Persistent Non-specific Low Back Pain Research Articles

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial.

The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. Five NHS acute trusts in England. Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. Poor recruitment was a limiting factor. This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. Further work is needed to test recruitment from alternative clinical situations. EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?

Low back pain (LBP) has a prevalence of 84% in Africa. The commonest form of imaging is plain lumbar spine x-ray. It gives a radiation dose equivalent to 65 times a chest x-ray dose and sends one of the highest doses to the human reproductive organs. The commonest cause of LBP in Africa is degenerative disease. X-ray findings do not change mode of treatment yet most physicians still routinely request for x-rays. This is a systematic review of databases including The Cochrane, CINAHL plus, AMED, and MEDLINE. Key evidence was clinical guidelines on x-ray use for low back pain. Key search terms included low back pain, x-rays, guidelines, Ghana. Four clinical guidelines on LBP emerged from two Systematic Reviews rated excellent and four good Randomized Controlled Trials: The European guidelines for acute and sub-acute non-specific Low Back Pain, The American College of Physicians and the American Pain Society guideline for diagnostic imaging for Low Back Pain, The NICE guidelines for persistent non-specific Low Back Pain and the Ghana Standard Treatment Guidelines (GSTG). All the guidelines agree that a good history and clinical examination for all LBP patients helps in diagnosing. Only GSTG recommends routine plain spinal x-rays. There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs. None declared.

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

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 < 20 or > 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 > 1=increased probability to success; OR < 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

Facet-joint injections for people with persistent non-specific low back pain (FIS): study protocol for a randomised controlled feasibility trial.

BackgroundThe role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin.Methods/DesignWe present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses.Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0–10 scale. Questionnaire follow-up will be at 3, 6, and 12 months.Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders.DiscussionWhilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain.Trial registrationEudraCT identifier 2014-000682-50, (registered on 12 February 14). ISRCTN registry number: ISRCTN93184143 DOI 10.1186/ISRCTN93184143 (registered on 27 February 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1117-z) contains supplementary material, which is available to authorized users.

The Use of Wet Cupping for Persistent Nonspecific Low Back Pain: Randomized Controlled Clinical Trial.

Objectives: To evaluate the effectiveness and safety of wet cupping therapy as a single treatment for persistent nonspecific low back pain (PNSLBP).Design: Randomized controlled trial comparing wet cupping versus no treatment in PNSLBP.Setting: Outpatient clinic in three secondary care hospitals in Saudi Arabia.Patients: Eighty eligible participants with PNSLBP for at least 3 months were randomly allocated to an intervention group (n=40) or to a control group (n=40).Interventions: Six wet cupping sessions within 2 weeks, each of which were done at two bladder meridian (BL) acupuncture points among BL23, BL24, and BL25. Only acetaminophen was allowed as a rescue treatment in both groups.Outcome measures: The Numeric Rating Scale (NRS), McGill Present Pain Intensity (PPI), and Oswestry Disability Questionnaire (ODQ) were used as outcome measures. Numbers of acetaminophen tablets taken were compared at 4 weeks from baseline. Adverse events were recorded.Results: At the end of the intervention, statistically significant differences in the three outcome measures favoring the wet cupping group compared with the control group were seen: NRS score, 29.2 (95% confidence interval [CI], 24.6–33.8) versus 57.9 (95% CI, 53.3–62.6), respectively; PPI score, 1.17 (95% CI, 0.96–1.4) versus 2.3 (95% CI, 2.1– 2.7); and ODQ score, 19.6 (95% CI, 16.5–22.7) versus 35.4 (95% CI, 32.3–38.5) (p=0.0001). This improvement continued for another 2 weeks after the end of the intervention. Acetaminophen was used less in the wet cupping group, but this difference was not statistically significant. No adverse events were reported.Conclusions: Wet cupping is potentially effective in reducing pain and improving disability associated with PNSLBP at least for 2 weeks after the end of the wet cupping period. Placebo-controlled trials are needed.

Physical Therapists' Views and Experiences of Pregnancy-Related Low Back Pain and the Role of Acupuncture: Qualitative Exploration.

Low back pain is often accepted as a "normal" part of pregnancy. Despite research suggesting that quality of life for women who are pregnant is adversely affected, most are advised to self-manage. Although the use of acupuncture for the management of persistent nonspecific low back pain has been recommended in recent UK national guidelines, its use in the management of pregnancy-related low back pain remains limited. This study aimed to explore the perceptions and experiences of physical therapists involved in treating women who are pregnant and have low back pain with the objective of informing the pretrial training program for a pilot randomized trial (Evaluating Acupuncture and Standard care for pregnant womEn with Back pain [EASE Back]). A qualitative phenomenological method with purposive sampling was used in the study. Three focus groups and 3 individual semistructured interviews were undertaken, and an iterative exploratory thematic analysis was performed. To ensure transparency of the research process and the decisions made, an audit trail was created. Twenty-one physical therapists participated, and emergent issues included: a lack of experience in treating pregnancy-related complaints, mixed messages from previous acupuncture education, a mistrust of the current evidence for acupuncture safety and effectiveness, and personal and professional fear of causing harm. The findings suggest that UK physical therapists are reluctant to use acupuncture in the management of pregnancy-related low back pain. The explanations for these findings include perceived lack of knowledge and confidence, as well as a pervasive professional culture of caution, particularly fears of inducing early labor and of litigation. These findings have been key to informing the content of the training program for physical therapists delivering acupuncture within the pilot EASE Back trial.

Chronic low back pain

The care of patients with persistent non-specific low back pain is a common situation in general practice. Chronic non-specific low back pain is defined as back pain persisting for more than 6 weeks in the absence of an underlying pathology. Multiple different permutations of the structures in the back, such as joints, discs, muscles, tendons and ligaments, play a part in the development of chronic non-specific low back pain. With the right management, low back pain resolves or improves significantly in the majority of cases. However, if patients do not receive appropriate management in a timely fashion, there is a higher risk of them going on to experience significant negative physical, social, psychological and economic outcomes.

Performance based on sEMG activity is related to psychosocial components: Differences between back and abdominal endurance tests

The influence of psychosocial components on back and abdominal endurance tests in patients with persistent non-specific low back pain should be investigated to ensure the correct interpretation of these measures. Three-hundred and thirty-two patients (291 men and 41 women) from 19 to 63years performed an abdominal and back muscle endurance test after completing some psychosocial questionnaires. During the endurance tests, surface electromyography signals of the internal obliques, the external obliques, the lumbar multifidus and the iliocostalis were recorded. Patients were dichotomized as underperformers and good performers, by comparing their real endurance time, to the expected time of endurance derived from the normalized median frequency slope. Independent t-tests were performed to examine the differences on the outcome of the questionnaires. In the back muscle endurance test, the underperformers had significantly lower (p<0.05) scores on some of the physical subscales of the SF-36. The underperformers group of the AE test scored significantly higher on the DRAM MZDI (p=0.018) and on the PCS scale (p=0.020) and showed also significantly lower scores on the SF-36 (p<0.05). Back muscle endurance tests are influenced by physical components, while abdominal endurance tests seem influenced by psychosocial components.

A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study

BackgroundPersistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs).MethodsTo encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 = nil and 5 = excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale).ResultsNinety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention.ConclusionAn interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.

The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain – A systematic review

BackgroundThere is considerable interest in whether best practice management of nonspecific low back pain (NSLBP) should include the targeting of treatment to subgroups of people with identifiable clinical characteristics. However, there are no published systematic reviews of the efficacy of targeted psychosocial interventions. AimThis review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics. MethodBibliographic databases were searched. Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment (treatment effect modification) for the outcomes of pain, activity limitation and psychosocial factors (fear avoidance, catastrophisation, anxiety and depression). Results and conclusionFour studies met the inclusion criteria and collectively investigated nine hypotheses about targeted treatment on 28 subgroup/treatment outcomes. There were only two statistically significant results. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targeted psychosocial interventions.

‘I can’t see any reason for stopping doing anything, but I might have to do it differently’ – restoring hope to patients with persistent non-specific low back pain – a qualitative study

Purpose: To explore the differences in narrative between patients with persistent non-specific low back pain (PLBP) who benefited from a pain management programme, and those who did not benefit. Method: We conducted interviews with 20 patients attending a pain management programme; prior to attending the programme, immediately following the programme and at one year. Our analysis focused on a theoretical sample of patients who either described dramatic life improvements at one year, and who described themselves as much worse. We used the methods of grounded theory. Results: We found that finding hope was central to good outcome. Patients restored hope by making certain changes; (a) deconstructing specific fears, (b) constructing an acceptable explanatory model (c) reconstructing self identity by making acceptable changes. Those who had not restored hope retained fears of loss of self, remained committed to the biomedical model and were unable to make acceptable changes. Conclusions: Our findings may help to operationalise the restoration of hope in patients with PLBP. Firstly, health care professionals need to identify and resolve any specific fears of movement. Secondly, patients need an acceptable explanatory model that fits their experience and personal narrative. Finally our study confirms the centrality of self concept to recovery.Implications for RehabilitationExplanatory models are likely to have an impact on recovery following pain rehabilitation.Adherence to a biomedical model may have a negative impact on recovery.Patients need an acceptable explanatory model that fits their experience.Defining an acceptable self concept is integral to recovery.

Tai chi exercise for treatment of pain and disability in people with persistent low back pain: A randomized controlled trial

To determine the effect of tai chi exercise on persistent low back pain. We performed a randomized controlled trial in a general community setting in Sydney, New South Wales, Australia. Participants consisted of 160 volunteers between ages 18 and 70 years with persistent nonspecific low back pain. The tai chi group (n = 80) consisted of 18 40-minute sessions over a 10-week period delivered in a group format by a qualified instructor. The waitlist control group continued with their usual health care. Bothersomeness of back symptoms was the primary outcome. Secondary outcomes included pain intensity and pain-related disability. Data were collected at pre- and postintervention and analyzed by intent-to-treat. Tai chi exercise reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale. The followup rate was >90% for all outcomes. These results were considered a worthwhile treatment effect by researchers and participants. This is the first pragmatic randomized controlled trial of tai chi exercise for people with low back pain. It showed that a 10-week tai chi program improved pain and disability outcomes and can be considered a safe and effective intervention for those experiencing long-term low back pain symptoms.

Persistent non-specific low back pain and patients’ experience of general practice: a qualitative study

This paper aims to present a conceptual analysis of patients' experience of general practice in relation to their persistent non-specific low back pain (PLBP). PLBP accounts for a considerable amount of the daily workload of the general practitioner (GP). GPs need to maintain a good relationship with their patient while following guidelines for best practice. The biomedical model can contribute to the tensions experienced by a person with PLBP and a shift in the prevailing model may facilitate the resolution of these tensions. Qualitative research can help clinicians to understand this process and thus facilitate the best possible outcome. We conducted a series of three in-depth interviews over a period of one year with 20 patients with PLBP who had been invited to attend a pain management programme. We used the methods of constructivist grounded theory to analyse the data. Several themes emerged that provide a deeper understanding of the context in which patient and GP negotiate their relationship. Patients describe how they have been fobbed off by a GP who is just a general practitioner and not an expert. This allowed patients to continue to use the biomedical model; I have something real but the GP lacks knowledge. To think that 'nothing can be done', would involve accepting the limits of medical knowledge. We also found that over time, as diagnosis and cure is not achieved, patient began to question the concept of the medical expert. This tension opens up the possibility for a shift away from the biomedical towards a biopsychosocial explanatory model.

Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot trial

BackgroundPersistent non-specific low back pain (PNSLBP) is one of the most frequently experienced types of back pain around the world. Wet-cupping is a common intervention for various pain conditions, especially in Korea. In this context, we conducted a pilot study to determine the effectiveness and safety of wet-cupping treatment for PNSLBP.MethodsWe recruited 32 participants (21 in the wet-cupping group and 11 in the waiting-list group) who had been having PNSLBP for at least 3 months. The participants were recruited at the clinical research centre of the Korea Institute of Oriental Medicine, Korea. Eligible participants were randomly allocated to wet-cupping and waiting-list groups. Following the practice of traditional Korean medicine, the treatment group was provided with wet-cupping treatment at two acupuncture points among the BL23, BL24 and BL25 6 times within 2 weeks. Usual care, including providing brochures for exercise, general advice for PNSLBP and acetaminophen, was allowed in both groups. Separate assessors participated in the outcome assessment. We used the 0 to100 numerical rating scale (NRS) for pain, the McGill Pain Questionnaire for pain intensity (PPI) and the Oswestry Disability Questionnaire (ODQ), and we assessed acetaminophen use and safety issues.ResultsThe results showed that the NRS score for pain decreased (-16.0 [95% CI: -24.4 to -7.7] in the wet-cupping group and -9.1 [-18.1 to -0.1] in the waiting-list group), but there was no statistical difference between the groups (p = 0.52). However, the PPI scores showed significant differences between the two groups (-1.2 [-1.6 to -0.8] for the wet-cupping group and -0.2 [-0.8 to 0.4] for the waiting-list group, p < 0.01). In addition, less acetaminophen was used in the wet-cupping group during 4 weeks (p = 0.09). The ODQ score did not show significant differences between the two groups (-5.60 [-8.90 to -2.30] in the wet-cupping group and -1.8 [-5.8 to 2.2] in the waiting-list group, p = 0.14). There was no report of adverse events due to wet-cupping.ConclusionThis pilot study may provide preliminary data on the effectiveness and safety of wet-cupping treatments for PNSLBP. Future full-scale randomised controlled trials will be needed to provide firm evidence of the effectiveness of this intervention.Trial RegistrationClinicalTrials.gov: (Identifier: NCT00925951)Date of trial registration: June 19th, 2009The date when the first patient was randomised: July 15th, 2009The date when the study was completed: November 27th, 2009

Evaluation of a radiographic technique: one dimension of critical thinking

Background: Previous articles in this series (July 2010 and April 2011) have looked at examples of how undergraduate students can demonstrate their ability to interpret data and generate new ideas as part of developing their critical thinking skills. As a final example, the evaluation component of critical thinking is explored that requires students to recognize arguments, separate fact from opinion and verify the value of evidence. In this way they can fully engage with evidence-based practice. Contents: The evaluation component of critical thinking encourages students to ask the right questions when considering research data and dig deeper into the motives, expertise and assumptions underlying the evidence presented. The worked example is for an evaluation of the effectiveness of X-ray imaging of the lumbar spine in patients presenting with persistent nonspecific low back pain (LBP). The structure of the evaluation includes clinical indications, diagnostic yield, effectiveness of current practice and comparison with other diagnostic imaging options. Conclusions: Since critical thinking is not a single entity, understanding the key components that contribute to the whole is important if undergraduate students are to be encouraged and supported in developing their critical thinking skills. The example of an evaluation of a radiographic technique illustrates how students are expected to go about demonstrating their understanding of the intentions and motivations behind judgements, protocols and guidelines that are aimed at improving the delivery of health care.

Acupuncture for low back pain: A survey of clinical practice in the UK

Acupuncture is recommended in official UK guidelines for persistent non-specific low back pain and is popular with patients. However, what UK-based acupuncturists actually do in every day clinical practice is poorly documented. We therefore conducted a survey of every-day clinical practice of acupuncture for low back pain in the UK. Cross-sectional postal survey. Random samples of 100 acupuncturists from each of the three main UK societies for acupuncturists were sent questionnaires. A questionnaire designed (and pilot-tested) for this study asked about: training and professional identity, current work situation, and typical approach to treating a patient with low back pain. Completed questionnaires were received from 129 respondents (53% male), representing each society approximately equally. Work situation (e.g. weekly hours practicing acupuncture) differed across societies. Respondents reported needling 2-30 acupuncture points in an average treatment (median=8) and leaving needles in for 0-40 min (median=20 min). A large number of individual points (121) were named as 'typical'. There is huge variation in how acupuncture is used by UK practitioners to treat people with low back pain. This probably constitutes a difficult situation for patients when selecting an acupuncturist. It may also translate into large variation in clinical outcomes for patients receiving care from different acupuncturists as well as difficulty in developing acupuncture protocols for pragmatic and other trials. Such diversity reflects the ongoing debate within the acupuncture profession about good practice for common conditions.

Effects of Pilates-Based Exercises on Pain and Disability in Individuals With Persistent Nonspecific Low Back Pain: A Systematic Review With Meta-analysis

A systematic review with meta-analysis. To compare pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to minimal or other interventions. Searches of Medline, CINAHL, Embase, Cochrane library, PEDro, and ProQuest Dissertations and Thesis databases were conducted. Randomized controlled trials (RCTs) were selected and reviewed if they compared pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to other treatment approaches. Quality of the trials was evaluated. Data for pain and disability scores were extracted. Narrative synthesis plus meta-analyses were performed, with either a fixed-effects or random-effects model, standardized mean differences (SMDs), and tests for heterogeneity. Seven RCTs were identified and included in the meta-analyses. Data pooling was performed using RevMan 5. When compared to minimal intervention, Pilates-based exercise provided superior pain relief (pooled SMD, -2.72; 95% CI: -5.33, -0.11; P = .04) but the pooled disability scores were not significantly different (pooled SMD, -0.74; 95% CI: -1.81, 0.33;P = .17). No significant differences were found when comparing Pilates-based exercise to other forms of exercise for pain (pooled SMD, 0.03; 95% CI: -0.52, 0.58; P = .92) or disability scores (pooled SMD, -0.41; 95% CI: -0.96, 0.14; P = .14). Pilates-based exercises are superior to minimal intervention for pain relief. Existing evidence does not establish superiority of Pilates-based exercise to other forms of exercise to reduce pain and disability for patients with persistent nonspecific low back pain. However, the relatively low quality of existing studies and the heterogeneity of pooled studies in this systematic review combine to suggest that these results should be interpreted with caution. Therapy, level 1a.

Group Cognitive Behavioral Intervention for Persistent Low Back Pain

In patients with persistent nonspecific low back pain, physical treatments (e.g., manipulation, acupuncture) or simple advice to remain active yields

Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain: A Systematic Review

Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. are presented as weighted mean differences with 95% confidence intervals. Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3-9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were -6.2 (-9.4 to -3.0), -5.5 (-9.9 to -1.0), -6.5 (-10.1 to -3.0), and -3.9 (-7.4 to -0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.