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Background: Moderately vigorous physical activity (PA) may be beneficial for people with sub-acute low back pain (LBP), but may initially be painful for patients and challenging for physical therapists to facilitate., Objectives: This study investigated motivational interviewing (MI) delivered by physical therapists and a smartphone app for increasing PA in people with LBP., Methods: A mixed methods cluster randomised controlled trial involving 46 adults with LBP in Melbourne, Australia. Participants attended weekly 30-min physical therapy consultations for 6 weeks. Experimental group physical therapists were taught to embed MI into consultations and patients were provided with a self-directed app. The primary outcome was accelerometer-derived moderately vigorous PA. Secondary outcomes were LBP disability (Oswestry Disability Index), functional capacity (Patient Specific Functional Scale), and self-efficacy (Pain Self-Efficacy Questionnaire). Between-group differences were analysed by ANCOVA post-intervention., Results: There was no statistically significant difference between the experimental group and control group for PA. Between-group differences in LBP disability (MD= 19.4 units, 95% CI: 8.5, 30.3), functional capacity (primary MD= -4.1 units, 95% CI: -6.9, -1.3; average MD= -3.1, 95% CI: -4.9, -1.2) and self-efficacy (MD -11.3 units, 95%CI -20.2, -2.5) favoured the control group with small to moderate effect sizes. There were low levels of overall engagement with the app., Conclusion: The embedded MI intervention was no more beneficial than physical therapy alone for PA and was associated with poorer LBP disability, function, and self-efficacy. The effectiveness of embedding MI and a smartphone app into usual care for LBP was not supported., Competing Interests: Conflicts of Interest The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy., Objectives: To determine the association between: the presence of DRAM and low back pain, lumbo-pelvic pain, incontinence, pelvic organ prolapse, abdominal muscle performance or health-related quality of life; and between DRAM width and severity of these outcomes., Data Sources: Six electronic databases (EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro)., Study Selection: Included studies of all designs with adults with DRAM that assessed low back pain, lumbo-pelvic pain incontinence, pelvic organ prolapse, abdominal performance or health-related quality of life., Study Appraisal & Synthesis Methods: Methodological quality was assessed using the Effective Public Health Practice Project tool. A narrative summary was completed for DRAM presence and presence of the various musculoskeletal dysfunctions, and DRAM width and the severity of these dysfunctions., Results: Twelve studies involving 2242 participants were included. There was no significant association between the presence of DRAM and lumbo-pelvic pain or incontinence. There was a small association between the presence of DRAM and pelvic organ prolapse. DRAM width may be associated with health-related quality of life, abdominal muscle strength and severity of low back pain., Limitations: Quality of studies was weak. There was variability in the methods used to assess DRAM., Conclusion: There is weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity. Systematic Review Registration Number: PROSPERO CRD42017058089., (Copyright © 2018 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objectives: To determine whether individualised manual therapy plus guideline-based advice results in superior outcomes to advice alone in participants with clinical features potentially indicative of lumbar zygapophyseal joint pain., Design: Multi centre parallel group randomised controlled trial., Setting: 14 physiotherapy clinics in Melbourne, Australia., Participants: Sixty-four participants with clinical features potentially indicative of lumbar zygapophyseal joint pain., Interventions: 10-weeks of physiotherapy comprising individualised manual therapy based on pathoanatomical, psychosocial and neurophysiological barriers to recovery plus guideline-based advice (10 sessions) or advice alone (two sessions)., Main Outcome Measures: Primary outcomes were activity limitation (Oswestry Disability Index), and separate 0 to 10 numerical rating scales for leg pain and back pain. Measures were taken at baseline and 5, 10, 26 and 52-week., Results: Between-group differences for back pain favoured individualised manual therapy over advice for back pain at 5 (1.0; 95% CI 0.6 to 2.0), 10 (1.5; 95% CI 0.5 to 2.4) and 26-weeks (1.4; 95% CI 0.4 to 2.3) as well as for activity limitation at 26 (8.3; 95% CI 2.6 to 14.2) and 52-weeks (8.2; 95% CI 2.3 to 14.2). There were no significant between-group differences for leg pain. Secondary outcomes and responder analyses also favoured individualised manual therapy at almost all time-points., Conclusions: In participants with clinical features potentially indicative of lumbar zygapophyseal joint pain, individualised manual therapy led to greater reduction in back pain at 5, 10 and 26-week follow-up as well as activity limitation at 26 and 52-weeks. Between-group differences were likely to be clinically important., Trial Registration: ACTRN12609000334202., (Copyright © 2018 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objective: To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs)., Design: Prospective inception cohort study., Setting: Primary care private physiotherapy clinics in Melbourne, Australia., Participants: Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration., Interventions: Not applicable., Main Outcome Measures: Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale., Results: Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome., Conclusions: This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Study Design: A preplanned effect modifier analysis of the Specific Treatment of Problems of the Spine randomized controlled trial., Objective: To identify characteristics associated with larger or smaller treatment effects in people with low back disorders undergoing either individualized physical therapy or guideline-based advice., Summary of Background Data: Identifying subgroups of people who attain a larger or smaller benefit from particular treatments has been identified as a high research priority for low back disorders., Methods: The trial involved 300 participants with low back pain and/or referred leg pain (≥6 wk, ≤6 mo duration), who satisfied criteria to be classified into five subgroups (with 228 participants classified into three subgroups relating to disc-related disorders, and 64 classified into the zygapophyseal joint dysfunction subgroup). Participants were randomly allocated to receive either two sessions of guideline based advice (n = 144), or 10 sessions of individualized physical therapy targeting pathoanatomical, psychosocial, and neurophysiological factors (n = 156). Univariate and multivariate linear mixed models determined the interaction between treatment group and potential effect modifiers (defined a priori) for the primary outcomes of back pain, leg pain (0-10 Numeric Rating Scale) and activity limitation (Oswestry Disability Index) over a 52-week follow-up., Results: Participants with higher levels of back pain, higher Örebro scores (indicative of higher risk of persistent pain) or longer duration of symptoms derived the largest benefits from individualized physical therapy relative to advice. Poorer coping also predicted larger benefits from individualized physical therapy in the univariate analysis., Conclusion: These findings suggest that people with low back disorders could be preferentially targeted for individualized physical therapy rather than advice if they have higher back pain levels, longer duration of symptoms, or higher Örebro scores., Level of Evidence: 2.

Study Design: A cost-utility analysis within a randomized controlled trial was conducted from the health care perspective., Objective: The aim of this study was to determine whether individualized physical therapy incorporating advice is cost-effective relative to guideline-based advice alone for people with low back pain and/or referred leg pain (≥6 weeks, ≤6 months duration of symptoms)., Summary of Background Data: Low back disorders are a burdensome and costly condition across the world. Cost-effective treatments are needed to address the global burden attributable to this condition., Methods: Three hundred participants were randomly allocated to receive either two sessions of guideline-based advice alone (n = 144), or 10 sessions of individualized physical therapy targeting pathoanatomical, psychosocial and neurophysiological factors, and incorporating advice (n = 156). Data relating to health care costs, health benefits (EuroQol-5D) and work absence were obtained from participants via questionnaires at 5, 10, 26, and 52-week follow-ups., Results: Total health care costs were similar for both groups: mean difference $27.03 [95% confidence interval (95% CI): -200.29 to 254.35]. Health benefits across the 12-month follow-up were significantly greater with individualized physical therapy: incremental quality-adjusted life years = 0.06 (95% CI: 0.02-0.10). The incremental cost-effectiveness ratio was $422 per quality-adjusted life year gained. The probability that individualized physical therapy was cost-effective reached 90% at a willingness-to-pay threshold of $36,000. A saving of $1995.51 (95% CI: 143.98-3847.03) per worker in income was realized in the individualized physical therapy group relative to the advice group. Sensitivity and subgroup analyses all revealed a dominant position for individualized physical therapy; hence, the base case analysis was the most conservative., Conclusion: Ten sessions of individualized physical therapy incorporating advice is cost-effective compared with two sessions of guideline-based advice alone for people with low back disorders., Level of Evidence: 2.

Background: Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders., Methods: This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models., Results: Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone., Conclusions: 10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant., Clinical Trial Registration: ACTRN12609000834257., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: A health coaching intervention in addition to usual physiotherapy care increased recovery expectation and activity in people with non-chronic NSLBP and low recovery expectation., Objective: We aimed to fully describe the coaching intervention to allow replication and enable a deeper understanding of the mechanisms behind health coaching in this setting., Methods: A qualitative analysis was conducted using notes taken by the coach during the health coaching intervention. Two researchers independently applied open coding and content analysis, using the factors of low recovery expectation identified in a previous qualitative investigation as a framework., Results: For the majority of participants coaching rapidly progressed to goal setting and action planning, with less time spent on increasing the importance and confidence to return to activity. The factors of the person, progression, pain, performance and treatment were addressed across all phases of the coaching intervention., Conclusion: This effective health coaching intervention for people with non-chronic NSLBP and low recovery expectation concentrated on goal setting and action planning and addressed the essential factors of recovery expectations. This study suggests that coaching interventions are likely to be different in this population compared to similar interventions in chronic conditions due to pre-existing levels of readiness to change.

Objective: Low recovery expectations have been identified as a strong and consistent predictor of poor outcome in non-chronic non-specific low back pain (NSLBP). The aim of this study was to explore how people determine their own recovery expectation during an episode of non-chronic NSLBP., Subjects and Methods: In-depth interviews were conducted with a purposive sample of people with non-chronic NSLBP and low recovery expectations. Interviews were audio--recorded and transcribed verbatim. Two researchers independently applied open coding, followed by axial coding to allow themes to emerge from the data using a constant comparison method., Results: The central theme of the person and 4 subthemes of pain, progress, performance, and treatment emerged from the data. The formation of recovery expectations was dependent on the person's unique apprasial of their pain, how the condition had progressed, the limitation of their performance of activities, and the impact of different aspects of treatment., Conclusion: Recovery expectation is a person's appraisal of several factors to determine when they are likely to return to their usual activities during an episode of non-chronic NSLBP. Health professionals should explore the person's perception of these factors as part of a tailored intervention to prevent non-chronic NSLBP progressing to chronic NSLBP.

Background: Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond., Objectives: To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy., Data Sources: A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity., Results: Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low., Conclusions: This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups., Methods/design: A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes., Discussion: This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder., Trial Registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.

Question: Does the addition of telephone coaching to usual physiotherapy care improve activity for people with non-chronic low back pain and low to moderate recovery expectations?, Design: Randomised trial with concealed allocation and intention-to-treat analysis., Participants: People attending the physiotherapy department of a public hospital for treatment within eight weeks of onset of non-specific low back pain. Eligible participants had low to moderate recovery expectations, defined as a response of 7 or less to the question 'How certain are you that you will return to all of your usual activities one month from today?' on a scale from 0 (not certain at all) to 10 (completely certain)., Intervention: Five sessions of telephone coaching by a physiotherapist trained in health coaching techniques in addition to usual physiotherapy compared to usual physiotherapy alone., Outcome Measures: The Patient Specific Functional Scale, Oswestry Disability Index, Pain Self Efficacy Questionnaire, and recovery expectation were measured at baseline, 4, and 12 weeks., Results: 30 participants were recruited, with 26 completing all measures at 12 weeks. There were no significant differences between groups at 4 weeks. After 12 weeks the coaching group improved significantly more than the control group on two 10-point scales: the Patient Specific Functional Scale (mean difference 3.0 points, 95% CI 0.7 to 5.4) and recovery expectation (mean difference 3.4 points, 95% CI 1.1 to 5.7). Estimates of effect sizes were moderate to large in favour of the intervention., Conclusion: The addition of telephone health coaching to usual physiotherapy care for people with non-chronic non-specific low back pain led to clinically important improvements in activity and recovery expectation., Trial Registration: ACTRN12607000458437., (Copyright © 2011 Australian Physiotherapy Association. Published by .. All rights reserved.)

Objective: The aim of the current review was to determine the predictive strength of low recovery expectations for activity limitation outcomes in people with non-chronic NSLBP., Methods: A systematic review of prognostic studies was performed. Included studies took baseline measures in the non-chronic phase of NSLBP, included at least one baseline measure of recovery expectation, defined as a prediction or judgement made by the person with NSLBP regarding any aspect of prognosis, and studied a sample with at least 75% of participants with NSLBP., Results: Recovery expectations measured using a time-based, specific single-item tool produced a strong prediction of work outcome. Recovery expectations measured within 3 weeks of NSLBP onset provide a strong prediction of outcome. It is not clear whether predictive strength of recovery expectations is affected by the length of time between the expectation measure and outcome measure., Conclusion: Recovery expectations when measured using a specific, time-based measure within the first 3 weeks of NSLBP can identify people at risk of poor outcome.

This study investigated the assessment of acute (<12 weeks duration) nonspecific low back pain (NSLBP) by primary care clinicians. The aims were to determine the methods used, whether methods differ across professional disciplines, and the extent to which clinicians assess across domains of health. Survey data were gathered from 651 primary care clinicians from six professional disciplines (Physiotherapy, Manipulative Physiotherapy, Chiropractic, Osteopathy, General Medicine, and Musculoskeletal Medicine). Descriptive statistics (proportions and frequency of use distributions) were used to describe assessment technique use, Mann-Whitney U tests were used to determine between-discipline differences in the use of each assessment technique, and Bonferroni-adjusted inferential confidence intervals were constructed to allow visual comparison of the use of assessment techniques from five health domains. The results indicate that the methods used by different professional disciplines to assess NSLBP vary considerably, as 44 out of 48 assessment techniques showed significantly different utilisation rates across professions. Furthermore, assessment across domains of health in this condition was variable, as clinicians commonly assess physical impairments and pain and less commonly assess activity limitation and psychosocial function (100% of clinicians very frequently or often assess physical impairment, 99% [95%CI 98-100%] assess pain, 21% [95%CI 15-27%] assess activity limitation, and 7% [95%CI 3-11%] assess psychosocial function). Adoption of greater standardisation of assessment by clinicians may require demonstration of the capacity of this standardisation to improve patient outcomes.

Objectives: To identify psychosocial predictors of failure to return to work in non-chronic (lasting less than 3 months) non-specific low back pain (NSLBP)., Methods: A systematic review of prognostic studies was carried out. Medline, Embase, PsychINFO, CINAHL and PEDro electronic bibliographic databases up to April 2006 were searched. Included studies took baseline measures in the non-chronic phase of NSLBP (ie, within 3 months of onset), included at least one psychosocial variable and studied a sample in which at least 75% of participants had NSLBP. Baseline measures had to be used to predict at least one work-specific outcome., Results: The search identified 24 studies meeting the inclusion criteria. From these studies there is strong evidence that recovery expectation is predictive of work outcome and that depression, job satisfaction and stress/psychological strain are not predictive of work outcome. There is moderate evidence that fear avoidance beliefs are predictive of work outcome and that anxiety is not predictive of work outcome. There is insufficient evidence to determine whether compensation or locus of control are predictive of work outcome., Conclusions: To predict work outcome in non-chronic NSLBP, psychosocial assessment should focus on recovery expectation and fear avoidance. More research is needed to determine the best method of measuring these constructs and to determine how to intervene when a worker has low recovery expectations.

Little is known about self-selected speed and fast walking in people with acute low back pain. This study aimed to investigate (1) the strategies that people with acute low back pain use to change from self-selected speed to fast walking and (2) the effect of a period of treadmill walking on level of back pain. Eight participants with acute low back pain and eight matched control participants were evaluated during self-selected speed and fast walking on a treadmill. The eight participants with back pain were retested 6 weeks later when pain had resolved. Measurements were taken of (1) three-dimensional angular movements of the pelvis and lumbar spine using a videoanalysis system, (2) the timing and distance parameters of walking, and (3) pain levels as measured by a visual analogue scale. We found that to walk faster, those with acute low back pain increased stride length and the frontal plane movements of pelvic list and lumbar lateral flexion (pelvis) to a greater extent than when symptoms had resolved. We also found that 10 min of treadmill walking at self-selected speed led to a reduction in the level of back pain and that there was a high degree of negative correlation between level of back pain and stride length. An additional 5 min of fast walking did not lead to any further changes in level of back pain. These findings support clinical recommendations that the moderate physical activity of walking may be beneficial in the management of people with acute low back pain. To walk faster, people with acute low back pain may utilise strategies that had been limited at self-selected speed, without any increase in pain.

Palpating a nominated spinal level is a prerequisite to more complex tasks such as palpating the level most likely to be the source of the patient's symptoms. The aim of this study was to investigate the reliability of physiotherapists with a post-graduate qualification in manipulation (manipulative physiotherapists) in palpating the lumbar spines of patients in a clinical setting. Three pairs of manipulative physiotherapists palpated the randomly-nominated lumbar spinal levels of 20 patients presenting to their practices for treatment of low-back pain. Each therapist marked the skin overlying the spinous process of the nominated spinal level with an ultraviolet pen and these marks were transcribed onto transparencies for analysis. The therapists obtained an overall weighted kappa of 0.92 indicating almost perfect agreement for locating the nominated spinal level. The results of this study indicate that manipulative physiotherapists can reliably palpate nominated lumbar spinal levels, suggesting further training in spinal therapy enhances the palpatory skills of physiotherapists in palpating nominated lumbar spinal levels.