Chinese physiotherapists’ perspectives on managing low back pain: a qualitative study

The global epidemic of low back pain.

A surface electromyographic procedure for evaluating back muscle impairment was studied in patients undergoing rehabilitation for low back pain. The results were analyzed to determine whether the electromyographic procedure was able to: 1) distinguish muscle impairment between patients with low back pain and normal subjects, and 2) monitor changes in muscle function after low back pain rehabilitation. Patients with chronic low back pain (n = 85) were tested to measure the median frequency of the electromyographic signals from six lumbar electrode sites during sustained trunk extensions. A subset (n = 28) of these patients was re-tested after low back pain rehabilitation. A discriminant function for classifying subjects into "low back pain" and "normal" groups was formulated using the electromyographic data from a subset of the patients with low back pain (n = 28) and a normative sample (n = 42). Results for this "learning" sample were compared with results using the same function on the remaining "holdout" sample of patients (n = 57) and an additional normative sample (n = 6). Differences in electromyographic parameters before and after rehabilitation also were analyzed. The discriminant function classified subjects into low back pain and normal groups, with 86% and 89% correct classification for the "learning" and "holdout" samples, respectively. These classification results were independent of trunk extensor strength. Changes in median frequency after the rehabilitation program were consistent with improvements in back muscle fatigability. These findings demonstrate how electromyographic spectral measurements may be used to identify and monitor back muscle impairment in patients undergoing rehabilitation for low back pain.

In this study three instruments measuring disability of patients with low-back pain are presented and evaluated: (1) the Behinderungsfragebogen (RM) - a German version of the Roland & Morris disability questionnaire (RDQ) (2) a numerical rating scale measuring disability in general and (2) eight numerical rating scales measuring specific dimensions of disability (standing, sitting, walking, driving a car, carrying light loads, carrying heavy loads, sleeping, and sexual intercourse). The psychometric evaluation, including the item analysis, test reliability, test validity, and responsiveness of the instruments, is based on two samples. Sample A comprises 345 patients with low-back pain: 282 of these patients took part in the Swiss multicentre intervention study testing the effectiveness of in-patient rehabilitation of sub-chronic and chronic low-back pain under an integrative group treatment program. The instruments were administered at different times in the therapeutic process (t1: at hospital admission; t4: follow-up after one year). 63 patients were hospitalized (orthopedic or rheumatological units) for medical examinations (myelography or infiltration of facets) or rehabilitation of low-back pain. The instruments were administered twice within 24 h to measure test-retest correlation. In order to determine the psychometric parameters as accurately as possible, the two samples were examined jointly. Sample B is composed of 41 patients with low-back pain participating in the study "Prädiktoren des Erfolgs bei stabilisierenden Wirbelsäuleneingriffen" (Success predictors of effectiveness of surgical interventions for spinal stabilization). All instruments proved to be generally reliable and valid (high or medium correlations with each other and with a German version of the Oswestry Disability Questionnaire) as well as responsive tools for measuring the momentary disability of patients with back pain. The psychometric examination of the test validity showed that patients' perceptions of their disability were influenced by their psychological well-being. The correlation between the 3 instruments and physical tests was low. The RM is not a homogeneous instrument. Factor analysis (principal component analysis, rotation Varimax) indicated 6 factors. Because of the small number of items for each factor it is not appropriate to treat RM in terms of dimensions of disability. The RM is an instrument measuring patients' perception of their disability that offers simple, fast practicability for patients and tester. The 2 rating scales: The 8 numerical rating scales measuring specific dimensions of disability (QL3) offer all the advantages of the numerical rating scale measuring disability in general (QL1) (simple instruction, high plausibility for the patients, and simple, fast practicability), but they provide more information about the patient's disability, which allows comparisons of disability at different times in the therapeutic process. Numerical rating scales are not suitable for patients with poor ability to abstract. For these patients it is necessary to use a questionnaire which asks concretely about what the patient can or cannot do (e. g. RM). Because of its better psychometric properties, the QL3 should be favored over the RM.

Population-based randomized controlled trial. To assess the effectiveness of workplace intervention and graded activity, separately and combined, for multidisciplinary rehabilitation of low back pain (LBP). Effective components for multidisciplinary rehabilitation of LBP are not yet established. Participants sick-listed 2 to 6 weeks due to nonspecific LBP were randomized to workplace intervention (n = 96) or usual care (n = 100). Workplace intervention consisted of workplace assessment, work modifications, and case management involving all stakeholders. Participants still sick-listed at 8 weeks were randomized for graded activity (n = 55) or usual care (n = 57). Graded activity comprised biweekly 1-hour exercise sessions based on operant-conditioning principles. Outcomes were lasting return to work, pain intensity and functional status, assessed at baseline, and at 12, 26, and 52 weeks after the start of sick leave. Time until return to work for workers with workplace intervention was 77 versus 104 days (median) for workers without this intervention (P = 0.02). Workplace intervention was effective on return to work (hazard ratio = 1.7; 95% CI, 1.2-2.3; P = 0.002). Graded activity had a negative effect on return to work (hazard ratio = 0.4; 95% CI, 0.3-0.6; P < 0.001) and functional status. Combined intervention had no effect. Workplace intervention is advised for multidisciplinary rehabilitation of subacute LBP. Graded activity or combined intervention is not advised.

Purpose: Everyday activities are important factors for avoiding the development of chronic low back pain (LBP). The purpose this study was to explore LBP patients' perspective on long-term effects of participating in a counseling intervention designed to motivate them to change work routines and to exercise. Method: Follow-up qualitative study. Semi-structured interviews were made of 25 LBP patients who had received the counseling intervention. Interviews were transcribed and explored with an interpretative thematic analysis. The findings were organized around Kleinman's conception of “explanatory models”. Results: For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants' overall explanatory model. Participation in the counseling intervention had created a sense of certainty and potential control over the disease and had legitimized their sick role at work and at home. The majority of the patients reported having integrated exercise into their explanatory models and understood exercise to be beneficial in their continual and concrete management of their LBP. Conclusions: The intervention had affected the patients' personal agency and space for action. We suggest that this effect was linked to the individually tailored approach drawing on both educational and motivational agents.Implications for RehabilitationMaintaining everyday activities, including retaining one's occupation, is an important factor in low back pain rehabilitation.Counselling on low back pain rehabilitation must be aligned with people's beliefs about their illness.A counselling intervention made patients adopt exercising into their long-term management of low back pain.

Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation

Comprehensive rehabilitation for lower back pain and back schools have both been reviewed by systematic reviews and large task-forces. These two topics will be reviewed for changes in management of the patient reporting low back pain in the subacute or chronic stage. There is evidence for back school efficacy in Cochrane reviews (1999 and 2004). There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status in the short and intermediate term, compared to exercises, manipulation, myofascial therapy, advice, placebo, or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodological quality and clinical relevance and evaluate the cost-effectiveness of back schools, and back schools based on traditional biomedical/biomechanical information, advice, and instruction are not recommended for prevention in LBP (strong evidence). High-intensity programs, which comprise both an educational/skills program and exercises, can be recommended for patients with recurrent and persistent back pain (moderate evidence). Back schools based on traditional biomedical/biomechanical information, advice, and instruction are not recommended for prevention in LBP (strong evidence). There is insufficient evidence to recommend for or against psychosocial information delivered at the worksite (weak evidence), but information oriented toward promoting activity and improving coping may promote a positive shift in beliefs (weak evidence). The components of comprehensive rehabilitation include exercise, cognitive behavioral treatment (CBT), education, and others. Few systematic reviews have been carried out as the field is still relatively new in combination treatment. The Cochrane Review (2002) concludes “that there is moderate evidence of positive effectiveness of multidisciplinary rehabilitation for sub-acute low back pain and that a workplace visit increases the effectiveness. But because this evidence is based on trials that had some methodological shortcomings, and several expensive multidisciplinary rehabilitation programs are commonly used for uncomplicated/nonspecific sub-acute low back problems, there is an obvious need for high quality trials in this field.”

Purpose We lack knowledge on whether the advice of “being physically active” should be the same for prevention and rehabilitation of low back pain (LBP). Sickness absence is a key outcome for LBP prevention and rehabilitation. We investigated the associations between physical activity and long-term sickness absence (LTSA) among employees with and without LBP. Methods Between 2011 and 2013, 925 Danish employees wore a Actigraph GTX3 accelerometer for 1–5 workdays to measure physical activity and reported LBP in past 7 days. Employees were followed for 4 years to determine their first register-based LTSA event (≥ 6 consecutive weeks). Results Among employees with LBP, increasing moderate-to-vigorous-intensity physical activity at work by 20 min and decreasing the remaining behaviors at work (ie., sitting, standing and light-intensity activity) by 20 min was associated with 38% (95% CI 17%; 63%) higher LTSA risk. Increasing light-intensity activity at work by 20 min and decreasing 20 min from the remaining behaviors was associated with 18% (95% CI 4%; 30%) lower risk. During leisure, increasing moderate-to-vigorous-intensity activity by 20 min or standing by 40 min was associated with 26% (95% CI 3%; 43%) lower and 37% (95% CI 0%; 87%) higher risk, respectively. Among employees without LBP, we found no such associations. Conclusions The physical activity advice ought to be different for LBP prevention and rehabilitation to reduce LTSA risk, and specified by domain and activity intensity. At work, employees with LBP should be advised to spend time on light-intensity physical activity and limit their time on moderate-to-vigorous-intensity physical activity. During leisure, employees should spend time on moderate-to-vigorous-intensity physical activity.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Clinical Reasoning for Manual Therapists

Lumbar musculoskeletal disorders were found to be one of the most common factors in Low Back Pain (LBP). Because of difficulties in the analysis and interpretation of surface electromyography (SEMG), specific muscular pathology associated with LBP continues to be debated. SEMG Topography is a novel method of visualizing the distribution of myoelectric signals during dynamic motion. SEMG topography provides a more comprehensive examination and contraction coordination insight into the fundamental muscular strategies. The purpose of this study was to assess the feasibility of SEMG topography as an assessment tool in LBP rehabilitation. Thirty healthy subjects were recruited to establish the normal database of SEMG topography pattern. Lumbar muscle activities were recorded during forward bending, by an array of SEMG electrodes applied over the low back area. The root mean square (RMS) of the SEMG signals was calculated in spatial distribution to produce topography of the muscle activity in the lumbar region. In addition, a preliminary clinical study was carried out with 5 LBP patients before and after LBP rehabilitation. In normal subjects, SEMG topography was consistent, reproducible, and reliable. In clinical observation, the SEMG topography of LBP patients was obviously different from normal pattern. However, after rehabilitation, SEMG pattern tended to return to normal pattern in some patients with pain released reported. The SEMG topography illustrates the distribution of muscle activities, which provides a visible result of lumbar muscles coordination. The results of this study suggested the use of SEMG topography as an objective assessment tool in LBP rehabilitation. © 2007 IEEE.

Low back pain (LBP) is a prevalent condition associated with disability. Treating patients with LBP becomes further complicated by the potential presence of underlying conditions, such as cancer or traumatic injury, or biopsychosocial aspects. LBP usually has a neuropathic component that must be assessed and treated appropriately. Pharmacological management of LBP requires a thorough knowledge of the available agents and the mechanisms of the LBP. Although there are effective pharmacological treatments for LBP, it is important to consider safety issues. Fixed-dose combination products may be helpful, as they can reduce opioid consumption without sacrificing analgesic benefits. Neuromodulation is an important and sometimes overlooked treatment option for LBP and may be appropriate for chronic LBP requiring long-term treatment. Imaging studies support neuroplastic changes in the brain as a result of neuromodulation. Interventional approaches to chronic LBP are numerous and must be appropriately selected based on the individual patient. Evidence in support of epidural injections for LBP is strong for short-term pain control but moderate to limited for long-term relief. Rehabilitation for LBP can be an important element of long-term care, and new forms of rehabilitation programs are being developed using telemedicine. A variety of new and established treatments are available for patients with LBP, and clinicians and patients may benefit from emerging new treatment modalities.

Young individuals with a more ankle-steered proprioceptive control strategy may develop mild non-specific low back pain

Effect of adjuvant frequency-specific microcurrents on pain and disability in patients treated with physical rehabilitation for neck and low back pain

The evidence gap in low back pain management strategies – Authors' reply