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Objectives: To explore how people perceive three different forms of advice for acute low back pain (LBP)., Design: Content analysis of qualitative data collected in a three-arm randomised experiment., Participants: 2200 participants with acute LBP (ie, pain duration for ≤6 weeks) were randomly assigned to receive three types of advice: guideline advice and guideline advice with the addition of either brief pain science or ergonomics messages., Primary and Secondary Outcomes: After receiving the advice, participants answered two questions: 'If your health professional gave you this advice, how would it make you feel?' and 'If your health professional gave you this advice, what treatments (if any) do you think you would need?' Two researchers coded responses using deductive content analysis., Results: We analysed 4400 free-text responses from 2200 participants. There were little to no differences in participants' feelings, thoughts and expectations after receiving three types of advice for acute LBP. Participants most commonly expressed feeling positive about the advice (38%-35%), reassured (23%-22%) and empowered (10%-8%). Some expressed being unhappy or being frustrated with the advice (4%-3%). Participants most commonly thought they needed no treatment apart from staying active, followed by exercise and medication., Conclusions: Guideline advice with or without the addition of brief pain science or ergonomics messages generated positive feelings, reassurance or a sense of empowerment in many people with acute LBP, with no difference between types of advice., Trial Registration Number: ACTRN12623000364673., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs., Methods: The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group., Results: Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described., Conclusion: We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs., (© 2024. The Author(s).)

Background: Understanding the clinical course of low back pain is essential to informing treatment recommendations and patient stratification. Our aim was to update our previous systematic review and meta-analysis to gain a better understanding of the clinical course of acute, subacute and persistent low back pain., Methods: To update our 2012 systematic review and meta-analysis, we searched the Embase, MEDLINE and CINAHL databases from 2011 until January 2023, using our previous search strategy. We included prospective inception cohort studies if they reported on participants with acute (< 6 wk), subacute (6 to less than 12 wk) or persistent (12 to less than 52 wk) nonspecific low back pain at study entry. Primary outcome measures included pain and disability (0-100 scale). We assessed risk of bias of included studies using a modified tool and assessed the level of confidence in pooled estimates using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. We used a mixed model design to calculate pooled estimates (mean, 95% confidence interval [CI]) of pain and disability at 0, 6, 12, 26 and 52 weeks. We treated time in 2 ways: time since study entry (inception time uncorrected) and time since pain onset (inception time corrected). We transformed the latter by adding the mean inception time to the time of study entry., Results: We included 95 studies, with 60 separate cohorts in the systematic review ( n = 17 974) and 47 cohorts ( n = 9224) in the meta-analysis. Risk of bias of included studies was variable, with poor study attrition and follow-up, and most studies did not select participants as consecutive cases. For the acute pain cohort, the estimated mean pain score with inception time uncorrected was 56 (95% CI 49-62) at baseline, 26 (95% CI 21-31) at 6 weeks, 22 (95% CI 18-26) at 26 weeks and 21 (95% CI 17-25) at 52 weeks (moderate-certainty evidence). For the subacute pain cohort, the mean pain score was 63 (95% CI 55-71) at baseline, 29 (95% CI 22-37) at 6 weeks, 29 (95% CI 22-36) at 26 weeks and 31 (95% 23-39) at 52 weeks (moderate-certainty evidence). For the persistent pain cohort, the mean pain score was 56 (95% CI 37-74) at baseline, 48 (95% CI 32-64) at 6 weeks, 43 (95% CI 29-57) at 26 weeks and 40 (95% CI 27-54) at 52 weeks (very low-certainty evidence). The clinical course of disability was slightly more favourable than the clinical course of pain., Interpretation: Participants with acute and subacute low back pain had substantial improvements in levels of pain and disability within the first 6 weeks ( moderate-certainty evidence); however, participants with persistent low back pain had high levels of pain and disability with minimal improvements over time (very low-certainty evidence). Identifying and escalating care in individuals with subacute low back pain who are recovering slowly could be a focus of intervention to reduce the likelihood of transition into persistent low back pain., Protocol Registration: PROSPERO - CRD42020207442., Competing Interests: Competing interests: Sarah Wallwork has received speaker fees from the Neuro Orthopaedic Institute and Exercise and Sport Science Australia. Felicity Braithwaite has received speaker fees from the Neuro Orthopaedic Institute, San Diego Pain Summit, Medicine Education Science and Health (MESH) . Mary O’Keeffe reports consulting fees from the European Pain Federation EFIC, honoraria from the Physio Network and travel support from INTERACT-EUROPE, PANACEA and Happy. Mervyn Travers has received speaker fees from Aalborg University, Australian Physiotherapy Association, Australian Podiatry Association, Life Ready Physiotherapy, Physio-Formation, Smart Education, O2 Academy, Healthia, Queensland Health, The University of Western Australia, Hemophilia Association Australia, Icelandic Physiotherapy Association and Rural Health West. Belinda Lange is a nonexecutive director of the Australian Physiotherapy Council and the Australasian Institute of Digital Health. G. Lorimer Moseley has received support from the National Health and Medical Research Council of Australia, the Medical Research Future Fund, Reality Health, Connect Health UK, Institutes of Health California, American International Assurance Australia, Workers’ Compensation Boards and professional sporting organisations (International Olympic Committee, English Premier League, La Liga, Australian Football League Clubs, National Basketball League, Athletics Australia, Cricket Australia). Professional and scientific bodies have reimbursed him for travel costs related to presentations of research on pain. He has received speaker fees for lectures on pain and rehabilitation from the Royal Australian College of General Practitioners, Noigroup Australia and MasterSessions. He receives royalties from Noigroup Publications, Orthopedic Physical Therapy Products and Dancing Giraffe Press. He sits on boards with Painaustralia and National Pain Solutions Research Alliance, and is chief executive officer with Pain Revolution. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090 .

Purpose: An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations., Methods: In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses., Results: Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain., Conclusion: Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP., (© 2022. The Author(s).)

Background: The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care., Design: A qualitative study., Methods: The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods., Results: Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity)., Conclusions: Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests. GM, CM, and KM report grants from the Australian National Health and Medical Research Council during the conduct of this trial (grant numbers: not applicable)., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: Pain relief and reduced disability are both common treatment targets for persistent disabling low back pain (LBP). Cross-sectional studies show a moderate relationship between functional disability and pain intensity, but little is known about the relationship between changes in pain intensity and functional disability over multiple time points. The objective of this study was to investigate the associations between changes in functional disability and pain intensity and whether changes occurred simultaneously or differentially during a course of cognitive functional therapy for people with persistent disabling LBP., Methods: Self-reported measures of pain intensity and patient-specific functional disability were collected prior to each treatment session from 40 participants during a 12-week intervention period. Linear mixed modeling was used to assess simultaneous and lagged associations between pain intensity and functional disability over time. Sensitivity analysis using nonparametric subject-specific methods (simulation modeling analysis) was also performed., Results: Thirty-five participants had sufficient data for analysis. Using the linear mixed-model approach, there was evidence of a moderate and simultaneous association between pain intensity and functional disability over time (regression coefficient = 0.56, 95% confidence interval: 0.44-0.68, p < 0.001). Simulation modeling analysis supported weak to mostly strong associations and supported for simultaneous change in pain and disability for the majority of participants (22 of 35, 64%)., Conclusion: Changes in pain intensity and functional disability were moderately related across the intervention. Visual inspection of graphs indicated a very close relationship in some individuals and a decoupling of pain intensity and functional disability in others. The changes in pain intensity and functional disability seem to occur simultaneously in most individuals., (© 2024 the author(s), published by De Gruyter.)

Background: Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, surgery, second opinion, seriousness, recovery, work, and physical activities., Methods: Six-arm online randomized experiment with blinded participants with and without LBP. Participants received one of six labels: 'disc bulge', 'degeneration', 'arthritis', 'lumbar sprain', 'non-specific LBP', 'episode of back pain'. The primary outcome was the belief about the need for imaging., Results: A total of 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. The need for imaging was rated lower with the labels 'episode of back pain' (4.2 [2.9]), 'lumbar sprain' (4.2 [2.9]) and 'non-specific LBP' (4.4 [3.0]) compared to the labels 'arthritis' (6.0 [2.9]), 'degeneration' (5.7 [3.2]) and 'disc bulge' (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery and perceived seriousness compared to 'disc bulge', 'degeneration' and 'arthritis'. Differences were larger amongst participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels., Conclusions: 'Episode of back pain', 'lumbar sprain' and 'non-specific LBP' reduced need for imaging, surgery and second opinion compared to 'arthritis', 'degeneration' and 'disc bulge' amongst public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant amongst those at risk of poor outcomes (participants with current LBP who had a history of seeking care)., (© 2022 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC®.)

Background: Cognitive Functional Therapy (CFT) is a physiotherapist-led individualized intervention for people with people with non-specific chronic low back pain (CLBP), involving biopsychosocial pain education, graded movement exposure and lifestyle coaching., Methods: A multicentre randomized controlled trial (RCT), including 206 participants with CLBP in Ireland, supported CFT's effectiveness for reducing disability, but not pain, compared to a group exercise and education intervention. In this study, causal mediation analysis was used to determine whether the effect of CFT on disability and the lack of effect on pain (relative to a group exercise and education intervention) is mediated by certain psychological and lifestyle factors. Hypothesized mediators measured were pain self-efficacy, stress, fear of physical activity, coping, depression, anxiety and sleep, at 6 months. The outcomes measured were functional disability and pain intensity at 12 months., Results: This causal mediation study shows that the majority of benefit of CFT (relative to a group exercise and education intervention) for disability is due to increasing pain self-efficacy., Conclusion: Conclusion: CFT did not improve the majority of the hypothesized mediators (stress, fear of physical activity, coping, depression, anxiety and sleep) and these mediators were not associated with either disability or pain. Unfortunately, the proportion of missing data in this study is substantial and these findings can only be considered hypothesis-generating. Therefore, future research should examine replicating the results of this study to verify the role of self-efficacy and other proposed mediators (e.g. stress, coping, sleep, fear) on clinical outcomes., Significance: An exploration of seven potential mediators was undertaken to determine the effect of Cognitive Functional Therapy (CFT) on disability and pain intensity in individuals with chronic low back pain compared to a group exercise and education intervention. CFT improved pain self-efficacy, which was associated with disability and pain outcomes. CFT did not improve the other six potential mediators (stress, fear of physical activity, coping, depression, anxiety and sleep) and these were not associated with disability or pain. The proportion of missing data in this study is substantial and these findings should be considered hypothesis-generating only., (© 2020 European Pain Federation - EFIC®.)

Aim: To compare and contrast the diagnostic codes for spinal causes of low back pain (LBP) in 3 disease classification systems (International Classification of Diseases [ICD]-10, International Classification of Primary Care [ICPC]-2 PLUS and Systematized Nomenclature of Medicine Clinical Terms - Australia [SNOMED CT-AU]) and consider how well they are aligned with the diagnostic approach recommended in contemporary clinical practice guidelines for LBP., Method: This was a descriptive study which included 3 disease classification systems: ICD-10, ICPC-2 PLUS and SNOMED CT-AU. Two independent authors extracted relevant LBP codes from each system and mapped the codes to 3 guideline-endorsed categories of spine-related diagnoses for LBP (specific spinal pathology, radicular syndromes, and non-specific LBP) and the various clinical conditions (sub-categories) within each of the 3 categories., Results: ICD-10, ICPC-2 PLUS, and SNOMED CT-AU had 126, 118 and 100 codes for LBP, respectively. All systems provided codes that would cover the 3 guideline-endorsed categories of spine-related diagnoses for LBP. On the basis of contemporary guidelines, the authors developed lists of discrete sub-categories of specific spinal pathology (56 sub-categories), radicular syndromes (7 sub-categories), and non-specific LBP (10 sub-categories). Each of the classification systems was then mapped against these sub-categories to tally redundancy and determine exhaustiveness. However, no system covered all 73 sub-categories of LBP, and within each system, there was substantial redundancy with up to 22 codes for the same clinical condition., Conclusion: LBP diagnostic codes used in popular disease classification systems are out of touch with current approaches to diagnosis, as reflected in contemporary LBP guidelines. Our findings suggest these disease classification systems need revision, but precisely how they should be revised is unclear., (© 2021 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Background: Prior research demonstrated that people in the United States and Canada (Northern America) hold predominantly biomedical beliefs about Low back pain (LBP); such beliefs were attributed to healthcare professionals (HCP). Further investigation is needed to understand HCP' LBP beliefs, preferred management strategies, and sources of beliefs., Methods: Participants were recruited via social media to complete a qualitative cross-sectional online survey. The survey was distributed to assess LBP beliefs in a U.S. and Canadian-based clinician population. Participants answered questions about the cause of LBP, reasons for recurrence or persistence, use of imaging, management strategies, and sources of beliefs. Responses were analysed using an inductive thematic analysis., Results: One hundred and sixty three participants were included, reporting multiple causes for LBP. However, many references were anchored to biological problems. When psychological variables were mentioned, it typically involved patient blaming. Like prior research studies, minimal attention was given to societal and environmental influences. Management strategies often aligned with guideline care except for the recommendation of inappropriate imaging and a reliance on passive interventions., Conclusions: These findings align with prior research studies on general population beliefs, demonstrating a preference for biological causes of LBP. Further updates are needed for clinical education, while future studies should seek to assess the translation of clinician beliefs into clinical practice and health system constraints., (© 2024 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: Antidepressants are commonly used to treat low back pain (LBP), but little is known about patterns of antidepressant use in this population. This study aimed to identify patterns of antidepressant dispensing and switching in Australian workers with an accepted workers' compensation claim for LBP, and to investigate factors associated with dispensing and switching., Methods: This retrospective study included data from accepted workers' compensation time loss claims for LBP between 2010 and 2018 with a 2-year follow-up. We described the type of antidepressant dispensed, the time for the index antidepressant to be dispensed, and whether people in the study switched to a different antidepressant. Logistic regression models investigated factors associated with antidepressants being dispensed for the first time and for switching to a different antidepressant., Results: Antidepressants were dispensed to 2476 people with LBP (14%) at least once after a median (IQR) of 28 (10.9-54.7) weeks. Amitriptyline was the most dispensed antidepressant at any one point (47.8%), and the most common index antidepressant (42.9%). Also, 32.7% of people switched to a different antidepressant at least once. Sex, age, having been dispensed opioids, gabapentinoids or diazepam prior to antidepressants being dispensed, having used psychological services, and socioeconomic disadvantage were associated with antidepressant dispensing., Conclusion: One in seven people with LBP were dispensed an antidepressant, most commonly amitriptyline. Antidepressants were commonly used in combination with other pain medicines such as opioids, gabapentinoids and diazepam., Significance: Antidepressants were dispensed to one in seven people with low back pain, most commonly amitriptyline followed by duloxetine. Antidepressants were typically dispensed after 6 months and after other medicines such as opioids, gabapentinoids and diazepam had been dispensed. Due to the administrative nature of the data, the study cannot infer whether antidepressants were dispensed to treat pain or other health problems, such as a mental health condition., (© 2024 European Pain Federation ‐ EFIC ®.)

Introduction: Despite advances in physiotherapy care for Low Back Pain (LBP) worldwide, studies suggest that physiotherapists in Nigeria do not adhere to international guidelines, and it is not known whether recent treatment approaches developed for LBP are recognized or applied by physiotherapists in Nigeria., Objectives: To evaluate the current assessment and treatment practices used by physiotherapists in Nigeria for people with recent onset, recurrent and chronic LBP., Design: A descriptive cross-sectional electronic national survey., Participants: Two hundred and sixty-seven registered physiotherapists who treat LBP across all 36 states of Nigeria completed the survey anonymously via REDCap., Results: Two hundred and sixty-seven physiotherapists (mean age = 37.6 years, SD = 9.1; 53.6% female) completed the survey in full. Although most physiotherapists (> 95%) regularly applied traditional assessment methods (e.g., history of presenting complaint, observation for spinal deformity, palpation), only approximately 30% screened for red flag pathology. Very few physiotherapists assessed patients with LBP for psychological distress (< 8%) or risk stratification/prognostic factors (< 4%). For treatment, electrophysical agents and muscle techniques (e.g., massage) predominated (> 95%), while few physiotherapists used cognitive-behavioural strategies (< 2%), individualised multimodal treatment programs (e.g., cognitive functional therapy, StarT Back or STOPS, < 1.5%), validated outcome measures (< 15%), clinical practice guidelines (< 10%) or a clinical reasoning strategy/framework (< 20%). Most Nigerian physiotherapists (> 99%) expressed interest in learning evidence-based LBP assessment and treatment methods from international experts., Conclusion: There is very limited application of contemporary assessment and treatment practices for LBP by Nigerian physiotherapists; however, they are very interested in learning these methods from international experts., (© 2024 John Wiley & Sons Ltd.)

Objective: To determine whether rates of ED presentations because of low back pain (LBP) have increased from 2016 to 2019 in New South Wales and map the geographical distribution of ED presentations because of LBP across New South Wales., Methods: We sourced data from the New South Wales Emergency Department Records for Epidemiology. We included all ED presentations aged 15 years and older with a diagnosis of LBP to the 178 public EDs across New South Wales from 1 January 2016 to 31 December 2019. We calculated the ratio (95% confidence interval) between the 2016 and 2019 age-standardised rates to determine whether an increase in the rate of ED LBP presentations has occurred. To assess geographical variation, we aggregated presentations by their home postcode. We calculated age-standardised rates per 100 000 person year for each of those areas using data from 2016 to 2019., Results: We included 188 275 LBP presentations for patients aged 15 years or older. Their mean (standard deviation) age was 51.3 (20.0) years. From 2016 to 2019, we observed a 5.3% increase in the age-adjusted LBP ED presentation rates (age-standardised ratio 1.05, 95% confidence interval 1.04-1.06). We found a 20-fold variation in LBP ED age-standardised presentation rates across the different local government areas of New South Wales. Higher rates were mostly observed in rural and regional areas., Conclusions: The demand for ED services because of LBP has increased in New South Wales over time, and we observed a 20-fold variation in presentation rates across different regions., (© 2021 Australasian College for Emergency Medicine.)

Abstract: An improved understanding of the biopsychosocial influences that contribute to and maintain pain has promoted the development of new efficacious treatments for chronic low back pain (CLBP). This study aimed to investigate the mechanisms of a new treatment-education and graded sensorimotor retraining-on pain and disability. We conducted a preplanned causal mediation analysis of a randomized clinical trial which allocated 276 participants with CLBP to 12 weekly clinical sessions of education and graded sensorimotor retraining (n = 138) or a sham and attention control (n = 138). Outcomes were pain intensity and disability, both assessed at 18 weeks. Hypothesized mediators included tactile acuity, motor coordination, back self-perception, beliefs about the consequences of back pain, kinesiophobia, pain self-efficacy, and pain catastrophizing, all assessed at the end of treatment (12 weeks). Four of 7 mechanisms (57%) mediated the intervention effect on pain; the largest mediated effects were for beliefs about back pain consequences (-0.96 [-1.47 to -0.64]), pain catastrophizing (-0.49 [-0.61 to -0.24]), and pain self-efficacy (-0.37 [-0.66 to -0.22]). Five of 7 mechanisms (71%) mediated the intervention effect on disability; the largest mediated effects were for beliefs about back pain consequences (-1.66 [-2.62 to -0.87]), pain catastrophizing (-1.06 [-1.79 to -0.53]), and pain self-efficacy (-0.84 [-1.89 to -0.45]). When all 7 mechanisms were considered simultaneously, the joint mediation effect explained most of the intervention effect for both pain and disability. Optimizing interventions to target beliefs about the consequences of back pain, pain catastrophizing, and pain self-efficacy is likely to lead to improved outcomes for people with CLBP., (Copyright © 2023 International Association for the Study of Pain.)

Introduction: Completeness of Global Burden of Disease (GBD) Study data is acknowledged as a limitation. To date, no study has evaluated this issue for low back pain, a leading contributor to disease burden globally., Methods: We retrieved reports, in any language, based on citation details from the GBD 2017 study website. Pairs of raters independently extracted the following data: number of prevalence reports tallied across countries, age groups, gender and years from 1987 to 2017. We also considered if studies enrolled a representative sample and/or used an acceptable measure of low back pain., Results: We retrieved 488 country-level reports that provide prevalence data for 103 of 204 countries (50.5%), with most prevalence reports (61%) being for high-income countries. Only 16 countries (7.8%) have prevalence reports for each of the three decades of the GBD. Most of the reports (79%) did not use an acceptable measure of low back pain when estimating prevalence., Conclusion: We found incomplete coverage across countries and time, and limitations in the primary prevalence studies included in the GBD 2017 study. This means there is considerable uncertainty about GBD estimates of low back pain prevalence and the disease burden metrics derived from prevalence., Competing Interests: Competing interests: AT reports he has received research grants from numerous Government and not for profit agencies outside the submitted work. CM reports he has received research grants from numerous Government and not for profit agencies outside the submitted work. His expenses have been covered by professional associations hosting conferences he has spoken at. Flexeze provide heat wraps at no cost for the SHaPED trial that he is an investigator on. MO received a Marie Curie Fellowship from the European Commission from 2018 to 2020, outside the submitted work. MT has nothing to disclose. Kharel has nothing to disclose. GF has nothing to disclose, (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the effects of information format on intentions to request diagnostic imaging for non-specific low back pain in members of the public., Methods: We performed a three arm, 1:1:1, superiority randomised trial on members of the public. Participants were randomised to one of the three groups: a Standard Care Leaflet group (standard information on low back pain), a Neutral Leaflet group (balanced information on the benefits and harms of imaging) and a Nudge Leaflet group (with behavioural cues to emphasise the harms of unnecessary imaging). Our primary outcome was intention to request imaging for low back pain., Results: 418 participants were randomised. After reading the leaflet, intention to request imaging (measured on an 11-point scale (0 = definitely would not request to 10 = definitely would request) was lower in the Nudge Leaflet group (mean = 4.6, SD = 3.4) compared with the Standard Care Leaflet group (mean = 5.3, SD = 3.3) and the Neutral Leaflet group (mean = 5.3, SD = 3.0) (adjusted mean difference between Nudge and Neutral, -1.0 points, 95%CI -1.6 to -0.4)., Conclusion: Framing information to emphasise potential harms from overdiagnosis reduced intention to request diagnostic imaging for low back pain., Practice Implications: Nudge leaflets could help clinicians manage patient pressure for unnecessary tests., Competing Interests: Declaration of Competing Interest Prof Chris Maher is supported by a Principal Research Fellowship from Australia’s National Health and Medical Research Council (APP1103022) as well as a Program grant (APP1113532) and two Centre for Research Excellence grants (APP1134856, APP1171459). He has received research grants from various government and not for profit agencies. Flexeze provided heat wraps at no cost for the SHaPED trial that he is an investigator on. His expenses have been covered by professional associations hosting conferences he has spoken at., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Primary health care is the gateway to low back pain (LBP) management. Effective management of LBP can reduce disability and socioeconomic burden. Standardised, accurate, and evidence-based information for assertive decision-making in care pathways for LBP has the potential to improve health service efficiency., Objective: To describe and analyse the accuracy of the information on the care pathway for the management of LBP in primary care provided by the Ministry of Health from Brazil., Methods: Descriptive study of the accuracy of information on the care pathway for LBP in primary care based on an official protocol of the Ministry of Health from Brazil. Information on non-pharmacological and pharmacological treatment, as well as health education, was extracted from the treatment protocol. The information was then compared with recent international guidelines for accuracy analysis. Each management recommendation was analysed by two independent researchers and classified as accurate, partially accurate, inaccurate or not mentioned according to the clarity and precision of the information., Results: The analysis revealed that 43% of the management recommendations were accurate, 30% were partially accurate, and 26% of the recommendations presented in the investigated guidelines were not mentioned in the Ministry of Health's care pathway. Pharmacological recommendations showed 50% accuracy, non-pharmacological recommendations 60%, and health education recommendations 14%. Additionally, the care pathway appears to be outdated in recommending educational guidance that is not aligned with current clinical guidelines., Conclusion: The results indicate that, although there some aspects of the information provided by the Brazilian official management protocol align with international clinical guidelines, there are substantial gaps, especially in the areas of health education and non-pharmacological interventions. This study may contribute to making more accurate information available on LBP, bringing primary care professionals in Brazil closer to evidence-based recommendations., (© 2024 John Wiley & Sons Ltd.)

Question: Do program and participant characteristics influence people's willingness to undertake exercise programs to prevent recurrence of low back pain?, Design: Discrete choice experiment., Participants: Six hundred and forty-seven people with a recent history of low back pain., Data Collection: Recruitment and participation occurred online. Participants were randomised to a block of 10 choice tasks, where the characteristics of the exercise program varied systematically. The characteristics that were presented for each exercise program were mode of exercise delivery, mode of supervision, setting, duration, weekly frequency, travel time, risk of recurrence, and costs. For each choice task, participants chose between no program or an exercise program with the characteristics as presented., Data Analysis: Choices were analysed using mixed logit models. Latent class models examined preference heterogeneity and identified participant-level characteristics predictive of preferences., Results: There appeared to be an underlying preference for exercise compared with no exercise, all else being equal. Preferences for programs were significantly influenced by the characteristics of the programs. Participants were less likely to choose exercise when programs were of a longer duration (OR 0.92, 95% CI 0.89 to 0.96 per extra month), but more likely to prefer programs offering greater reduction in the risk of recurrence of low back pain (OR 3.91, 95% CI 3.20 to 4.79 per 10% reduction in risk of recurrence). Preferences for engaging in exercise programs to prevent recurrent of low back pain were influenced by the characteristics of the programs themselves. However, there was mismatch between the preferred characteristics of exercise programs and the characteristics of known effective programs., Conclusion: People who have had low back pain should be advised explicitly about which exercise programs reduce recurrence. Understanding low back pain patients' preferences can help inform the implementation of existing prevention programs and guide the design of new prevention programs., (Copyright © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: One-size-fits-all interventions reduce chronic low back pain (CLBP) a small amount. An individualised intervention called cognitive functional therapy (CFT) was superior for CLBP compared with manual therapy and exercise in one randomised controlled trial (RCT). However, systematic reviews show group interventions are as effective as one-to-one interventions for musculoskeletal pain. This RCT investigated whether a physiotherapist-delivered individualised intervention (CFT) was more effective than physiotherapist-delivered group-based exercise and education for individuals with CLBP., Methods: 206 adults with CLBP were randomised to either CFT (n=106) or group-based exercise and education (n=100). The length of the CFT intervention varied according to the clinical progression of participants (mean=5 treatments). The group intervention consisted of up to 6 classes (mean=4 classes) over 6-8 weeks. Primary outcomes were disability and pain intensity in the past week at 6 months and 12months postrandomisation. Analysis was by intention-to-treat using linear mixed models., Results: CFT reduced disability more than the group intervention at 6 months (mean difference, 8.65; 95% CI 3.66 to 13.64; p=0.001), and at 12 months (mean difference, 7.02; 95% CI 2.24 to 11.80; p=0.004). There were no between-group differences observed in pain intensity at 6 months (mean difference, 0.76; 95% CI -0.02 to 1.54; p=0.056) or 12 months (mean difference, 0.65; 95% CI -0.20 to 1.50; p=0.134)., Conclusion: CFT reduced disability, but not pain, at 6 and 12 months compared with the group-based exercise and education intervention. Future research should examine whether the greater reduction in disability achieved by CFT renders worthwhile differences for health systems and patients., Trial Registration Number: ClinicalTrials.gov registry (NCT02145728)., Competing Interests: Competing interests: MO received payments in 2016 for providing a professional development workshop and lecture for clinicians in the individualised multidimensional intervention (CFT) examined in this trial. KO and PO receive payments for CFT workshops and lectures. MO, PO and KO have written editorials and viewpoints which encourage the use of CFT, or its principles, in clinical practice., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Workers with low back pain (LBP) frequently seek care from physiotherapists. We sought to identify patterns of physiotherapy attendance and factors associated with these patterns in Australian workers with accepted compensation claims for LBP. We included workers with accepted workers' compensation claims for LBP from 4 Australian states between 2011 and 2015. We used trajectory modelling to identify distinct groups of workers based on the number (ie, volume) of monthly physiotherapy attendances over a 2-year period from claim acceptance. Descriptive statistics and logistic regression models were used to compare the characteristics of the groups. A small but significant proportion attend numerous times over a long period. 79.0% of the sample (N = 22,767) attended physiotherapy at least once in the 2 years after claim acceptance. Among these, trajectory modelling identified 4 distinct patterns of attendance. Most (N = 11,808, 51.9%) recorded a short-term low-volume pattern, 26.8% (n = 6089) recorded a short-term high-volume pattern, 14.3% (n = 3255) recorded a long-term low-volume pattern, and 7.1% (n = 1615) recorded a long-term high-volume pattern. Workers from Victoria (OR 0.34, 99% CI 0.31, 0.37), South Australia (OR 0.69, 99% CI 0.60, 0.80), and Western Australia (OR 0.79, 99% CI 0.69, 0.88) were significantly less likely to attend physiotherapy than workers from Queensland. Victorian workers were significantly more likely to be in one of the 2 long-term trajectory groups (OR 8.17, 99% CI 6.86, 9.73; OR 18.68, 99% CI 13.57, 25.70). In conclusion, most compensated Australian workers with LBP attend physiotherapy. Significant interjurisdictional differences between attendance patterns suggests that policy may play an important role in healthcare delivery., (Copyright © 2024 International Association for the Study of Pain.)

Background: Low back pain (LBP) poses a significant global health burden where a biopsychosocial model of care has been recommended. Physiotherapists (PTs) play a crucial role in LBP management; however, their attitudes and beliefs towards LBP were not reviewed in detail., Objective: This systematic review aims to summarise the attitudes and beliefs of PTs towards LBP and the factors influencing them., Methods: The review protocol and methods adhere to the PRISMA-P and Meta Analyses and Systematic Reviews for Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search of PubMed, Scopus, CINAHL, Web of Science, PEDro and Ovid databases will be conducted to search for cross-sectional studies evaluating PTs' attitudes and beliefs towards LBP. Two reviewers will independently screen the articles, conduct data extraction and assess methodological quality using the Joanna Briggs Institute's critical appraisal tool for prevalence studies. Data synthesis will involve a narrative synthesis of study characteristics, attitudes, beliefs, and methodological quality. If feasible, a meta-analysis will be performed to quantify the pooled effects., Conclusion: Despite the emphasis on biopsychosocial approaches for managing LBP, the adoption of such approaches in physiotherapy practice is still suboptimal, with attitudes and beliefs of PTs being considered an important factor influencing treatment practices. Our review will summarise the literature on attitudes and beliefs of PTs towards LBP. Such knowledge would inform the need for development of additional interventions addressing the attitudes and beliefs that would eventually enhance the update of the biopsychosocial model of care in physiotherapy management of LBP., (© 2024 John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared. Disclosure of conflicts of interest form(s) are published online as supplementary files.

Background: Low back pain (LBP) affects millions of people worldwide, and misconceptions about effective treatment options for this condition are very common. Websites sponsored by organizations recognized as trustworthy by the public, such as government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations are an important source of health information for many people. However, the content of these websites regarding treatment recommendations for LBP has not been fully evaluated., Objective: This study aimed to determine the credibility, accuracy, and comprehensiveness of treatment recommendations for LBP in noncommercial, freely accessible websites., Methods: We conducted a systematic review of websites from government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations. We conducted searches on Google. Treatment recommendations were coded based on the 2016 National Institute for Health and Care Excellence (NICE) guidelines and the 2017 American College of Physicians guideline on LBP. Primary outcomes were credibility of the website (4-item Journal of the American Medical Association benchmark), accuracy (proportion of website treatment recommendations that were appropriate), and comprehensiveness of website treatment recommendations (proportion of guideline treatment recommendations that were appropriately covered by a website)., Results: We included 79 websites from 6 English-speaking countries. In terms of credibility, 31% (25/79) of the websites clearly disclosed that they had been updated after the publication of the NICE guidelines. Only 43.28% (487/1125) website treatment recommendations were judged as accurate. Comprehensiveness of treatment recommendations correctly covered by websites was very low across all types of LBP. For acute LBP, an average of 28% (4/14) guideline recommendations were correctly covered by websites. Websites for radicular LBP were the least comprehensive, correctly covering an average of 16% (2.3/14) recommendations., Conclusions: Noncommercial freely accessible websites demonstrated low credibility standards, provided mostly inaccurate information, and lacked comprehensiveness across all types of LBP., (©Giovanni Ferreira, Adrian C Traeger, Gustavo Machado, Mary O'Keeffe, Christopher G Maher. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.05.2019.)

Objective: To determine patterns of physiotherapy and opioid use among compensated workers with low back pain (LBP), factors associated with these, and their association with time loss., Methods: Accepted Victorian and South Australian workers' compensation claims, services, and medicines data for LBP claims lodged June 30, 2010-July 1, 2015. Descriptive statistics, multinomial logistic, and Cox regression were used to determine usage groups, their predictors, and effect of these on time loss., Results: Of 15,728 claims, 24.4% received no services, 3.6% received opioids only, 43.3% received physiotherapy only, and 28.8% received both opioids and physiotherapy. Sex, age, occupation, remoteness, jurisdiction, and socioeconomic status were significantly associated with usage groups. Using opioids and physiotherapy had the longest time loss., Conclusions: Any services/medicine usage was associated with increased time loss and was longest for combined physiotherapy and opioids., Competing Interests: Conflicts of Interest: None declared., (Copyright © 2024 American College of Occupational and Environmental Medicine.)

Background: The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process., Aim: Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management., Design: Scoping review., Method: This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories., Results: After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors., Conclusions: The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour., (© 2024 The Author(s). Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: This study investigated the impact of Chronic Low Back Pain (CLBP) on individuals' physical activity (PA) behaviours, specifically, how they modify, cease, or continue PA when experiencing CLBP. The primary aim was to explore the relationship between CLBP and PA and how this is influenced in different contexts (e.g., necessity of a task)., Methods: A mixed-methods survey was administered to 220 participants, including self-reported outcomes, and capturing responses to three distinct questions related to PA and CLBP. The data was analysed via a content analysis., Results: The findings revealed that individuals with CLBP are most likely to modify PA in work-related contexts and least likely to cease it in the same setting. Housework emerged as the most common domain for cessation of PA, while work/study activities were predominantly continued. Reasons for these trends were typically task-based rather than health or enjoyment based and influenced by the perceived necessity of the task in question., Conclusion: The study highlights the role of occupational and educational settings in individual responses to CLBP. The findings also highlight a gap in public awareness regarding effective CLBP management strategies, emphasising the need for increased education and awareness programs., (© 2024 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Objective: To evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain., Introduction: Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low-dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP)., Inclusion Criteria: Randomized controlled trials that evaluate low-dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary-based rehabilitation (MBR) were excluded., Methods: Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13-item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed., Systematic Review Registration Number: PROSPERO 2022 CRD42022302771., Results: Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta-analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post-treatment (standardized mean difference (SMD) = -1.09, 95% confidence interval (CI) = -1.84 to -0.34, I 2  = 97%, p = 0.004) as well as at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I 2  = 0%, p = 0.004), long term (SMD = -0.79, 95% CI = -1.42 to -0.17, I 2  = 96%, p = 0.01) and very long-term (SMD = -1.13, 95% CI = -1.93 to -0.33, I 2  = 94%, p = 0.005) follow-up. Significant effects in favor of PCBI for physical function were found post-treatment (SMD = -1.33, 95% CI = -2.17 to -0.49, I 2  = 97%, p = 0.002) at short-term (SMD = -0.20, 95% CI = -0.36 to -0.04, I 2  = 0%, p = 0.01) and at long-term follow-up (SMD = -1.17, 95% CI = -2.06 to -0.28, I 2  = 98%, p = 0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain-neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3-12 weeks) and contact times (2-15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I 2  = 0%, p = 0.004) and long-term follow-up (SMD = -0.22, 95% CI = -0.41 to -0.03, I 2  = 39%, p = 0.02)., Conclusions: This meta-analysis suggests that low-dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta-analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low-dosed) CLBP interventions., (© 2023 The Authors. Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.)

Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach - Cognitive Functional Therapy - which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual's disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

Abstract: Cognitive functional therapy (CFT) is a physiotherapy-led intervention that has evolved from an integration of foundational behavioral psychology and neuroscience within the physiotherapist practice directed at the multidimensional nature of chronic low back pain (CLBP). The current evidence about the comparative effectiveness of CFT for CLBP is still scarce. We aimed to investigate whether CFT is more effective than core training exercise and manual therapy (CORE-MT) in pain and disability in patients with CLBP. A total of 148 adults with CLBP were randomly assigned to receive 5 one-hour individualized sessions of either CFT (n = 74) or CORE-MT (n = 74) within a period of 8 weeks. Primary outcomes were pain intensity (numeric pain rating scale, 0-10) and disability (Oswestry Disability Index, 0-100) at 8 weeks. Patients were assessed preintervention, at 8 weeks and 6 and 12 months after the first treatment session. Altogether, 97.3% (n = 72) of patients in each intervention group completed the 8 weeks of the trial. Cognitive functional therapy was more effective than CORE-MT in disability at 8 weeks (MD = -4.75; 95% CI -8.38 to -1.11; P = 0.011, effect size= 0.55) but not in pain intensity (MD = -0.04; 95% CI -0.79 to 0.71; P = 0.916). Treatment with CFT reduced disability, but the difference was not clinically important compared with CORE-MT postintervention (short term) in patients with CLBP. There was no difference in pain intensity between interventions, and the treatment effect was not maintained in the mid-term and long-term follow-ups., (Copyright © 2022 International Association for the Study of Pain.)

Abstract: To individually prescribe rehabilitation contents, it is of importance to know and quantify factors for rehabilitation success and the risk for a future healthcare use. The objective of our multivariable prediction model was to determine factors of rehabilitation success and the risk for a future healthcare use in patients with high-grade, chronic low back pain. We included members of the German pension fund who participated from 2012 to 2019 in multimodal medical rehabilitation with physical and psychological treatment strategies because of low back pain (ICD10:M54.5). Candidate prognostic factors for rehabilitation success and for a future healthcare use were identified using Gradient Boosting Machines and Random Forest algorithms in the R-package caret on a 70% training and a 30% test set. We analysed data from 154,167 patients; 8015 with a second medical rehabilitation measure and 5161 who retired because of low back pain within the study period. The root-mean-square errors ranged between 494 (recurrent rehabilitation) and 523 (retirement) days ( R2 = 0.183-0.229), whereas the prediction accuracy ranged between 81.9% for the prediction of the rehabilitation outcome, and 94.8% for the future healthcare use prediction model. Many modifiable prognostic factors (such as duration of the rehabilitation [inverted u-shaped], type of the rehabilitation, and aftercare measure), nonmodifiable prognostic factors (such as sex and age), and disease-specific factors (such as sick leave days before the rehabilitation [linear positive] together with the pain grades) for rehabilitation success were identified. Inpatient medical rehabilitation programmes (3 weeks) may be more effective in preventing a second rehabilitation measure and/or early retirement because of low back pain compared with outpatient rehabilitation programs. Subsequent implementation of additional exercise programmes, cognitive behavioural aftercare treatment, and following scheduled aftercare are likely to be beneficial., (Copyright © 2023 International Association for the Study of Pain.)

Background: Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions., Objective: To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high-value interventions on the management of non-specific low back pain., Design: Scoping review., Methods: We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non-specific low back pain., Results: Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high-income countries including, the United States, Canada and UK. Twenty-six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors., Conclusion: Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed., (© 2021 John Wiley & Sons Ltd.)

Objectives: To investigate the efficacy of interventions for the prevention and treatment of low back pain in nurses., Design: Systematic review., Data Sources: The review was registered on the PROSPERO database (CRD42015026941) and followed the PRISMA statement guidelines. A two phase approach was used. In phase one, all randomised controlled trials included in the systematic review of Dawson et al. (2007) which reviewed interventions for low back pain in nurses until 2004 were selected. In phase two, relevant randomised controlled trials and cluster randomised controlled trials published from 2004 until December 2015 were identified by an electronic search of nine databases (Embase, CINAHL, SPORTDiscus, PsycARTICLES, Cochrane Library, Web of Science, PEDro, Scopus and MEDLINE). To be eligible, trials had to examine the efficacy of interventions either for the prevention or treatment of low back pain in nurses. Primary outcomes of interest were any measure of pain and/or disability., Review Methods: Three reviewers independently assessed eligibility and two reviewers independently conducted a risk of bias assessment (Cochrane Back and Neck Group)., Results: Four studies were retrieved from phase one. In phase two, 15,628 titles and abstracts were scanned. From these, 150 full-text studies were retrieved and ten were eligible. Fourteen studies (four from phase one, ten from phase two) were eligible for risk of bias assessment. The included trials were highly heterogeneous, differing in pain and disability outcome measures, types of intervention, types of control group and follow-up durations. Only four of the included studies (n=644 subjects) had a low risk of bias (≥6/12). Manual handling training and stress management in isolation were not effective in nurses with and without low back pain (risk of bias, 7/12, n=210); the addition of a stretching exercise intervention was better than only performing usual activities (risk of bias, 6/12, n=127); combining manual handling training and back school was better than passive physiotherapy (risk of bias, 7/12, n=124); and a multidimensional intervention (risk of bias, 7/12, n=183) was not superior to a general exercise program in reducing low back pain in nurses., Conclusions: Only four relevant low risk of bias randomised controlled trials were found. At present there is no strong evidence of efficacy for any intervention in preventing or treating low back pain in nurses. Additional high quality randomised controlled trials are required. It may be worth exploring the efficacy of more individualised multidimensional interventions for low back pain in the nursing population., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: The objective of the review is to map the content of intervention education in people with acute nonspecific lumbar low back pain (LBP) to make it available in a synopsis., Background: In the care of people with acute non-specific LBP, education is recommended as an elementary treatment component. However, the proposed content is proving to be heterogenic and the question arises as to how education should be designed in the future., Method: A systematic literature search and content analysis of studies with content on pain education was conducted as part of a scoping review. Inclusion criteria were: provision of relevant information on the content of pain education, patients with acute nonspecific low back pain, 18 years or older, publication in English or German. The search was conducted in the Medline, CINAHL, Cochrane Library, and PEDro databases and supplemented by a hand search. The search was completed in February 2021., Results: A total of 4239 hits were identified, of which 90 studies were included. A wide range of content was found and clustered into ten categories. The most frequent statements were in the categories "recommendations for dealing with LRS," "education, reassuring aspects, and relieving basic messages," and "information and recommendations about medications.", Conclusion: The teaching of pathoanatomical information can potentially trigger or increase anxiety and worry, whereas information on neurophysiological mechanisms of pain development and processing is more likely to have an anxiety-reducing effect. The results can contribute to the design of the intervention in different settings., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain., Methods: Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements., Results: In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources., Conclusions: This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention., (© 2024. The Author(s).)

Introduction: Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high-value interventions in the management of non-specific LBP., Methods: This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand-searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim., Ethics and Dissemination: This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non-specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics., (© 2021 John Wiley & Sons Ltd.)

Background: Many people with non-specific chronic low back pain (NSCLBP) do not recover with current conventional management. Systematic reviews show multidimensional treatment improves pain better than usual active interventions. It is unclear whether multidimensional physiotherapy improves pain better than usual physiotherapy. This study determines the effectiveness of this treatment to reduce pain and disability and improve quality of life, pain cognitions, and electroencephalographic pattern in individuals with NSCLBP., Methods: 70 eligible participants aged 18 to 50 years with NSCLBP were randomized into either the experimental group (multidimensional physiotherapy) or the active control group (usual physiotherapy). Pain intensity was measured as the primary outcome. Disability, quality of life, pain Catastrophizing, kinesiophobia, fear Avoidance Beliefs, active lumbar range of motion, and brain function were measured as secondary outcomes. The outcomes were measured at pre-treatment, post-treatment, 10, and 22 weeks. Data were analyzed using intention-to-treat approaches., Results: There were 17 men and 18 women in the experimental group (mean [SD] age, 34.57 [6.98] years) and 18 men and 17 women in the active control group (mean [SD] age, 35.94 [7.51] years). Multidimensional physiotherapy was not more effective than usual physiotherapy at reducing pain intensity at the end of treatment. At the 10 weeks and 22 weeks follow-up, there were statistically significant differences between multidimensional physiotherapy and usual physiotherapy (mean difference at 10 weeks, -1.54; 95% CI, -2.59 to -0.49 and mean difference at 22 weeks, -2.20; 95% CI, - 3.25 to - 1.15). The standardized mean difference and their 95% confidence intervals (Cohen's d) revealed a large effect of pain at 22 weeks: (Cohen's d, -0.89; 95% CI (-1.38 to-0.39)). There were no statistically significant differences in secondary outcomes., Conclusions: In this randomized controlled trial, multidimensional physiotherapy resulted in statistically and clinically significant improvements in pain compared to usual physiotherapy in individuals with NSCLBP at 10 and 22 weeks., Trial Registration: ClinicalTrials.gov NCT04270422; IRCT IRCT20140810018754N11., (© 2023. The Author(s).)

Background: Orthopaedists are often the first point of contact for patients who present with low back pain (LBP) and chronic LBP in Brazil., Aim: To explore the views of orthopaedists on therapeutic approaches for chronic non-specific low back pain (CNLBP) with a view to gain insights into aspects of clinical practice considered important to them., Methods: A qualitative design underpinned by interpretivism was employed. Participants were (n = 13) orthopaedists with experience in treating patients with CNLBP. Following the pilot interviews, semi-structured interviews were conducted, audio-recorded, transcribed and de-identified. Interview data were thematically analysed., Results: Four themes were identified. (1) Biophysical aspects are important and predominate, but sometimes their relevance can be unclear; (2) Psychosocial aspects and lifestyle factors influence the therapeutic approach; (3) Treatment of CNLBP - including medication, physical activity, surgery and other invasive procedures and other therapeutic modalities; and (4) Nuances of clinical practice - "it goes beyond medicine"., Conclusion: Brazilian orthopaedists value identifying the biophysical cause(s) of chronic low back pain. Psychological factors were often discussed secondary to biophysical aspects, whereas social aspects were rarely mentioned. Orthopaedists highlighted their difficulties in navigating patients' emotions and reassuring patients without referrals to imaging tests. Orthopaedists may benefit from training that targets communication and other relational aspects of care in order to work with people who present with CNLBP., (© 2023 John Wiley & Sons Ltd.)

Chronic pain is the most common cause of impaired work ability and thus represents a significant social and economic burden. STarT Back Screening Tool (SBT) is the most often used screening tool for rapid identification and classification of patients for their risk of development of chronic low back pain, which is valid and reliable in the original English version and translation into other languages. The aim of the present study was to translate the SBT into Slovenian and to evaluate its content validity and reliability. We translated the SBT from English into Slovenian and back according to the standard protocol. We tested its metric properties on a group of patients with low back pain aged 18 to 65 years. The reliability of the reassessment was calculated using the ICC and specific agreement, while the content validity of the questionnaire was determined using the ceiling and floor effect. Of the 42 patients who participated in the study, 42.9% were at low risk, 33.3% were at moderate risk, and 23.8% were at high risk of developing chronic pain, according to the SBT. The ICC for the entire sample was 0.96 (95% CI 0.92-0.98). The Slovenian translation of the SBT showed excellent specific agreement between the initial and repeat assessments: 91.4% for the low-risk group, 85.7% for the moderate-risk group, and 95.2% for the high-risk group. In addition, it showed good content validity, as no ceiling or floor effects were detected. The Slovenian translation of the questionnaire is suitable for clinical use., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)