FOTO - Focus on Therapeutic Outcomes | Low Back Pain Archives

Cognitive Functional Therapy and Nonspecific Low Back Pain

Selena Horner — Mon, 31 Dec 2018 14:15:00 +0000

As a curious soul, I appreciate qualitative studies that shed light on how we think and feel. This study investigates the physical therapists’ perspectives of cognitive functional training.

Treating and managing individuals who have persistent low back pain can be quite challenging. One of the reasons I am changing my practice focus truly has to do with how individuals in my local region who have persistent back pain are treated.

As this study highlights, I am not alone in my thoughts about the difficulty in treating these individuals. It’s quite difficult to work with these individuals who have strong biomedical beliefs. The main reason, in my opinion, is the fact that all the interacting health care professionals are not on the same page providing the same message to these patients.

Since I know that the majority of patients seeking services for physical therapy will have low back pain as their main reason for services, I thought this study would be helpful for the majority of physical therapists. Often times departmental strategies are implemented without considering how the strategy will be perceived by the clinicians. This study sheds light on the perception of physical therapists who underwent cognitive functional therapy training and implemented it into practice.

The abstract is included below for you to review.

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study.

Cowell I¹, O’Sullivan P^2,³, O’Sullivan K^4,⁵, Poyton R¹, McGregor A¹, Murtagh G¹.

Abstract

BACKGROUND:

It has long been acknowledged that nonspecific chronic low back pain (NSCLBP) is associated with a complex combination of biopsychosocial (BPS) factors, and recent guidelines advocate that the management of back pain should reflect this multidimensional complexity. Cognitive functional therapy (CFT) is a behaviourally oriented intervention that targets patients’ individual BPS profiles. Although the efficacy of CFT has been demonstrated in primary care, little evidence exists about the training requirements of this approach.

METHODS:

Qualitative semistructured interviews were conducted with 10 physiotherapists working in primary care, who had undergone a formal training programme in CFT. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes.

RESULTS:

Five main themes emerged: (i) the learning challenge; (ii) self-reported changes in confidence; (iii) self-reported changes in communication practice; (iv) self-reported changes in attitudes and understanding; (v) the physiotherapists felt that CFT was more effective than their usual approach for NSCLBP but identified barriers to successful implementation, which included a lack of time and difficulties in engaging patients with strong biomedical beliefs.

CONCLUSIONS:

The study suggested that training in CFT has the capacity to produce self-reported changes in physiotherapists’ attitudes, confidence and practice. The provision of such training has implications in terms of time and costs; however, this this may be warranted, given the physiotherapists’ strong allegiance to the approach compared with their usual practice.

Musculoskeletal Care. 2018 Nov 23. doi: 10.1002/msc.1370. [Epub ahead of print]

The post Cognitive Functional Therapy and Nonspecific Low Back Pain appeared first on FOTO Patient Outcomes.

Education: Placebo vs Intensive Pain Education Appear Equal

Selena Horner — Mon, 24 Dec 2018 11:00:00 +0000

Last month this study rumbled around in my brain. I wonder if this study teaches us how not to do what something that does have supportive evidence.

The patients in this study were all identified as being at risk for persistent pain. The patients were experiencing low back pain with an onset within the previous 6 weeks. If I were to guess (because I cannot acquire full text access), these patients probably had higher levels of fear or anxiety or depression as part of their presentation.

What’s interesting is the fact that there is plenty of research substantiating the value of spending time educating about pain. This study compared basically pain education with what appears to be active listening.

What I am unable to determine is how the education occurred or who provided the education. The one thing that I do know is that the experimental group underwent two sessions of one hour duration of education about their pain. Apparently the other group underwent two sessions of one hour duration of active listening. I don’t know about the rest of you, but a few things immediately pop into my head.

The patients had to have felt uncomfortable. Think about it: most patients who have a recent onset of low back pain do not appreciate being in a single position like sitting or standing for one hour at a time.
When I am at conferences, I wonder why the planners like to have long sessions. We already know from neuroscience that our attention spans are not likely to be able to pay attention for 50-minutes.
How much interaction did the patients actually have during the educational process in the experimental group? What I mean is, was the education individualized for the specific patient or was the educational aspect a formalized situation where each patient was educated in the same manner with the same information?
Was the educational component one-on-one or a group situation?
Why was the study oversimplified and focused only on education? When someone has an acute musculoskeletal condition, I am not aware of education being the go-to answer to solve the situation.

This study obviously points to the lack of value educating patients who are at risk for having persistent pain. I honestly cannot take that particular stance. What this study really indicates is that spending 2 sessions of an hour duration educating about pain is not an adequate plan. This is great news, because I highly doubt that any of us in rehabilitation would even think of spending an hour of a chunk of time solely focused on pain education. The study really wasn’t based on reality. The dosage of the education was definitely too high. We also know that telling someone to “stay active” may be really, really vague for the person experiencing pain. We know that we use our assessment and evaluation to prescribe targeted activities for the patient to perform. We use our education and our activity prescriptions to be highly specific to the individual sitting in front of us.

You’ll find the abstract to the recent study below.

Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial.

Traeger AC^1,², Lee H^1,³, Hübscher M¹, Skinner IW^1,⁴, Moseley GL^1,⁵, Nicholas MK⁶, Henschke N², Refshauge KM⁷, Blyth FM⁸, Main CJ⁹, Hush JM¹⁰, Lo S^11,¹², McAuley JH^1,¹³.

Abstract

IMPORTANCE:

Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care.

OBJECTIVE:

To determine the effectiveness of intensive patient education for patients with acute low back pain.

DESIGN, SETTING, AND PARTICIPANTS:

This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks’ duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education.

INTERVENTIONS:

All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice).

MAIN OUTCOMES AND MEASURES:

The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months.

RESULTS:

Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, -0.3 [95% CI, -1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, -1.6 points on a 24-point scale [95% CI, -3.1 to -0.1]) and 3 months (mean difference, -1.7 points, [95% CI, -3.2 to -0.2]) but not at 6 or 12 months.

CONCLUSIONS AND RELEVANCE:

Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.

JAMA Neurol. 2018 Nov 5. doi: 10.1001/jamaneurol.2018.3376. [Epub ahead of print]

The post Education: Placebo vs Intensive Pain Education Appear Equal appeared first on FOTO Patient Outcomes.

Artificial Intelligence-Embedded Mobile App for Chronic Neck and Back Pain

Selena Horner — Wed, 19 Dec 2018 11:00:00 +0000

Could a mobile app with artificial intelligence built into the program be helpful for patients?

As I often say in the clinic that the brick and mortar clinic rates 3-star, but as soon as I walk in we reach 5-star rating. As I read more and more about various technologies being created to help provide do-it-yourself or self-care management solutions, I admittedly feel a tad threatened. Although I know what I do isn’t necessarily rocket science, it stings just a little bit thinking that technology just might replace me.

As I read this particular study, I focused on “artificial intelligence.” When a product truly has artificial intelligence, the product is continually learning and making decisions based on boatloads of data. This particular product, from what I am interpreting, seems to have a decision algorithm within it based on guidelines and professional expertise. The questions asked within the app to determine the output. The questions focus on: present condition, history, past treatment, 24-hour pattern, drug history, and social history. From my perspective the artificial intelligence kicks in more strongly every 14 days as the app user is reassessed.

So, what is missing in the app? Based on the study, I’m not sure if a differential diagnosis occurred. I don’t believe it is reasonable to believe that every person who has persistent pain just needs exercise to improve the condition. Granted, the app does have a disclaimer that the app does not replace medical services.

For the last 12 weeks I have been participating in a group strengthening program at the local YMCA. Interesting to me, the instructor seems more focused on designing changes versus focusing on the quality of the performance of the exercise. As I watch others performing the exercises, what I see missing is good form and appropriate recruitment of muscles to perform the activity. After some sessions, some of the participants mention back or shoulder pain – and I know the reason is because the instructor provides very little guidance on the amount of resistance for each participant nor cues to ensure the exercise is performed safely. From this experience, I truly do wonder if a do-it-yourself self-management without any face-to-face time or supervision will actually provide the intended results.

I can appreciate the fact that this study was basically really looking at the feasibility of an app for these people. The findings indicate that those in the study did receive and appreciate educational material. Those in the study also increased their exercise levels. Pain level also reduced. The study has limitations that there is no comparison group.

I’m crossing my fingers and hoping that apps don’t replace 5-star me!

You’ll find the abstract to the recent study below.

The Perceived Benefits of an Artificial Intelligence-Embedded Mobile App Implementing Evidence-Based Guidelines for the Self-Management of Chronic Neck and Back Pain: Observational Study.

Lo WLA^1,², Lei D¹, Li L¹, Huang DF¹, Tong KF².

Abstract

BACKGROUND:

Chronic musculoskeletal neck and back pain are disabling conditions among adults. Use of technology has been suggested as an alternative way to increase adherence to exercise therapy, which may improve clinical outcomes.

OBJECTIVE:

The aim was to investigate the self-perceived benefits of an artificial intelligence (AI)-embedded mobile app to self-manage chronic neck and back pain.

METHODS:

A total of 161 participants responded to the invitation. The evaluation questionnaire included 14 questions that were intended to explore if using the AI rehabilitation system may (1) increase time spent on therapeutic exercise, (2) affect pain level (assessed by the 0-10 Numerical Pain Rating Scale), and (3) reduce the need for other interventions.

RESULTS:

An increase in time spent on therapeutic exercise per day was observed. The median Numerical Pain Rating Scale scores were 6 (interquartile range [IQR] 5-8) before and 4 (IQR 3-6) after using the AI-embedded mobile app (95% CI 1.18-1.81). A 3-point reduction was reported by the participants who used the AI-embedded mobile app for more than 6 months. Reduction in the usage of other interventions while using the AI-embedded mobile app was also reported.

CONCLUSIONS:

This study demonstrated the positive self-perceived beneficiary effect of using the AI-embedded mobile app to provide a personalized therapeutic exercise program. The positive results suggest that it at least warrants further study to investigate the physiological effect of the AI-embedded mobile app and how it compares with routine clinical care.

JMIR Mhealth Uhealth. 2018 Nov 26;6(11):e198. doi: 10.2196/mhealth.8127.

The post Artificial Intelligence-Embedded Mobile App for Chronic Neck and Back Pain appeared first on FOTO Patient Outcomes.

Treatment Preference of People with Chronic Low Back Pain

Selena Horner — Mon, 16 Jul 2018 10:00:00 +0000

We know that patient expectations and beliefs play a role in outcomes. Have you ever conversed about what interventions a patient expects to receive?

Shared decision making is one option that can help a clinician gain information about a patient’s perception about available interventions.

In this study, I tend to think that patients preferred strength and flexibility exercises due to familiarity. Strengthening and stretching would be considered more mainstream to the typical patient. Granted, “familiarity” wasn’t really a variable captured within this study – unless one considers “acceptability” and “appropriateness” as factors that sort of fall in the same line of thought as familiarity.

One important aspect of this study is that patients appreciate options that are convenient for them. Convenient may not only refer to the availability of resources but also to how easily it is to blend a home exercise program into one’s daily activities.

You’ll find the abstract to the recent study below.

A Cross-Sectional Study Assessing Treatment Preference of People with Chronic Low Back Pain.

Francois SJ¹, Lanier VM², Marich AV¹, Wallendorf M³, Van Dillen LR⁴.

Abstract

OBJECTIVE:

To assess treatment preference and attributes of two exercise-based treatments for people with chronic low back pain (LBP).

DESIGN:

Cross-sectional study.

SETTING:

Academic research setting.

PARTICIPANTS:

Individuals (n=154) with chronic LBP.

INTERVENTIONS:

Not applicable.

MAIN OUTCOME MEASURE(S):

Participants completed a treatment preference assessment measure that described two treatments for chronic LBP [strength and flexibility (SF) and motor skill training (MST)]. Participants rated each treatment on four attributes: effectiveness, acceptability/logicality, suitability/appropriateness, and convenience. An overall score for each treatment was calculated as the mean of the four attribute ratings. The participants indicated either (1) no treatment preference or (2) preference for SF or MST.

RESULTS:

One hundred four participants (67.5%) had a treatment preference; of those, 95 (91.3%) preferred SF and nine (8.7%) preferred MST. The SF preference group rated SF higher than MST overall and on all attributes (all ps < .01, ds ranged from .48-1.07). The MST preference group did not rate the treatments differently overall or on any of the attributes (all ps > .05, ds ranged from .43-.66). Convenience of SF (p = .05, d = .79) and effectiveness (d = 1.20), acceptability/logicality (d = 1.27), and suitability/appropriateness (d = 1.52) of MST (all ps < .01) were rated differently between the two preference groups.

CONCLUSIONS:

When presented with two treatment options, a majority of patients preferred SF over MST. Convenience was a particularly important attribute impacting preference. Assessing treatment preference and attributes prior to treatment initiation allows the clinician to identify factors that may need to be addressed to enhance adherence to, and outcomes of, treatment.

Arch Phys Med Rehabil. 2018 May 28. pii: S0003-9993(18)30318-6. doi: 10.1016/j.apmr.2018.04.027. [Epub ahead of print]

The post Treatment Preference of People with Chronic Low Back Pain appeared first on FOTO Patient Outcomes.

When is Surgery Indicated for Lumbar Spinal Stenosis?

Selena Horner — Mon, 09 Apr 2018 10:00:00 +0000

In the majority of rehabilitation literature, the research focuses on treatment and interventions. Although this is a reasonable focus, I tend to believe it is just as valuable to know when surgical intervention is warranted.

I missed this longitudinal study from a year ago.

My first concern for every patient who has low back pain is on whether physical therapy services will be beneficial. In the back of my mind, the option for surgery always lingers. I know from the upcoming report, Data Trends in U.S. Healthcare and Patient Rehabilitation – Focus Patient Characteristics, Patient Outcomes and Clinical Performance, a large amount of patients in rehabilitation are treated for low back pain.

The study population happened to be Japanese patients. I’m not sure if the findings are considered universal.

You’ll find the abstract below.

Prognostic factors associated with the surgical indication for lumbar spinal stenosis patients less responsive to conservative treatments: An investigator-initiated observational cohort study.

Fukushima M¹, Oka H², Hara N³, Oshima Y⁴, Chikuda H⁴, Tanaka S⁴, Takeshita K⁵, Matsudaira K².

Abstract

BACKGROUND:

A few cohort studies have determined which patients with lumbar spinal stenosis are likely to need surgery because of the deterioration of symptoms. However, there are still insufficient data regarding the management of lumbar spinal stenosis due to lack of prognostic factors associated with the need for surgery. The purpose of this study was to identify the prognostic factors associated with the need for surgical treatment in patients with lumbar spinal stenosis.

METHODS:

Patients with lumbar spinal stenosis from our hospital and related facilities were enrolled. Eligibility criteria were as follows: age 50-85 years and the patient’s conditions met the definition of lumbar spinal stenosis; the presence of neurogenic intermittent claudication caused by numbness and/or pain in the lower limbs; and magnetic resonance imaging-confirmed symptomatic LSS. We followed 274 patients (151 men; mean age, 71 ± 7.4 years) for 3 years to identify prognostic factors. We used a multivariate logistic regression model to investigate the association between the indication for surgical treatment (within 3 years) and age, sex, complications, depression, illness duration, the presence of cauda equina symptoms, and the presence of degenerative spondylolisthesis/scoliosis.

RESULTS:

In the survey conducted 3 years after treatment, 185 patients responded (follow-up rate 67.5%). In 82 patients, surgery was performed during the follow-up period. The multivariate logistic regression model showed that the presence of cauda equina symptoms and the presence of degenerative spondylolisthesis/scoliosis were significantly associated with the indication for surgical treatment within 3 years.

CONCLUSIONS:

This study showed that the presence of cauda equina symptoms and degenerative spondylolisthesis/scoliosis were prognostic factors associated with the indication for surgery in patients with lumbar spinal stenosis.

J Orthop Sci. 2017 May;22(3):411-414. doi: 10.1016/j.jos.2017.01.021. Epub 2017 Feb 20.

The post When is Surgery Indicated for Lumbar Spinal Stenosis? appeared first on FOTO Patient Outcomes.

FOTO - Focus on Therapeutic Outcomes | Low Back Pain Archives

Cognitive Functional Therapy and Nonspecific Low Back Pain

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study.

Abstract

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Education: Placebo vs Intensive Pain Education Appear Equal

Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial.

Abstract

IMPORTANCE:

OBJECTIVE:

DESIGN, SETTING, AND PARTICIPANTS:

INTERVENTIONS:

MAIN OUTCOMES AND MEASURES:

RESULTS:

CONCLUSIONS AND RELEVANCE:

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Artificial Intelligence-Embedded Mobile App for Chronic Neck and Back Pain

The Perceived Benefits of an Artificial Intelligence-Embedded Mobile App Implementing Evidence-Based Guidelines for the Self-Management of Chronic Neck and Back Pain: Observational Study.

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Treatment Preference of People with Chronic Low Back Pain

A Cross-Sectional Study Assessing Treatment Preference of People with Chronic Low Back Pain.

Abstract

OBJECTIVE:

DESIGN:

SETTING:

PARTICIPANTS:

INTERVENTIONS:

MAIN OUTCOME MEASURE(S):

RESULTS:

CONCLUSIONS:

When is Surgery Indicated for Lumbar Spinal Stenosis?

Prognostic factors associated with the surgical indication for lumbar spinal stenosis patients less responsive to conservative treatments: An investigator-initiated observational cohort study.

Abstract

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS: