Purpose and background

Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation.

Patients and methods

Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given.

Aims

Clinical decision support systems (CDSS) can support clinicians in selecting appropriate treatments for patients. The objective of this study was to examine if triaging patients with LBP to the most optimal treatment can be improved by using a data-driven approach with the help of machine learning as base of such a CDSS.

Methods

A clinical database of the Groningen Spine Center containing patient-reported data from 1546 patients with LBP was used. From this dataset, a training dataset with 354 features was labeled on eight different treatments actually received by these patients. With this dataset, models were trained. A test dataset with 50 cases judged on treatments by 4 experts in LBP triage was used to test these models with data not used to train the models. Prediction accuracy and average area under curve (AUC) were used as performance measures for the models.

Background

Patients with Neck and/or Low Back Pain (NLBP) constitute a heterogeneous group with the prognosis and precise mix of factors involved varying substantially between individuals. This means that a one-size-fits-all approach is not recommended, but methods to tailor treatment to the individual needs are still relatively under-developed. Moreover, the fragmentation of disciplines involved in its study hampers achieving sound answers to clinical questions. Data mining techniques open new horizons by combining data from existing datasets, in order to select the best treatment at each moment in time to a patient based on the individual characteristics.

Method

Within the Back-UP project (H2020 #777090) a multidisciplinary consortium is creating a prognostic model to support more effective and efficient management of NLBP, based on the digital representation of multidimensional clinical information. Patient-specific models provide a personalized evaluation of the patient case, using multidimensional health data from the following sources: (1) psychological, behavioral, and socioeconomic factors, (2) biological patient characteristics, including musculoskeletal structures and function, and molecular data, (3) workplace and lifestyle risk factors.

Purposes and Background

Musculoskeletal disorders including as back and neck pain are leading causes of work disability. Effective interventions exist (i.e. functional restoration, multidisciplinary biopsychosocial rehabilitation, workplace-based interventions, etc.), but it is difficult to select the optimal intervention for specific patients. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions. The WATT algorithm categorizes patients based on individual, occupational, and clinical characteristics according to likelihood of successful return-to-work following rehabilitation. Internal validation showed acceptable classification accuracy, but WATT has not been tested beyond the original development sample. Our purpose was to externally validate the WATT.

Methods and Results

A population-based cohort design was used, with administrative and clinical data extracted from a Canadian provincial compensation database. Data were available on workers being considered for rehabilitation between January 2013 and December 2016. Data was obtained on patient characteristics (ie. age, sex, education level), clinical factors (ie. diagnosis, part of body affected, pain and disability ratings), occupational factors (ie. occupation, employment status, modified work availability), type of rehabilitation program undertaken, and return-to-work outcomes (receipt of wage replacement benefits 30 days after assessment). Analysis included classification accuracy statistics of WATT recommendations for selecting interventions that lead to successful RTW outcomes. The sample included 5296 workers of which 33% had spinal conditions. Sensitivity of the WATT was 0.35 while specificity was 0.83. Overall accuracy was 73%.

Purpose

The behavioural change wheel methodology and social cognitive theory were combined to inform and develop a rehabilitation programme following lumbar fusion surgery (REFS).

This qualitative study evaluated participant's experiences of lumbar fusion surgery, including REFS, to identify valued programme content (‘active ingredients’).

Background

A feasibility-RCT suggested REFS achieved a meaningful impact in disability and pain self-efficacy compared to ‘usual care’ (p=0.014, p=0.007).

In keeping with MRC guidance a qualitative evaluation was undertaken to understand possible mechanisms of action.

Purposes And Background

Having found a significant limitation of neural movement (66.6%) during SLR performed on the symptomatic side in patients with sub-acute lumbar intervertebral disc herniation (LIDH), we followed up on the same patients over 1.5 years to ascertain if changes in cord excursion accompany changes in clinical symptoms.

Methods

14 patients, who originally had sciatic symptoms due to subacute LIDH, were re-assessed both clinically and radiologically with a 1.5T magnetic resonance (MR) scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between maneuvers and with data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with decrease in low back pain and radicular symptoms.

Introduction

The intervertebral disc (IVD) is a highly hydrated and hyperosmotic tissue, water and salt content fluctuate daily due to mechanical loading. Resident IVD cells must adapt to this ever-changing osmotic environment, to maintain normal behaviour. However, during IVD degeneration the disc becomes permanently dehydrated and cells can no longer perform their correct function. Here, we investigated how human nucleus pulposus (NP) cells respond to altered osmolality with regards to cell size and the rate of water permeability, along with the potential involvement of aquaporins (AQPs) and transient receptor potential vanilloid (TRPV) membrane channels.

Methods

Water permeability of NP cells exposed to altered osmolality (225–525mOsm/kg) in the presence or absence of AQP and TRPV channel inhibitors was investigated with the cell-permeable calcein-AM fluorescent dye, and cell size determined using microscopy and flow cytometry.

Background

Dynamic measurement of continuous intervertebral motion in low back pain (LBP) research in-vivo is developing. Lumbar motion parameters with the features of biomarkers are emerging and show promise for advancing understanding of personalised biometrics of LBP. However, measurement of changes over time inevitably involve error, due to subjects' natural variation and/or variation in the measurement process. Thus, intra-subject repeatability of parameters to measure changes over time should be established.

Methods

Seven lumbar spine motion parameters, measured using quantitative fluoroscopy (QF), were assessed for intra-subject repeatability: Intervertebral range-of-motion (IV-RoM), laxity, motion sharing inequality (MSI), motion sharing variability (MSV), flexion translation and flexion disc height. Intra-subject reliability (ICC) and minimal detectable change (MDC95) of baseline and 6-week follow-up measurements were obtained for 109 healthy volunteers (54 coronal and 55 sagittal).

Introduction

Chronic low back pain (LBP) is globally recognised as a leading cause of disability, with a global point-prevalence of 540 million people experiencing ‘activity-limiting’ LBP. A lack of muscle endurance is common in people with LBP, however the mechanisms underlying reduced endurance remain unclear. This study utilised high-density EMG (HDEMG) to evaluate differences in the spatial distribution and redistribution of lumbar erector spinae (ES) activity during an endurance task.

Methods

Thirteen control (Age:26.46±5.0, 7 Males) and 13 LBP participants (Age:27.39±9.7, 6 Males) were recruited and HDEMG signals were detected from ES unilaterally using a 13×5 electrode grid adhered 2cm lateral to the L5 spinous process. Participants were asked to complete an isometric endurance task until failure (>10° trunk deviation) with muscle activity simultaneously recorded. The activity was computed to form a map of the EMG amplitude distribution and the position of the centre of activity (centroid) was monitored throughout the task.

Introduction

Patients with recurrent low back pain (LBP) exhibit changes in postural control. Stereotypical muscle activations resulting from external perturbations include anticipatory (APAs) and compensatory (CPAs) postural adjustments. This study aimed to determine differences in postural control strategies (APAs and CPAs) between those with and without lumbar disc degeneration (LDD) and LBP.

Methods

Ninety-seven subjects participated in the study (mean age 50 years (SD 12)). 3T MRI was used to acquire T2 weighted images (L1-S1). LDD was determined using Pfirrmann grading and LBP using the numerical rating scale (NRS). A bespoke perturbation platform was designed to deliver postural perturbations. Electrical activity was analysed from 16 trunk and lower limb muscles during four typical APA and CPA epochs. A Kruskal-Wallis H test with Bonferroni correction for multiple comparisons was conducted.

Purpose and background

There is lacking evidence about the prognostic role of anxiety as prognostic in acute low back pain patients. The objective of this study was to determine whether patients with acute low back pain (ALBP) are at risk to develop chronic low back pain (CLBP) and pain-related disability after 12 weeks due to high anxiety levels.

Methods and results

An observational multi-centre study was conducted in primary physiotherapy care with measurements at baseline and at 12 weeks including known prognostic factors and psychological candidate predictors for CLBP. Two hundred and four participants completed both assessments of which 51 and 54 were classified as having less than 50% decrease in pain and pain-related disability, respectively. For pain, the final model contained higher pain intensity, longer pain duration, depression symptoms, and state anxiety with explained variance 0.30, sensitivity 0.74, specificity 0.82, Likelihood Ratio 4.1 (95% CI 2.0 to 6.1) and Area Under the Curve 0.78 (95% CI 0.70 to 0.85). For pain-related disability, trait anxiety, depression symptoms, and state anxiety contributed independently to the prediction with the model's explained variance of 0.19, sensitivity 0.78, specificity 0.78, Likelihood Ratio 3.0 (95% CI 2.0 to 4.5), and Area Under the Curve 0.73 (95% CI 0.65 to 0.81).

Background

Exercise is a complex intervention, and often has more than one treatment target. Results from randomised controlled trials (RCTs) of exercise interventions for chronic low back pain (CLBP) typically show small to moderate effect sizes, but these may differ where outcomes better reflect the targets of interventions. This review aimed to describe what treatment targets, outcome domains and primary outcome measures are used in exercise RCTs, and examined how well the selected outcome domains match the treatment targets used in each RCT.

Methods and Results

A computer-aided literature search was performed in eight databases, from inception to August 2018. Inclusion criteria: RCTs in CLBP, exercise compared to a non-exercise arm, sample size >60 per arm. Title and abstract review, subsequent full text review, data extraction and risk of bias assessment were independently undertaken by pairs of reviewers.

Of 18251 initially identified titles and abstracts, 23 trials were included in the review. 30 treatment targets were extracted, and 6 primary outcome domains identified. A logic model of the treatment targets and outcomes demonstrated diverse relationships. Only 5 RCTs matched their primary outcome domain to the identified treatment targets, 12 used primary outcomes that did not match the reported treatment targets, and 6 were partially matched.

Background

An understanding of the patterns of healthcare services used after MRI of the spine in general practice would provide information about how MRI scans are used in primary care.

Aim

To describe the healthcare use of patients referred for lumbar MRI in general practice, and to investigate the association between specific patient characteristics, back pain characteristics and MRI abnormalities with subsequent specialist consultation.

Purposes and Background

Musculoskeletal disorders are leading causes of work disability. Our purpose was to develop a predictive model in a cohort from 2012 and validate the model in 2016 data.

Methods and Results

Prospectively collected data was used to identify inception cohorts in 2012 (n=1652) and 2016 (n=199). Data from back pain claimants receiving treatment in physiotherapy clinics and the Ontario workers' compensation database were linked. Patients were followed for 1 year.

Variables from a back pain questionnaire and clinical, demographic and administrative factors were assessed for predictive value. The outcome was cumulative number of calendar days receiving wage-replacement benefits.

Cox regression revealed 8 significant predictors of shorter time on benefits in the 2012 cohort: early intervention (HR=1.51), symptom duration < 31 days (HR=0.88), not in construction industry (HR=1.89), high Low Back Outcome Score (HR=1.03), younger age (HR=0.99), higher benefit rate (HR=1.00), intermittent pain (HR=1.15), no sleep disturbance (HR=1.15). The 2012 model c-statistic was 0.73 with a calibration slope of 0.90 (SE=0.19, p=0.61) in the 2016 data, meaning not significantly different. The c-statistic in the 2016 data was 0.69. Median duration on benefits of those with a high risk score was 129 days in 2012 and 45 days in 2016.

Purpose of the study and background

A 2011 Cochrane review concluded that spinal manipulative therapy (SMT) is no better than other interventions for reducing pain and improving function in chronic low back pain (CLBP). Using individual participant data (IPD) from trials has advantages, among others: a more precise estimate of the effect and the potential to identify moderators. Our objective was to assess the effect of SMT in adults with CLBP and to identify relevant moderators.

Methods

All trials from the 2011 Cochrane review were included in this IPD. We updated the search (April 2016) IPD from eligible studies was requested. Primary outcomes were pain intensity (VAS/NRS) and back-specific function (RMDQ). Risk of bias was assessed. For the treatment effect, an one-stage approach (mixed model technique, intention-to-treat principle) was used; a second-stage approach was conducted as confirmation. For the moderator analyses, one-stage approach was conducted for 19 variables.

Aim

To develop a clinical core set of outcome measures that is accepted for relevance, feasibility and validity by stakeholders and useful for a) interaction between patient and professional, b) internal quality improvement, and c) external transparency in patients with NSLBP in primary care physical therapy.

Method

We used a consensus-driven modified RAND-UCLA Delphi technique. We conducted seven separate steps with panellists (physical therapists, patient representatives, health insurers) to select accepted outcomes. These seven steps consisted of a literature search, two online surveys, patient interviews, an experts meeting, a consensus meeting and final approval of an advisory board. Results of previous steps were discussed during the consensus meeting, and then panellists voted for inclusion per measure. The final core set was rated on relevance and feasibility on a 9-point Likert scale, when the median was ≥7 the core set was accepted.

Purpose of the study

To investigate the feasibility of undertaking a definitive Randomised Controlled Trial (RCT) to determine the effectiveness of early physiotherapy for sciatica.

Methods

Patients over 18 presenting to their G.P with sciatica were eligible to participate in the study, those without a clear understanding of English or had co-morbidities preventing rehabilitation were ineligible. Process and patient reported outcomes including self-rated disability, pain and general health, were collected at baseline, 6,12 and 26 weeks post randomisation.

Participants were randomised into either early physiotherapy, receiving treatment within 2 weeks after randomisation or usual care with physiotherapy commencing 6 weeks post randomisation. Both groups received up to 6 treatment sessions of a patient-centred, goal orientated physiotherapy programme specific to their needs.

Purpose of the study

The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision.

Methods

This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging.

Introduction

The PACE trial was the first randomized controlled trial (RCT) investigating the efficacy of paracetamol in acute low back pain. Non-compliance to study medication was considered to be a limitation of this RCT. In contrast to conventional statistical methods, complier average causal effects (CACE) analysis may provide unbiased estimates of the effects for participants compliant to paracetamol.

Methods

Intention to treat (ITT), as-treated, propensity weighted CACE and joint modeling CACE estimates were calculated for pain intensity, disability, global perceived effect and function at two weeks of follow up with compliance defined as an average of at least four tablets per day during the first two weeks of the trial. For pain intensity, exploratory analyses were conducted using additional time points and definitions of compliance.

Background

Medication prescribing patterns for patients with neuropathic low back-related leg pain (LBLP) in primary care are unknown.

Purpose

To estimate the proportion of patients prescribed pain medications, describe baseline characteristics of patients prescribed neuropathic pain (NP) medication and estimate the proportion of LBLP patients with refractory NP.

Background

Sciatica is common and associated with significant impacts for the individual, health care and society. The SCOPiC randomised controlled trial (RCT) is investigating whether stratified primary care for sciatica is more effective and cost-effective than usual, non-stratified primary care. Stratified care involves subgrouping patients to one of three groups based on a combination of prognostic and clinical indicators. Patients in one of these groups are ‘fast-tracked’ with an MRI scan to spinal specialist opinion. Our aim was to understand the perspectives of clinicians on the acceptability of this ‘fast-track’ pathway.

Methods

Qualitative, semi-structured interviews were conducted with general practitioners, spinal specialist physiotherapists and spinal surgeons (n=20 in total). Interviews were fully transcribed, and data were analysed using the constant comparison method.

Background

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). We have developed an injectable hydrogel (NPgel), which following injection into bovine IVD explants, integrates with IVD tissue and promotes disc cell differentiation of delivered mesenchymal stem cells (MSCs) without growth factors. Here, we investigated the injection of NPgel+MSCs into IVD explants under degenerate culture conditions.

Methods and Results

The NPgel integrated with bovine and human degenerate Nucleus Pulposus (NP) tissue and hMSCs produced matrix components: aggrecan, collagen type II and chondroitin sulphate in standard and degenerate culture conditions. Significantly increased cellular immunopositivty for aggrecan was observed within native NP cells surrounding the site where NPgel+MSCs were injected (P≤0.05). In NP explants a significant decrease in catabolic factors were observed where NPgel+MSCs was injected in comparison to controls.

Background

Endplate defect is an MRI trait, found to be associated with intervertebral disc degeneration. There is a lack of understanding regarding the mechanism underlying lumbar disc degeneration (LDD). This large-scale longitudinal population-based study aimed to determine the order of appearance of degenerative change in the vertebral body and intervertebral disc, the influence of endplate degeneration on LBP and whether there is a genetic influence on endplate damage.

Methods

Individuals from the TwinsUK spine study having longitudinal T2-weighted lumbar MRI scans at baseline (n=996) and a decade later (n=438) were included. LDD, vertebral endplate defect expressed as a total endplate (TEP) score and Modic change (MC) were assessed using standard techniques. Mixed-effects models were used to determine the association between spine pathology features adjusted for covariates. Endplate defect heritability was estimated using variance component analysis.

Objective

Modic changes (MC), a form of intervertebral disc degeneration visible as subchondral and vertebral bone marrow changes on spine magnetic resonance (MR), are known to be associated with low back pain. This study aimed to identify genes contributing to the development of MC using genome-wide association study.

Methods

Presence of MC was evaluated in lumbar MR images in the Northern Finland Birth Cohort 1966 (NFBC1966, N=1182) and TwinsUK (N=647). Genome-wide association analyses were carried out in the cohorts separately using a linear regression model fitted to test for additive effects of SNPs and adjusting for age, sex, BMI, and either family relatedness via a kinship matrix (TwinsUK) or population stratification using principal components (NFBC1966). Meta-analysis of the two studies was carried out using the inverse-variance weighting approach.

Purpose

Back pain is the primary cause of disability worldwide yet surprisingly little is known of the underlying pathobiology. We conducted a genome-wide association study (GWAS) meta-analysis of chronic back pain (CBP). Adults of European ancestry from 15 cohorts in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium, and UK Biobank were studied.

Methods

CBP cases were defined as reporting back pain present for ≥3–6 months; non-cases were included as comparisons (“controls”). Each cohort conducted genotyping followed by imputation. GWAS used logistic regression with additive genetic effects adjusting for age, sex, study-specific covariates, and population substructure. Suggestive (p<5×10^–7) & genome-wide significant (p<5×10^–8) variants were carried forward for replication in an independent sample of UK Biobank participants. Discovery sample n = 158,025 individuals, including 29,531 CBP cases.

Objective

Low back pain (LBP) is a common debilitating condition with great socioeconomic impact. Identifying individuals at risk of LBP is challenging. We have shown IgG N-glycans are associated with LBP. Herewith, we used polygenic risk scores (PRS) from IgG-glycome to test predictability for LBP.

Methods

Clusters of IgG-glycans were identified using weighted correlation network approach in TwinsUK (n = 4246). Genome-wide association studies were carried out for the clusters and top associated SNPs (p<5e-8) were extracted. Weighted PRS was calculated as the sum of the number of copies of effect allele from GWAS multiplied by their effect size using the UK Biobank data (n = 350000). The predictive capacity of the PRS for back pain in UK Biobank was estimated using logistic regression.

Background

The majority of adults will experience an episode of low back pain during their life. Patients with non-specific low back pain and lumbar disc degeneration (LDD) may experience spinal pain and morning stiffness because of a comparable inflammatory process as in patients with osteoarthritis of the knee and/or hip. Therefore, this study assessed the association between spinal morning stiffness, LDD and systemic inflammation in middle aged and elderly patients with low back pain.

Methods

This cross-sectional study used the baseline data of the BACE study, including patients aged ≥55 years visiting a general practitioner with a new episode of back pain. The association between spinal morning stiffness, the radiographic features of lumbar disc degeneration and systemic inflammation measured with serum C-reactive protein was assessed with multivariable logistic regression models.

Aims

The aims of this study were to investigate whether 1) multispecialist tertiary intervention for complex spinal pain lead to reductions in spine-related healthcare costs and 2) baseline characteristics are related to health care consuming costs.

Patients and methods

A cost study in a natural prospective cohort was carried out to investigate healthcare data of patients admitted to the Groningen Spine Center (GSC) ranging from two years prior to referral until two year after discharge. GSC intervention consisted of a multi-professional and -specialist based diagnosis and treatment. Patients (18 and 80 years) were included, suffering from specific as well as multifactorial spinal pain. Clinical data was merged with Health Care Insurance data and included questionnaires on demographics, work, pain, disability, quality of life and psychosocial functioning. Univariable (paired sample t-tests) and multivariable analyses (pooled OLS Regression and fixed effects models) were carried out.

Background and purpose

The Fear Avoidance Model is used to explain why some patients with acute low back pain develop chronic low back pain (CLBP). Cognitive behavioural therapy (CBT) targeting dysfunctional behavioural cognitions (pain catastrophizing and fear of movement) is recommended.

Purpose: to investigate whether a two-week CBT-based pain management program results in improvement in dysfunctional behavioural cognitions and whether these improved cognitions improve functional outcomes.

Methods and Results

Cohort study including 524 consecutive CLBP-patients. Main outcome: functioning (ODI). Secondary outcomes: pain severity (NRS), pain catastrophizing (PCS), fear of movement (TSK). Assessments: pre- and post-treatment, 1 and 12-months follow-up (FU). Improvement over time was analysed with repeated measures ANOVA. Path analyses were used to examine the influence of pain catastrophizing and fear of movement on functional disability and pain severity. Multiple imputation was used to complete missing data.

Participants with incomplete data (12.8%) did not differ from those with complete data (n= 457). 59% were females, mean age 46 (± 9.5) years, mean CLBP-duration 12 (± 10.8) years. All outcomes significantly improved at post-treatment and a slight significant improvement between post-treatment and 12 months FU was observed. Path analyses showed a direct effect for catastrophizing on post-treatment functioning and an indirect effect for catastrophizing through fear of movement on post-treatment functioning. Comparable results with pain severity as outcome.

Background

There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care.

Purpose

To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP).

Introduction

The Odom's criteria are, since 1958, a widely used 4-point rating scale for assessing the clinical outcome after cervical spine surgery. Surprisingly, the Odom's criteria have never been validated. The aim of this study was to investigate the reliability and validity of the Odom's criteria for the evaluation of surgical procedures of the cervical spine.

Methods

Patients with degenerative cervical spine disease were included and divided into two groups, based on their most predominant symptom: myelopathy or radiculopathy. Reliability was assessed with inter-rater and test-retest design using a quadratic weighted Kappa coefficient. Construct validity was assessed by means of hypothesis testing with related constructs. To evaluate if the Odom's criteria could act as a global perceived effect (GPE) scale, we assessed concurrent validity by comparing the areas under the curves (AUCs) of the receiver operating characteristic curves (ROCs) with both the Odom's criteria, as the GPE as an anchor.

Background

Routine imaging (radiography, CT, MRI) provides no health benefits for low back pain (LBP) patients and is not recommended in clinical practice guidelines. Whether imaging leads to increased costs, healthcare utilization or absence from work is unclear.

Purpose

To systematically review if imaging in patients with LBP increases costs, leads to higher health care utilization or increases absence from work.

Introduction

A minority of patients with chronic low back pain (CLBP) account for a majority of disability and costs. This subgroup has potentially most to gain from effective treatment. The Groningen Spine Cohort will provide a 10-year prospective insight into the burden of CLBP for patients referred to multispecialty tertiary spine care in the Netherlands. This study reports first baseline results.

Objective

To study the personal and societal impact of CLBP in patients visiting the UMCG tertiary spine center.

Introduction

Analgesic drugs are often prescribed to patients with low back pain (LBP). Recommendations for non-invasive pharmacological management of LBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy.

Methods

Guideline recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacotherapy, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized.

Purpose and background

Recent research has identified possible functional biomarkers in chronic, nonspecific back pain (CNSLBP) based on intervertebral kinematics. Although excessive IV-RoM is no longer regarded as a clear motion abnormality, some studies have found subtle kinematic measures such as mid-range laxity and motion sharing inequality to be greater in CNSLBP patients. We studied a group of such patients who were investigated following failed interventions in terms of these subtle measures.

Methods

Thirty-seven patients (mean age 47.5 years SD10.87, F14, M23) with CNSLBP that had recently failed to respond to a range of treatments and 37 healthy controls received passive recumbent lumbar intervertebral flexion assessments following a standardised quantitative fluoroscopy (QF) protocol. Groups were compared for motion sharing inequality (MSI) and variability (MSV) (L2-S1), for level by level laxity and translation, and with reference ranges of these from a separate group of healthy controls (n=54).

Purpose and background of the study

When talking to patients about pain, it has been shown that practitioners can positively or negatively influence health beliefs and treatment outcomes. Multidisciplinary physical and psychological interventions have demonstrated better outcomes for patients with long-term pain. Acceptance and Commitment Therapy (ACT) is a form of ‘third wave’ Cognitive Behavioural Therapy (CBT) that has been shown to promote resilience and wellbeing. A qualitative auto-ethnographic case study design was used to explore the communication processes and therapeutic outcomes associated with developing an innovative course integrating ACT interventions with osteopathic treatment, delivered by a single practitioner.

Methods

Six individual consultations with four patients were audio-recorded, transcribed verbatim and coded. Linguistic Ethnography was used to identify pain discourses and analyse links with clinical decisions and patient responses. Transcript extracts were analysed at three levels; micro-level Conversation Analysis of communication processes; Interactional Sociolinguistic Analysis of changes in patient-practitioner roles; and macro-level Discourse Analysis of the wider biomedical and biopsychosocial context.

Study Aim

To design an educational resource for people with lower back pain (LBP) using creative co-production.

Background

Beliefs associated with a traditional biomedical view of LBP can be a barrier to recovery. Education that reframes the problem as complex and multifactorial may help patients except and engage with more positive attitudes and behaviours.

Creative co-production provides a different approach to research intervention development. It encourages a collaborative problem-solving and non-hierarchical approach to knowledge mobilisation.

Introduction

Degeneration of the cervical spine can lead to neurological symptoms that require surgical intervention. Often, an anterior cervical discectomy (ACD) with fusion is performed with interposition of a cage. However, a cage substantially increases health care costs. The polymer polymethylmethacrylate (PMMA) is an alternative to cages, associated with lower costs. The reported high-occurrence of non-fusion with PMMA is often seen as a drawback, but evidence for a correlation between radiological fusion and clinical outcome is absent. To investigate if the lower rate of fusion with PMMA has negative effects on long-term clinical outcome, we assessed the clinical results of ACD with PMMA as a intervertebral spacer with a 5–10 year follow-up.

Methods

A retrospective cohort study among all patients who underwent a mono-level ACD with PMMA for degenerative cervical disease, between 2007–2012, was performed. Patients filled out an online questionnaire, developed to assess clinical long-term outcome, complications and re-operation rates. The primary outcome measure was the Neck Disability Index (NDI), secondary outcome measures were re-operation and complication rates.

Background

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). Degenerate discs are associated with accelerated cellular senescence. Cell senescence is associated with a secretory phenotype characterised by increased production of catabolic enzymes and cytokines. However to date, the mechanism of cell senescence within disc degeneration is unclear. Senescence can be induced by increased replication or induced by stress such as reactive oxygen species or cytokines. This study investigated the association of cellular senescence with markers of DNA damage and presence of cytoplasmic DNA (which in cancer cells has been shown to be a key regulator of the secretory phenotype), to determine mechanisms of senescence in disc degeneration.

Methods and Results

Immunohistochemistry for the senescence marker: p16^INK4A was firstly utilised to screen human intervertebral discs for discs displaying at least 30% immunopostivity. These discs were then subsequently analysed for immunopostivity for DNA damage markers γH2AX and cGAS and the presence of cytoplasmic DNA. The number of immunopositive cells for p16^INK4A positively correlated with the expression of γH2AX and cGAS. Senescent cells were also associated with the presence of cytoplasmic DNA.

Purposes of the study and background

Clinical assessment of spinal function is a routine part of low back pain (LBP) assessment, yet there is no clear consensus on what constitutes ‘spinal dysfunction’ and how this informs treatment. This study's aims to develop a spinal function classification framework by gaining expert academic and clinical consensus on (i) spinal function assessment tests (ii) encountered LBP motor control/movement impairment (MCI/MI) sub-types (iii) their characteristics and (iii) exercises and feedback for each sub-type.

Methods and Results

An online 2-round Delphi-survey of 4 world-leading academic experts and 36 clinical physiotherapists world-wide was employed. A five-point response scale was used to rate level of agreement on 174 items with a priori consensus defined by a ≠>80% level of agreement (LOA). Out of 15 spinal function assessment tests, 5 reached consensus with forward bend and sitting/standing tests highest scoring. 7 MCI/MI sub-types reached consensus as clinically encountered. 12 out of 128 of posture/movement descriptors within the 7 sub-types reached consensus. 7 exercises gained consensus in being considered as ‘important’ or ‘very important’ with exercises involving sitting, standing, forward bend scoring highest. Consensus was reached on MCI/MI sub-type specific exercises, compensation strategies and feedback to remedy these compensations.

Background

About 85% of the patients with low back pain seeking medical care have nonspecific low back pain (NsLBP), implying that no definitive cause can be identified. Many pain conditions are linked with elevated serum levels of (pro-)inflammatory biomarkers.

Purpose

To unravel the etiology and get better insight in the prognosis of NsLBP, the aim of this study was to assess the association between (pro-)inflammatory biomarkers and the presence and severity of NsLBP.

Background

There is an increasing burden of LBP. Clinical guidelines promote physical activity (PA) and self-management strategies and aim to reform unhelpful clinical activity. This study explores osteopaths' beliefs about non-specific low back pain (NSLBP) and the role of activity in the treatment of NSLBP.

Methods

Semi-structured interviews were conducted with a purposive sample of twelve qualified osteopaths in the UK. Interviews were transcribed verbatim and constructivist grounded theory was used to conceptualise, collect and analyse data.

Introduction

The aim of this study was to assess patients and healthcare professionals (HCPs) opinions on the validity of using a biopsychosocial model rather than a biomedical model in alleviating patient symptoms/pain.

Method

We constructed a questionnaire to assess beliefs on the effectiveness of using a biopsychosocial or biomedical model to develop a treatment plan to optimise patient symptoms/pain. We distributed the questionnaire to new and follow-up patients and healthcare professional in the orthopaedic department.

Background

Advice to stay active should be delivered to all patients with low back pain (LBP) without a serious underlying condition. However, some patients still believe that the avoidance of activities will help them to recover. These patients may be less likely to experience favourable outcomes.

Purpose

To investigate how many patients consider LBP to be a signal to stop being active.

Background

Information about low back pain (LBP) and help to support patients' self-management are recommended in the majority of guidelines for LBP management. However, the delivery of patient information and advice can be time consuming, and with short available consultation times for general practitioners (GPs), new methods to support the delivery of sufficient patient information is called for.

Purpose

To identify general practitioners' perspectives on recommending online information to patients with LBP.

Purpose and background

Static plain radiographs at the end of uncontrolled bending are the current standard of care for measuring translatory slip in back pain patients. Quantitative fluoroscopy systems (QF) that employ standardised bending protocols have been found to improve precision and reduce dose, but comparative data are lacking. We compared 4 QF methods with static radiographs in a control population, calculating ranges, population variation and measurement errors over 6 weeks.

Methods

Fifty-four healthy controls (F=22, M=23) received passive recumbent and active weight bearing QF screenings during controlled motion, plus still fluoro imaging in neutral, flexion and extension. The translatory slip of all levels from L2-S1 was determined for each condition using bespoke image tracking codes (Matlab) and pooled to provide means and ranges of variation (+/-1.96SD). The pooled measurement error, or minimal detectable change (MDC₉₅), reflecting the intra subject repeatability over 6 weeks was calculated. Ranges of translation for each level (L2-S1), for each type of motion were also calculated.

Aim of Study and Background

The vertebral endplate (VEP) is characterised as a bilayer of cartilage and bone, acting as a boundary between the disc and the vertebra. The disc being the largest avascular tissue in the body, relies primarily on the nutritional pathways from the vascular network in the adjacent VEP. Disruption of this nutrient supply has been identified as a major contributor to disc degeneration, yet the 3D topology of the network is poorly understood.

The aim of this work is the characterisation of this vascular network to further understand the physiology of the vascular network and the correlation between disc degeneration and nutrient supply.

Methods and Results

Caudal and cranial VEP sections were sampled from lumbar ovine spines and imaged using high-resolution micro-computed tomography (micro-CT) at 4.92 µm pixel size. The diameter, length, orientation and depth from the VEP surface were measured for individual canals using 3D canal centreline models using ScanIP.

The results showed higher concentration of canals in the central regions of the VEP and in caudal VEP to the disc. Large transverse canals were identified running parallel to the VEP surface connected to both the disc and the vertebra, and depth-dependence of the length and diameter of the canals was recorded.

Introduction

Injectable hydrogels via minimally invasive surgery reduce the risk of infection, scar formation and the cost of treatment. Degradation of the intervertebral disc (IVD) currently has no preventative treatment. An injectable hydrogel material could restore disc height, reinforce local mechanical properties, and promote tissue regeneration. We present a hydrogel material Laponite^® associated poly(N-isopropylacrylamide)-co-poly(dimethylacrylamide) (NPGel). Understanding how the components of this hydrogel system influence material properties, is crucial for tailoring treatment strategies for the IVD and other tissues.

Methods & Results

The effect of hydrogel wt./wt., clay and co-monomer percentages were assessed using a box-Behnken design. Rheometry, SEM, FTIR and swelling was used to measure changes in material properties in simulated physiological conditions. Rheometry revealed gelation temperature of hydrogel materials could be modified with dimethyl-acrylamide co-monomer; however, final maximum mechanical properties remained unaffected. Increasing the weight % and clay % increased resultant mechanical properties from ∼500–2500 G' (Pa), increased viscosity, but retained the ability to flow through a 26G needle at 39°C.

Purpose

The aim of this study was to explore the usefulness and feasibility of comprehensive vocational rehabilitation (C-VR) and less comprehensive vocational rehabilitation (LC-VR) for workers on sick leave due to CMP, from the perspective of patients, professionals, and managers.

Methods

Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, interviewees were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using thematic analysis.

Purposes of the study and background

An increasing number of clinical studies involving a range of chronic pain conditions report widespread mechanical pressure pain hypersensitivity, which is commonly interpreted as resulting from central sensitization (CS). Secondary hyperalgesia (increased pinprick sensitivity surrounding the site of injury) is considered to be a manifestation of central sensitization. However, it has not been rigorously tested whether central sensitization induced by peripheral nociceptive input, involves widespread mechanical pressure pain hypersensitivity. The aim of this study was to assess whether high frequency electrical stimulation (HFS), which induces a robust secondary hyperalgesia, also induces a widespread decrease of pain pressure thresholds (PPTs).

Summary of the methods and results

We measured PPTs bilaterally on the temples (temporalis muscles), on the legs (tibialis anterior muscles) and on the ventral forearm (flexor carpi radialis muscles) before, 20 min after, and 45 min after applying HFS on the ventral forearm of sixteen healthy young volunteers. To evaluate the presence of secondary hyperalgesia, mechanical pin-prick sensitivity was assessed on the skin surrounding the site where HFS was applied and also on the contralateral arm. HFS induced a significant increase in mechanical pinprick sensitivity on the HFS-treated arm. However, HFS did not decrease PPTs either in the area of increased pinprick sensitivity nor at more distant sites.

Background

There is growing evidence for an important role of central sensitization (CS) in the development and maintenance of chronic pain. Consequently, alleviation of CS might be helpful, as was demonstrated for pregabalin. For tapentadol this is unknown.

Tapentadol is a drug with a dual mechanism: 1) it acts on the mu-opioid receptor (µ-OR) and 2) it inhibits the reuptake of noradrenalin in the central nervous system3. The noradrenergic effect might involve a modulation of descending pain pathways and thereby reduce or alleviate CS.

Aim

The aim of the present study is to determine the alterations in CS parameters by tapentadol in patients with chronic visceral (endometriosis) pain and deep somatic (low back) pain, using pregabalin as comparator.

Background

A cornerstone in treating low back pain (LBP) is the provision of information to patients, and the internet is increasingly being used as a source of health information delivery. However, the effect of and satisfaction with online information have been questioned.

Purpose

To develop a multi-item instrument to measure an index score of satisfaction with online information for patients with LBP.

Purpose of the study and background

The biopsychosocial (BPS) model is now widely implemented in clinical practice. Most research on manual therapists' attitudes regarding psychosocial (PS) factors and NSLBP is from the physiotherapy profession. There is currently no literature available to understand how osteopaths integrate those factors with patients presenting with NSLBP. The University College of Osteopathy students being the future of the profession and receiving an accredited BPS teaching warranted the need for an investigation about their attitudes towards PS factors and NSLBP.

Methods and results

A qualitative research design with elements of grounded theory was used. Nine final year UCO students were recruited and interviewed at the UCO teaching centre. Data collection and analysis occurred simultaneously through the constant comparative method of analysis.

Three main themes emerged from the data analysis: 1) Definition and interpretation of PS factors towards LBP; 2) Assessment and management of PS factors; 3) Competence and difficulties towards PS factors.

Background

There is growing evidence for an important role of central sensitization (CS) in the development and maintenance of chronic pain. This accounts for patients with chronic low back pain radiating to the leg (CLBPr) as well. Care as Usual (CaU) in these patients consists of diagnostic segmental nerve root blocks (dSNRB) followed by therapeutic interventions, i.e. a therapeutic segmental nerve root block (tSNRB) or pulsed radiofrequency (pRF). However, it is unknown if these procedures affect the amount of CS in these patients.

Aim

The aim of the present study is to determine the alterations in the presentation of CS in CLBPr patients during care as usual.

Purpose & Background

The ability to jump higher is a key factor for athletic performance and relies on many factors including spinal movement and trunk muscle activity. Manual therapy including Mulligan' Sustained Natural Apophyseal Glide (SNAG) techniques are proposed to increase spinal movement and thus function. The evidence pf the effect of manual therapy on muscle activity is limited. We aimed to determine the immediate effects of an extension SNAG on the lower lumbar spine on jump height and rectus abdominis (RA), external oblique (EO), multifidus (M) and iliocostalis Lumborum (IL) muscle activity during the flight phase of vertical jump compared to a placebo intervention (flat hand pressure).

Method

Eighteen healthy participants (16 males, age 28.11±5.01 years, weight 70.58±11.9 kg, height 1.70±0.07m, body mass index 24.28±3.30)from Cardiff University were randomly allocated to either an extension SNAG or placebo intervention. Surface Electromyography was normalised to maximum voluntary contraction and was collected during the flight phase of the jump and jump height was measured using jump and reach test.

Background and purposes

Central Sensitization (CS) may occur in patients with Chronic Low Back Pain (CLBP). Functional capacity these patients is limited. However, the association of CLBP with functioning assessed via lifting and aerobic capacity tests has been moderately explained and results are contradictory. Let alone pain response following strenuous exercise. Finally, whether CS is associated with either or both lifting and aerobic capacities is unknown.

To analyze the relationship between CS, and lifting and aerobic capacities in patients with CLBP.

Methods

Cross-sectional observational study. CS, lifting and aerobic capacities, and pain response were respectively measured with Central Sensitization Inventory (CSI), floor-to-waist lifting test, Cardiopulmonary Exercise Test (CPET), and Pain response questionnaire.

Statistical analyses:

Stepwise-forward multiple regression with lifting and aerobic capacities (dependent), CSI (independent), physical, work- and disability-related characteristics (covariates);

Purpose & Background

Back and lower limb injuries are prevalent in athletes who perform novel weight-lifting techniques with inappropriate kinematics. Visual-auditory instructions and knowledge of performance (KP) verbal instructions are utilised to help novices execute novel skills. Effectiveness of these methods on executing appropriate front-squat lifting kinematics is limited.

Aim: to investigate the effects of visual-auditory instructions compared to KP verbal instructions on front-squat kinematics at sticking point in novice lifters, with improvement determined by proximity to the kinematics of an expert lifter at sticking point when performing optimal front-squat lift.

Methods

Twenty-four novices were randomised into two groups and performed front-squat lift. The novices in visual-auditory group (n = 12, age = 24.33 ± 2.93 years) received videoaudio instructions, verbal group (n = 12, Age= 22.66 ± 2.34 years) received KP verbal instructions. MATLAB software measured kinematic lumbar angles, Kinovea software measured hip, knee, ankle angles at sticking point of front-squat. Data were collected from video recordings of novices and an expert pre-and post-instructions in one session and expert data were used as reference values of proximity for both groups.

Aim

To systematically review the literature and anatomical atlases on LM morphology.

Methods

Relevant studies were searched in PubMed (Medline) and Science Direct. Anatomical atlases were retrieved from multiple university libraries and online.

Included atlases and studies were assessed at five items: visuals present(y/n), quality of visuals(in-/sufficient), labelling of multifidus (y/n), clear description of region of interest(y/n), description of plane has been described(y/n).

This risk of bias assessment tool was developed to assess the quality of description of anatomy, since existing risk of bias tables have only been developed to assess the methodology of studies.

Background

The aim of the Groningen Spine Center (GSC) is to provide personalized and effective interventions to patients with spine-related disorders. The GSC comprises a multidisciplinary team to triage and treat patients most optimally.

Aim

To investigate the patient reported clinical results of the treatments of the GSC during seven years of its existence.

Aims

The aim of this study was to investigate the agreement of physician assistants (PAs) in the triaging of patients with Low Back Pain (LBP) based on self-reported data.

Patients and methods

A cross sectional vignette study among four PAs was carried out. Vignettes (cases) were constructed including 26 factors that can be self-reported, identified in literature that have predictive value in treatment outcomes (for example red flags indicating serious underlying conditions and yellow flags indicating psychosocial factors). All vignettes were randomly assigned to the PAs who should determine what intervention would be most optimal to the patient (rehabilitation, injections, medications, surgery, primary care psychology, primary care physical therapy). PAs were allowed to advise more than one intervention. Per vignette, 3 PAs were assigned randomly to advise on intervention. Fleish kappas were calculated to determine the interrater reliability.