associated with pain intensity at 6-month follow-up. However, age, disability at baseline and perceived physical overload related to postures of the trunk (B = -0.60 95% CI - 1.18 to - 0.02) and related to positions of the arms (B = 2.72 95% CI 0.07 to 5.37) were significantly associated with disability at 6-month follow-up. CONCLUSION: Although perceived physical overload at work was not associated with pain intensity in patients with chronic LBP at 6-month follow-up, we identified a significant association between perceived physical overload related to postures of the trunk and positions of the arms with disability at 6-month follow-up. These slides can be retrieved under Electronic Supplementary Material.

Physical Activity-Based Interventions Using Electronic Feedback May Be Ineffective in Reducing Pain and Disability in Patients With Chronic Musculoskeletal Pain: A Systematic Review With Meta-Analysis.

OBJECTIVE: To investigate the effectiveness of physical activity-based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain. DATA SOURCES: The following electronic databases were searched: EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Web of Science, Physiotherapy Evidence Database, and main clinical trial registers. STUDY SELECTION: Randomized controlled trials investigating the effect of physical activity interventions using electronic feedback (eg, physical activity monitors) on pain and disability compared to minimal or no interventions in adults with chronic musculoskeletal pain were considered eligible. DATA EXTRACTION: Pooled effects were calculated using the standardized mean difference (SMD), and the Grading of Recommendations Assessment, Development and Evaluation system was used to assess the overall quality of the evidence. DATA SYNTHESIS: Four published randomized controlled trials and 4 registered unpublished randomized controlled trials were included. At short-term follow-up, pooled estimations showed no significant differences in pain (2 trials: n=116; SMD=-.50; 95% confidence interval, -1.91 to 0.91) and disability (2 trials: n=116; SMD=-.81; 95% confidence interval, -2.34 to 0.73) between physical activity-based interventions and minimal interventions. Similarly, nonsignificant results were found at intermediate-term follow-up. According to Grading of Recommendations Assessment, Development and Evaluation, the overall quality of the evidence was considered to be of low quality. CONCLUSIONS: Our findings suggest that physical activity-based interventions using electronic feedback may be ineffective in reducing pain and disability compared to minimal interventions in patients with chronic musculoskeletal pain. Clinicians should be cautious when implementing this intervention in patients with chronic musculoskeletal pain.

Physical activity and disability measures in chronic non-specific low back pain: a study of responsiveness.

OBJECTIVES:: To compare the responsiveness of disability measures with physical activity measures in patients with chronic low back pain (CLBP) undergoing a course of physical therapy treatment. DESIGN:: This is a prospective cohort study with two-month follow-up. SUBJECTS:: A total of 106 patients presenting with non-specific CLBP of more than three months duration were recruited. MAIN MEASURES:: Disability measures investigated were Quebec Back Pain Disability Scale and Roland Morris Disability Questionnaire. Physical activity measures analyzed include the Baecke Habitual Physical Activity Questionnaire and objective measures derived from an accelerometer (i.e. total time spent in moderate-to-vigorous and light physical activity, number of steps and counts per minute). Disability and physical activity measures were collected at the baseline and after eight weeks of treatment. For the responsiveness analyses, effect size (ES) and standardized response mean (SRM) were calculated. Correlations between the change in disability and physical activity measures were calculated. RESULTS:: Responsiveness for disability measures was considered to be large with ESs ranging from -1.03 to -1.45 and SRMs ranging from -0.99 to -1.34, whereas all physical activity measures showed values lower than 0.20. Changes in disability measures did not correlate with changes in physical activity measures (correlation coefficients ranged from -0.10 to 0.09). CONCLUSION:: Disability measures were responsive after a course of physical therapy treatment in patients with CLBP. The lack of responsiveness in the physical activity measures might be due to the inability of these measures to detect change over time or the use of an intervention not designed to increase physical activity levels.

Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview.

OBJECTIVE: The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010. METHOD: The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines. RESULTS: We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments. These slides can be retrieved under Electronic Supplementary Material.

Fear of Movement Is Not Associated With Objective and Subjective Physical Activity Levels in Chronic Nonspecific Low Back Pain.

OBJECTIVES: To assess the association of physical activity measures, derived with an accelerometer and a self-reported questionnaire, with fear of movement in patients with chronic nonspecific low back pain (LBP) and to investigate the association between disability and fear of movement in this population. DESIGN: Cross-sectional study. SETTING: Outpatient physical therapy university clinics. PARTICIPANTS: Patients (N=119) presenting with nonspecific LBP of >3 months' duration. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical activity levels measured objectively with an accelerometer (ie, counts per minute, time spent in moderate-to-vigorous and light physical activity per day, number of steps per day, and number of 10-minute bouts of moderate-to-vigorous physical activity per day) and subjectively with a self-reported questionnaire (Baecke Physical Activity Questionnaire); fear of movement (Tampa Scale of Kinesiophobia); pain (11-point numerical rating scale); disability (Roland Morris Disability Questionnaire); and depression (Beck Depression Inventory). The associations were examined with correlational, univariate, and multivariable linear regression analyses. RESULTS: None of the objective physical activity measures were associated with fear of movement. The apparent association of self-reported physical activity levels with fear of movement (correlational analyses: r=-.18; P<.05; univariate regression analyses: ß=-.04; 95% confidence interval [CI], -.07 to -.01; P=.04) was not confirmed in multivariable analyses. Fear of movement was consistently associated with disability in both correlational (r=.42; P<.01) and multivariable (ß=.21; 95% CI, .11-.31; P<.001) analyses. CONCLUSIONS: Our data support one aspect of the fear-avoidance model-that higher fear of movement is associated with more disability-but not the aspect of the model linking fear of movement with inactivity.