Back Pain Guidelines Research Articles

Italian Translation and Cross-Cultural Adaptation of a Back Pain Screening Questionnaire (Start Back Screening Tool).

Low back pain is a heterogeneous condition, from which most patients recover after a few months. However, a considerable proportion of patients develop chronic pain despite different types of treatment. Primary care evidence-based guidelines for non-specific back pain highlight the importance of identifying indicators of poor prognosis in order for treatment to be appropriately targeted. The Start Back Screening Tool Questionnaire (SBST) is a prognostic tool developed and validated to identify subgroups of patients and guide the decision-making process for the initial primary care of the acute back pain. The aim of this project is the translation and the cross-cultural adaptation of an Italian SBST version. The development of a reliable and validated questionnaire would be useful for different health professionals in the management of low back pain. The translation and validation of this tool was divided in different steps, following the guidance of questionnaire translation: contact with the SBST developers, translation from English to Italian, synthesis, retranslation from Italian to English, expert committee review, test of the pre-final version on 30 individuals with LBP, and the final version being approved by the original Author. For the linguistic translation it was necessary to make some semantic variations. The interviewed participants reported a good general understanding of the questions. However, 6 subjects (14%) wondered if two questions were related to back pain or general health. After discussion within the expert committee and with the SBST developer, the wording was modified to add a reference to back pain in these two questions. The Italian version of STST is now ready for validation.

Complementing or conflicting? A qualitative study of osteopaths’ perceptions of NICE low back pain and sciatica guidelines in the UK

ObjectivesClinical practice guidelines (CPGs) have been developed to improve standards of healthcare delivery and are associated with better clinical outcomes. In the UK, the National Institute for Health and Care Excellence (NICE) produced guidelines for the treatment of low back pain and sciatica. However, guideline resistant attitudes have been demonstrated by healthcare professionals, including osteopaths. MethodsA qualitative study design was chosen, utilising constructivist grounded theory method as a framework to explore osteopaths’ perceptions of NICE low back pain and sciatica guidelines in the UK. Seven participants were interviewed, with their interviews transcribed and coded. ResultsOsteopaths’ perceptions of NICE Low Back Pain and Sciatica guidelines are influenced by their conception of uncertainty in the clinical environment, their views of knowledge, approach to clinical decision-making and their professional identity. ConclusionsOsteopaths' views of NICE low back pain and sciatica guidelines are varied. Some of these views of LBP guidelines may act as obstacles to their implementation. Pre- and post- osteopathy registration educational strategies should aim to facilitate positive attitudes towards the use of clinical guidance abd the utilisation CPGs in clinical practice.

Physical Therapy Approaches in the Treatment of Low Back Pain.

Globally, in 2016, low back pain (LBP) contributed 57.6 million of total years lived with disability. Low Back Pain Guidelines regularly recommend the use of physical exercise for non-specific LBP. Early non-pharmacological treatment is endorsed. This includes education and self-management, and the recommencement of normal activities and exercise, with the addition of psychological programs in those whose symptoms persist. The aim of physical treatments is to improve function and prevent disability from getting worse. There is no evidence available to show that one type of exercise is superior to another, and participation can be in a group or in an individual exercise program. Active strategies such as exercise are related to decreased disability. Passive methods (rest, medications) are associated with worsening disability, and are not recommended. The Danish, United States of America, and the United Kingdom Guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies. These include tai chi, yoga, massage, and spinal manipulation. Public health programs should educate the public on the prevention of low back pain. In chronic low back pain, the physical therapy exercise approach remains a first-line treatment, and should routinely be used.

Primary healthcare physicians' adherence to acute lower back pain referral guidelines in Riyadh, Saudi Arabia.

Objectives:To assess the primary healthcare physicians’ adherence to referral guidelines for acute low back pain and if there is any association with experience level.Methods:A cross-sectional study held in Tertiary care hospital, Riyadh, Kingdom of Saudi Arabia. Questionnaires were distributed in-person between October 2017 and January 2018 among 100 primary healthcare physicians, with a 79% response rate.Results:The distribution between male to female was 43%-57%. Twenty-five percent of physicians encounter 1-5 patients weekly, while 28% encounter more than 15 patients. The physicians included had a higher than expected adherence to referral guidelines with percentages ranging between 63-94% referral rates for back pain related red flags. A trend was noted where there was an increase in referral decisions with increased experience when encountering red flags. More experienced physicians were more likely to refer when encountering; pain worse after prolonged sitting, limited mobility, and pain worse while coughing or sneezing (p<0.05).Conclusion:Primary healthcare physicians working in one health system in Riyadh had a higher than expected adherence to referral guidelines for back pain related red flags.

Biopsychosocial multidisciplinary rehabilitation in low back pain: A comparison of effects after 12 months in patients older and younger than 65 years

In patients with chronic low back pain (cLBP) guidelines recommend multidisciplinary biopsychosocial rehabilitation (MBR) if other treatments were unsuccessful. However, little is known about the long-term effects of MBR in patients older than 65 years. The objective of this study was to compare the 12 months course of effects of MBR in patients older than 65 years to younger patients. In this naturalistic prospective observational cohort study, 118 participants of a 3-week MBR were included. The MBR comprised exercise therapy, hydrotherapy, occupational therapy, psychological interventions, patient education and instructions to home exercise programs. Outcome was assessed by the condition specific North American Spine Society (NASS) questionnaire pain/function scale and the generic Short-Form 36 Health Survey (SF-36). From the eight SF-36 scales only Physical Functioning (PF), Bodily Pain (BP) and Mental Health (MH) were included in the analyses. Data were collected at the beginning of treatment, after 3 months and after 12 months. Participants were grouped into “Old” or “Young” with the cut-off 65 years. Statistical differences between follow-up and baseline scores were tested by paired t-tests. Standardized Effect Size (ES) was calculated by dividing the difference between entry and follow-up by the standard deviation (SD) of the baseline score. In this study, 59 patients were older than 65 years and 59 were younger. The mean ages of the groups old/young were 70 years and 57years respectively. In the group old 64% of patients were female and in the young group 73% were female. The course of the outcomes and the statistical significance of changes are presented in Table 1 , Table 2 . This study shows that a MBR program in cLBP patients has similar beneficial long-term effects on pain and condition specific function in patients older than 65 years compared to younger patients.

Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study.

The profession of the health-care providers (HCPs) influences their recommendations to the patients. Conversely, interdisciplinarity seeks to challenge such differences, so that the patient receives one single and consistent therapeutic message. Some studies also suggest associations between HCPs life habits and recommendations. Our hypotheses were (1) that despite interdisciplinary work, the profession remains a predictor of recommendations and (2) that HCPs who are more physically active recommend more activity. Three clinical vignettes were presented to a group of experts of low back pain (LBP) (guidelines), and 20 physicians, 22 physiotherapists, and 23 nurses to assess how they evaluate the symptoms and pathologies of LBP patients and how much work and physical activity they recommend. Physical activity was assessed with accelerometers and questionnaires. Some interprofessional differences remained present within an interdisciplinary team. The nurses were more restrictive and further away from the guidelines. The physicians were the most in line with them. The physiotherapists recommend as much physical activity, but less work activity than the physicians. The level of physical activity of the HCPs is not associated with their recommendations. To ensure a clear and unique message, educational actions may be undertaken to promote the biopsychosocial model and clarify the guidelines.

Effectiveness of a multifaceted implementation strategy compared to usual care on low back pain guideline adherence among general practitioners

BackgroundTo improve patient care, and to reduce unnecessary referrals for diagnostic imaging and medical specialist care for low back pain, an evidence-based guideline for low back pain was developed in the Netherlands in 2010. The current study evaluated the effect of a multifaceted implementation strategy on guideline adherence among Dutch general practitioners.MethodsThe implementation strategy included a multidisciplinary training, provision of educational material and an interactive website for healthcare professionals, supported by a multimedia eHealth intervention for patients with low back pain. Adherence was measured using performance indicators based on 3 months data extracted from the contacts with patients with low back pain recorded in the electronic medical records of participating general practitioners. Performance indicators were compared between two groups: a usual care group and an implementation group. Performance indicators were referrals to consultations with medical specialists, to diagnostic imaging, and to psychosocial and/or occupational physician consultations, and inquiries about psychosocial and occupational risk factors.ResultsThe electronic medical records of 5130 patient contacts for LBP were analysed; 2453 patient contacts in the usual care group and 2677 patient contacts in the implementation group. Overall, rates of referral and of recorded inquiries regarding psychosocial and occupational risk factors remained low in both groups over time. The only statistically significant difference found was a reduction in the number of referrals to neurologists in the implementation group (from 100 (7%) to 50 (4%)) compared to the usual care group (from 48 (4%) to 50 (4%), (p < 0.01)). There were no other between-group differences in referrals.ConclusionIn the short term, the strategy did not result in improved guideline adherence among general practitioners, and it is not recommended for widespread use. However, baseline referral rates in participating practices were already low, possibly leaving only little room for improvement. Inquiries for psychosocial and occupational risk factors remained low and this leaves room for improvement.Trial registrationThis trial is registered in the Netherlands Trial Register (NTR): NTR4329. Registration date: December 20th, 2013.

(325) - Association between global DNA methylation and exercise in chronic low back pain

Underlying biologic mechanisms in chronic low back pain remain unclear. A critical component in understanding biologic mechanisms is the human genome. Modifications in the human genome have been found to turn genes on or off leading to persistent chronic pain and decreased effectiveness to treatment response. Global DNA methylation is one of the primary ways that the epigenome marks the genome thereby potentially causing alterations impacting function. These epigenomic alterations have not been fully clarified among individuals with chronic low back pain. Exercise is a highly recommended standard of care in chronic low back pain guidelines. This IRB-approved descriptive, cross-sectional, pilot study evaluated the association between global DNA methylation and exercise to assist in advancing genomic science in chronic low back pain. Self-report questionnaires including a validated instrument to measure exercise and peripheral blood samples were collected from females (N = 39) with chronic low back in a pain center. Global DNA methylation was measured using Enzyme-linked Immunosorbent Assay. Ages ranged from 32–64 (mean = 50), 92.3% were non-Hispanic, 48.7% were Black, and 38.5% were White. Years of chronic low back pain ranged from 1–28 years (mean = 11.7 years); they used several different pain treatments ranging from 1–15 (mean = 6.36). They rated their overall health to be poor to fair at 76.9% and good to very good at 23.1%. They spent 0 to 780 minutes/week of aerobic exercise (mean = 96.54 minutes/week). Global DNA methylation ranged from .15% to 1.23% (mean = .47%). Global DNA methylation was found to be significantly associated with exercise (r = .399, p = .012). Hypomethylation appears to correlate with lower amounts of time spent in aerobic exercise. Results suggest a significant role of exercise in global DNA methylation. Interventional and longitudinal studies need to be conducted to increase our understanding of the role of epigenomics and epigenetics in chronic low back pain.

Musculoskeletal Guidelines—Including Back Pain and Spine Guidelines—of Poor Quality?

Musculoskeletal Guidelines—Including Back Pain and Spine Guidelines—of Poor Quality?

Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management.

The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer experiencing joint pain. The use of epidural local analgesia for perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients undergoing abdominal surgery. In a retrospective study involving over 390,000 outpatients more than 66 years of age who underwent minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. In a review of 11 million patients undergoing elective surgery from 2002 to 2011, both opioid overdoses and opioid dependence were found to be increasing over time. Opioid-dependent surgical patients were more likely to experience postoperative pulmonary complications, require longer hospital stays, and increase costs to the health-care system. The Centers for Disease Control and Prevention emphasized the importance of finding alternatives to opioid medication for treating pain. In the new clinical practice guidelines for back pain, the authors endorsed the use of non-pharmacologic therapies. However, one of the more widely used non-pharmacologic treatments for chronic pain (namely radiofrequency ablation therapy) was recently reported to have no clinical benefit. Therefore, this clinical commentary will review evidence in the peer-reviewed literature supporting the use of electroanalgesia and laser therapies for treating acute pain, cervical (neck) pain, low back pain, persistent post-surgical pain after spine surgery (“failed back syndrome”), major joint replacements, and abdominal surgery as well as other common chronic pain syndromes (for example, myofascial pain, peripheral neuropathic pain, fibromyalgia, degenerative joint disease/osteoarthritis, and migraine headaches).

An Updated Overview of Low Back Pain Management in Primary Care.

Currently, guidelines for lower back pain (LBP) treatment are needed. We reviewed the current guidelines and high-quality articles to confirm the LBP guidelines for the Korean Society of Spine Surgery. We searched available databases for high-quality articles in English on LBP published from 2000 to the present year. Literature searches using these guidelines included studies from MEDLINE, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Embase. We analyzed a total of 132 randomized clinical trials, 116 systematic reviews, 9 meta-analyses, and 4 clinical guideline reviews. We adopted the SIGN checklist for the assessment of article quality. Data were subsequently abstracted by a reviewer and verified. Many treatment options exist for LBP, with a variety of recommendation grades. We assessed the recommendation grade for general behavior, pharmacological therapy, psychological therapy, and specific exercises. This information should be helpful to physicians in the treatment of LBP patients.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up

BackgroundThe McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with...

Are They Complying? Physicians' Knowledge, Attitudes, and Readiness to Change Regarding Low Back Pain Treatment Guideline Adherence.

Cross-sectional survey of 145 primary care practitioners (PCPs). To examine low back pain (LBP) guideline knowledge, readiness to implement (RTI) these guidelines, and LBP attitudes and beliefs among Israeli PCPs and determine whether physician age, guideline familiarity, and medical specialty affect these variables. LBP is a common condition managed primarily by PCPs. Little is known, however, about physician's LBP knowledge, attitudes, and beliefs and how these factors (knowledge, A&B) influence their practice behavior. Knowledge, attitudes, and beliefs of PCPs have been shown to influence the course of their patients' LBP, and guidelines were devised in an attempt to improve the effectiveness and quality of LBP care. Research worldwide and in Israel has shown that LBP guideline implementation is not yet optimal. Participants completed a questionnaire. Variables were measured using a translated, validated version of the Health Care Providers' Pain and Impairment Relationship Scale; demographic and professional characteristics were analyzed for correlation with the outcome variables. The likelihood of PCPs having nonguideline-consistent attitudes and beliefs (A&B) was greater among those older than 50 years (P < 0.05). Family medicine specialists (family practitioners [FPs]) were more likely to have a high level of guideline knowledge as compared to nonfamily medicine specialists (general practitioners (83.8 vs. 61.9, respectively; P < 0.001). Differences between FPs and general practitioners were also observed for the mean Health Care Providers' Pain and Impairment Relationship Scale score (34.6 vs. 41.1, respectively, P = 0.00), indicating a higher consistency of attitudes and beliefs with guidelines among FPs. No significant association was found between PCPs' knowledge level and RTI the guidelines. The present study showed that PCPs, especially FPs, had high levels of LBP guideline knowledge, although RTI was limited. The need for greater exposure to and understanding of the importance of implementation of LBP guidelines is essential for future guideline adherence. 3.

A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial

BackgroundGuidelines are often slowly adapted into clinical practice. However, actively supporting healthcare professionals in evidence-based treatment may speed up guideline implementation. Danish low back pain (LBP) guidelines focus on primary care treatment of LBP, to reduce referrals from primary care to secondary care. The primary aim of this project was to reduce secondary care referral within 12 weeks by a multifaceted implementation strategy (MuIS).MethodsIn a cluster randomised design, 189 general practices from the North Denmark Region were invited to participate. Practices were randomised (1:1) and stratified by practice size to MuIS (28 practices) or a passive implementation strategy (PaIS; 32 practices). Included were patients with LBP aged 18 to 65 years who were able to complete questionnaires, had no serious underlying pathology, and were not pregnant. We developed a MuIS including outreach visits, quality reports, and the STarT Back Tool for subgrouping patients with LBP. Both groups were offered the usual dissemination of guidelines, guideline-concordant structuring of the medical record, and a new referral opportunity for patients with psycho-social problems. In an intention-to-treat analysis, the primary and secondary outcomes pertained to the patient, and a cost-effectiveness analysis was performed from a healthcare sector perspective. Patients and the assessment of outcomes were blinded. Practices and caregivers delivering the interventions were not blinded.ResultsBetween January 2013 and July 2014, 60 practices were included, of which 54 practices (28 MuIS, 26 PaIS) included 1101 patients (539 MuIS, 562 PaIS). Follow-up data for the primary outcome were available on 100 % of these patients. Twenty-seven patients (5.0 %) in the MuIS group were referred to secondary care vs. 59 patients (10.5 %) in the PaIS group. The adjusted odds ratio (AOR) was 0.52 [95 % CI 0.30 to 0.90; p = 0.020]. The MuIS was cost-saving £−93.20 (£406.51 vs. £499.71 per patient) after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]).ConclusionsUsing a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines.Trial registrationClinicalTrials.gov, NCT01699256 Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0509-0) contains supplementary material, which is available to authorized users.

Red flags presented in current low back pain guidelines: a review.

The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care. We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags. We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided. A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.

Systematic review of the cost-effectiveness of implementing guidelines on low back pain management in primary care: is transferability to other countries possible?

ObjectiveThe primary aim is to identify, summarise and quality assess the available literature on the cost-effectiveness of implementing low back pain guidelines in primary care. The secondary aim is to...

Prediction of Treatment Outcomes for Patients with Chronic Low Back Pain: the Development of a Clinical Decision Guideline for Spine Surgeons

Introduction Low back pain (LBP) is responsible for the greatest burden of all diseases.1 Chronic Low Back Pain (CLBP) is among the most common reasons why patients visit a spine surgeon. As the CLBP population is heterogeneous, it remains a challenge to address etiology and to suggest treatment options. Evidence2–4 recommends developing a decision tool to triage toward either surgical or nonsurgical interventions. The Nijmegen decision tool, consisting of a web-based questionnaire, a systematic follow up of outcomes built in the patient-based system of the SweSpine Registry,5 is developed to support patient-triage and is based on evidence and professional (Delphi) consensus. Since April2012 all new patients complete the questionnaire, consisting of 47 indicators potentially predicting successful treatment outcome or persistence of pain complaints, and are systematically followed over time.5 In this study pre-intervention patient profiles have been determined and a decision algorithm has been developed, based on indicators predicting successful one-year follow-up outcome of spine surgery and of a non-surgical, multidisciplinary Combined Physical and Psychological (CPP) program. Material and Methods A consecutive cohort study was performed. Diagnostics and decision-making were performed ‘as usual’. Data of patients were included who completed the one-year follow-up assessment: 219 had surgery and 171 followed a multidisciplinary CPP-program. The outcome was functional status (Oswestry Disability Index v2.1a [ODI]) and being successful was defined as one-year improvement to an absolute (‘normal’/healthy) ODI-threshold (value≤22). The 47 potential predictive indicators included indicators in the sociodemographic, pain-related, somatic, psychological, functional and quality of life domains.5 After data-cleaning and having fulfilled all assumptions for analyses, for each cohort a separate multiple logistic regression analysis was performed. Results Probability of successful surgical outcome: the prediction model (R2=31%) included pre-treatment previous surgery(OR 0.390 [95%CI 0.201–0.757]), expectations of recovery (OR 2.830 [95%CI 1.391–5.756]), expectation of work return (OR 0.824 [95%CI 0.706–0.960]), pre-treatment functioning (OR 0.961 [95%CI 0.939–0.984]), and ‘red flag’ for age (pain started age &lt; 20 or &gt; 50 years; OR 2.321 [95%CI 1.214–4.435]). Probability of successful CPP-program outcome: the prediction model (R2=26%) included pre-treatment functioning (OR 0.963 [95%CI 0.937–0.990]), catastrophizing (OR 0.199 [95%CI 0.065–0.610]), and depressed mood (OR 0.205 [95%CI 0.063–0.665]). Interpretation Odds Ratio (OR): OR &gt; 1=increased probability to success; OR &lt; 1=reduced probability to success) Conclusion This is the first clinical decision tool available, created with a rigorous scientific basis that is designed for patient-triage. Different patient profiles predicting either a successful outcome for spine surgery or for CPP program are determined. The presented profiles are based on first analyses, after final analyses the two prediction models will be converted to probability formulae and built in the online tool. For every new patient the probabilities for treatment success will be available in the electronic patient file. The next step is to validate the tool in different hospitals. We expect that this relatively simple tool, based on validated questionnaires and current evidence, will considerably help in daily spine practice to guide the right patients to the right practitioners and to enhance personalized care. We will present the final prediction models at the Global Spine Congress. References Vos T; Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386(9995):743–800 Chou R, Loeser JD, Owens DK, et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066–1077 National Institute for Health and Clinical Excellence. Low Back Pain: Early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care. London, UK: NICE Clinical Guideline; 2009:88 Fairbank J, Gwilym SE, France JC, et al. The role of classification of chronic low back pain. Spine 2011;36(21, Suppl):S19–S42 Van Hooff ML, Van Loon J, Van Limbeek J, De Kleuver M. The Nijmegen Decision Tool for CLBP. Development of a clinical decision tool to select patients for secondary care. PLoS ONE 2014;9(8):104226

Long-term follow-up Results of a Combined Physical and Psychological Program for Patients with Chronic Low Back Pain

Introduction For patients with persistent and disabling chronic low back pain (CLBP) who failed to improve after less intensive interventions, a combined physical and psychological (CPP) program including exercises and a cognitive behavioral approach, is recommended.1–3 These patients with CLBP participating in a two-week CPP-program improve in functional status and quality of life during the program and these positive results are maintained at one4 and at two-year follow-up assessment.5 Purpose To evaluate the long-term results of a short, intensive, evidence based CPP-program. Material and Methods A consecutive cohort study with a mean follow up of 6.5 years (range: 5.5–7.5) was performed. At follow up a response rate of 85% ( n = 277) was achieved. Primary outcome was functional status (Oswestry Disability Index [ODI;0–100]). Secondary outcomes were pain intensity, quality of life, and patient reported satisfaction. A Repeated Measures analysis of variance was used to identify changes over time. The two-week residential program is in line with recommendations in international guidelines1–3 and provided in collaboration with orthopedic spine surgeons at Sint Maartenskliniek Nijmegen, The Netherlands. Results At pre-treatment assessment the mean age was 46.1years (SD9.3) and the mean CLBP-duration 12.3 years (SD10.9). The mean ODI-score showed improvement at post-treatment and maintenance of results over time (ODI df[1,276],F = 0.146, p = 0.703). Secondary outcomes showed the same pattern. At long-term follow up more than half of the CLBP-patients (59.2%) showed a clinically relevant improvement of ≥10 points on the ODI and 45.3% of the patients reached a functional status equivalent to an acceptable, normal healthy population value (ODI ≤ 22). This is comparable to the one-year follow-up assessment. 80.1% of the participants are satisfied with the treatment results and 76.2% would recommend the program to family/friends. Conclusion The positive short-term effectiveness at one-year follow up of a two-week CPP-program is demonstrated to maintain over time. Patients demonstrate continued improvement of functional status and quality of life after 6.5 years of follow up. Moreover, at long-term follow up a high percentage of patients were satisfied with the results of the program and they would recommend the program to family and/or friends. References National Institute for Health and Care Excellence. Clinical Guideline 88. Low back pain: Early management of persistent non-specific low back pain. May 2009 Chou R, Loeser JD, Owens DK, et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066–1077 Airaksinen O, Brox JI, Cedraschi C, et al; COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15(Suppl 2):S192–S300 van Hooff ML, van der Merwe JD, O'Dowd J, et al. Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management. Eur Spine J 2010;19(9):1517–1526 van Hooff ML, Ter Avest W, Horsting PP, et al. A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain: two-year follow-up results of a prospective cohort. Eur Spine J 2012;21(7):1257–1264

Effectiveness of multifaceted implementation strategies for the implementation of back and neck pain guidelines in health care: a systematic review.

BackgroundFor the optimal use of clinical guidelines in daily practice, mere distribution of guidelines and materials is not enough, and active implementation is needed. This review investigated the effectiveness of multifaceted implementation strategies compared to minimal, single, or no implementation strategy for the implementation of non-specific low back and/or neck pain guidelines in health care.MethodsThe following electronic databases were searched from inception to June 1, 2015: MEDLINE, Embase, PsycInfo, the Cochrane Library, and CINAHL. The search strategy was restricted to low back pain, neck pain, and implementation research. Studies were included if their design was a randomized controlled trial, reporting on patients (age ≥18 years) with non-specific low back pain or neck pain (with or without radiating pain). Trials were eligible if they reported patient outcomes, measures of healthcare professional behaviour, and/or outcomes on healthcare level. The primary outcome was professional behaviour. Guidelines that were evaluated in the studies had to be implemented in a healthcare setting. No language restrictions were applied, and studies had to be published full-text in peer-reviewed journals, thus excluding abstract only publications, conference abstracts, and dissertation articles. Two researchers independently screened titles and abstract, extracted data from included studies, and performed risk of bias assessments.ResultsAfter removal of duplicates, the search resulted in 4750 abstracts to be screened. Of 43 full-text articles assessed for eligibility, 12 were included in this review, reporting on 9 individual studies, and separate cost-effectiveness analyses of 3 included studies. Implementation strategies varied between studies. Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls.ConclusionThis review showed that multifaceted strategies for the implementation of neck and/or back pain guidelines in health care do not significantly improve professional behaviour outcomes. No effects on patient outcomes or cost of care could be found. More research is necessary to determine whether multifaceted implementation strategies are conducted as planned and whether these strategies are effective in changing professional behaviour and thereby clinical practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0482-7) contains supplementary material, which is available to authorized users.

Critical features of peer assessment of clinical performance to enhance adherence to a low back pain guideline for physical therapists: a mixed methods design.

BackgroundClinical practice guidelines are intended to improve the process and outcomes of patient care. However, their implementation remains a challenge. We designed an implementation strategy, based on peer assessment (PA) focusing on barriers to change in physical therapy care. A previously published randomized controlled trial showed that PA was more effective than the usual strategy “case discussion” in improving adherence to a low back pain guideline. Peer assessment aims to enhance knowledge, communication, and hands-on clinical skills consistent with guideline recommendations. Participants observed and evaluated clinical performance on the spot in a role-play simulating clinical practice. Participants performed three roles: physical therapist, assessor, and patient. This study explored the critical features of the PA program that contributed to improved guideline adherence in the perception of participants.MethodsDutch physical therapists working in primary care (n = 49) organized in communities of practice (n = 6) participated in the PA program. By unpacking the program we identified three main tasks and eleven subtasks. After the program was finished, a questionnaire was administered in which participants were asked to rank the program tasks from high to low learning value and to describe their impact on performance improvement. Overall ranking results were calculated. Additional semi-structured interviews were conducted to elaborate on the questionnaires results and were transcribed verbatim. Questionnaires comments and interview transcripts were analyzed using template analysis.ResultsProgram tasks related to performance in the therapist role were perceived to have the highest impact on learning, although task perceptions varied from challenging to threatening. Perceptions were affected by the role-play format and the time schedule. Learning outcomes were awareness of performance, improved attitudes towards the guideline, and increased self-efficacy beliefs in managing patients with low back pain. Learning was facilitated by psychological safety and the quality of feedback.ConclusionThe effectiveness of PA can be attributed to the structured and performance-based design of the program. Participants showed a strong cognitive and emotional commitment to performing the physical therapist role. That might have contributed to an increased awareness of strength and weakness in clinical performance and a motivation to change routine practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-015-0484-1) contains supplementary material, which is available to authorized users.