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STUDY DESIGN Observational cohort design involving measurement property assessment. OBJECTIVES The aim of this study was to assess construct validity through hypothesis testing and to examine reliability and discrimination of the PROMIS-29 v2.0 using item response theory (IRT) analyses. SUMMARY OF BACKGROUND DATA Patient-Reported Outcomes Measurement Information System (PROMIS) 29.0 version 2.0 includes 28 questions for the seven domains of Physical function, Anxiety, Depression, Fatigue, Sleep disturbance, Social role, and Pain interference, and one item related to pain intensity. To date, the tool has not been tested for construct validity for selected concepts, nor has it been evaluated using IRT in a population of spine surgery recipients. METHODS Using the Quality Outcomes Dataset lumbar registry, we evaluated the construct validity of the PROMIS-29 v2.0 against pain intensity measures for back and leg, the Oswestry Disability Index, the EQ5D 3L-visual analog scale (quality of life) and proxy measures of activities, mobility and self-care. IRT was used to test PROMIS-29 v2.0 assumptions and fit. RESULTS The sample included 652 surgery recipients (mean age = 60.1, SD = 14.0) who had a high level of baseline disability. Hypothesis testing confirmed direction and magnitude of correlation between the PROMIS and legacy measures in 10 of the 12 hypotheses. IRT identified three misfit items, but otherwise adequate scale reliability and unidimensionality. CONCLUSION The PROMIS-29 v2.0 measures several different constructs pertinent to a patient's health and recovery during spine surgery. We feel that the PROMIS-29 v2.0 tool is a useful and effective outcome measure for populations who receive spine surgery.Level of Evidence: 4.

Introduction: Employment status plays an essential role as a social determinant of health. Unemployed are more likely to have a longer length of hospital stay and a nearly twofold greater rate of 30 day readmission than those who were well employed at the time of back surgery. This study aimed to investigate whether employment status influenced post-surgery outcomes and if so, the differences were clinically meaningful among groups. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Registry. Data refinement was used to isolate individuals 18 to 64 who received primary spine surgeries and had a designation of employed, unemployed, or disabled. Outcomes included 12 and 24 month back and leg pain, disability, patient satisfaction, and quality of life. Differences in descriptive variables, comorbidities, and outcomes measures (at 12 and 24 months) were analyzed using chi-square and linear mixed-effects modeling. When differences were present among groups, we evaluated whether they were clinically significant or not. Results: Differences (between employed, unemployed, and disabled) among baseline characteristics and comorbidities were present in nearly every category (p

Background Patient experience is an important component of quality and patient centered health care not fully explored in physical therapy. Main body This article addresses (1) concept of patient experience, (2) importance of capturing the patient experience, (3) measures to capture patient experience and whether these measures exhibit psychometrically sound measurement properties, (4) relationship between patient experience and clinical effectiveness outcomes, and (5) clinical applications of patient experience measures in the outpatient physical therapy setting, including suggestions for future studies. Short conclusion Employing patient experience measures into physical therapy practice may be an important key to improve clinical effectiveness outcomes and provide excellent patient-centered care delivery. An area of continued research should be focused on demonstrating the generalizability and measurement properties of patient reported experience measures for the musculoskeletal outpatient physical therapy population focusing first on the most common musculoskeletal conditions such as cervical, low back, and shoulder pain.

Overcoming overuse in musculoskeletal health care requires an understanding of its drivers. In this, the third article in a series on "Overcoming Overuse" of musculoskeletal health care, we consider the drivers of overuse under 4 domains: (1) the culture of health care consumption, (2) patient factors and experiences, (3) clinician factors and experiences, and (4) practice environment. These domains are interrelated, interact, and influence the clinician-patient interaction. We map drivers to potential solutions to overcome overuse.

To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect.Intervention systematic review with meta-analysis and meta-regression.An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain.We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability.Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes.Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain.

STUDY DESIGN This is an observational study on the measurement properties of the Oswestry Disability Index (ODI) version 1.0. OBJECTIVES To (1) determine the construct validity of the tool, specifically structural validity; (2) analyze the criterion validity of the tool, specifically concurrent validity against proxy measures of pain, function, and quality of life and predictive validity of each item to proxy measures of disability; and (3) reliability of the tool, specifically internal consistency. SUMMARY OF BACKGROUND DATA We endeavored to investigate the measurement properties of the ODI on a spine surgery population to test the assumption that a more disabled population may influence the properties of the tool. METHODS Data were pulled from the Quality Outcomes Database (QOD) Spine Registry. A total of 57,199 participants who underwent primary or revision lumbar spine surgeries were included. Structural validity was assessed by exploratory and confirmatory factor analysis, concurrent validity, predictive validity by odds ratios, and internal consistency by Cronbach alpha. The Visual Analog Scale for back pain, two standard open questions, and the EuroQol 5 Dimension/Visual Analogue Scale were included as proxy measures of pain, function, and quality of life, respectively. Hospital readmission, return to operating room for treatment and revision surgery (all within 30 days) were included as proxy measures of disability to assess the predictive validity of each ODI item. RESULTS The ODI demonstrated a two-factor structural solution, which explained 54.9% of the total variance. Fair internal consistency (0.74-0.77), and fair criterion validity (concurrent) and significant findings with predictive validity (P

To analyze the collective effect of social determinants of health (SDH) on lumbar spine revision surgery outcomes using a retrospective cohort study design.Data from the Quality Outcomes Database were used, including 7889 adults who received lumbar spine revision surgery and completed 3 and 12 months' follow-up. The SDH of interest included race/ethnicity, educational attainment, employment status, insurance payer, and sex. A stepwise regression model using each number of SDH conditions present (0 of 5, 1 of 5, 2 of 5, ≥3 of 5) was used to assess the collective influence of SDH. The odds of demonstrating a minimum clinically important difference was evaluated in back and leg, disability, quality of life, and patient satisfaction at 3-months and 12-months follow-up.An additive effect for SDH was found across all outcome variables at 3 and 12 months. Individuals with ≥3 SDH were at the lowest odds of meeting the minimum clinically important difference of each outcome. At 12 months, individuals with ≥3 SDH had a 67%, 65%, 71%, 65%, and 46% decrease in the odds of a clinically meaningful outcome in back and leg pain, disability, quality of life, and patient satisfaction.Health care teams should evaluate SDH in individuals who may be considered for lumbar spine revision surgery. Viewing social factors in aggregate may be useful as a screening tool for lumbar spine revision surgeries to identify at risk patients who may require pre-emptive care strategies and postoperative resources to mitigate these risks.

BACKGROUND: Physical therapists obtain information from a variety of sources. The sources may influence their believability and use in clinical practice. OBJECTIVES: In this hypothesis-based study, we queried physical therapists (PTs) on the believability of evidence across six musculoskeletal treatment domains and analyzed variables that predicted the strength of beliefs. METHODS: This international survey included six different language portals and used a snowball dispensation strategy. PTs who were credentialed, licensed, or who practiced in the field, were queried on the believability of six treatment domains (i.e., exercise, manual therapy, psychologically-informed practice, sports/occupational performance, thermal/electrical agents, and pain science/patient education) and potential predictors of believability (i.e., social media use, years of practice, time and access to literature, specialization, confidence in reviewing literature and attributions of the researcher). RESULTS: In total, 1098 PTs from 36 countries completed the survey. PTs had strong beliefs in what they read or hear about exercise, sports/occupational performance, pain science/patient education, and psychologically-informed interventions. There was only moderate believability regarding manual therapy treatment and weak believability associated with thermal/electrical agents. Multiple linear regression analyses revealed that the most robust predictor to outcome relationships included time and access to literature and believability of pain science/patient education, years of clinical practice and believability of psychologically informed practice, and believability of thermal/electrical agents. CONCLUSION: An important takeaway from this study is that believability was influenced by several factors (primarily by years of practice, attributions of the researcher, and time and access to literature) and appeared to vary across treatment domains.

Lumbar surgery is a commonly prescribed intervention for low back pain but poses higher risks and worse outcomes for older adults. Identifying clinical phenotypes based on biopsychosocial factors may help identify older adults who are at greatest risk for poor postoperative recovery. This study aimed to (a) classify older adults who underwent lumbar surgery based on preoperative biopsychosocial factors, and (b) quantify the association between preoperative biopsychosocial classifications and 3 and 12 months postoperative improvement outcomes. Latent class analysis was used to identify biopsychosocial classifications in 10,283 individuals aged ≥60 from the Quality Outcomes Database (the United States, 2021-2018). Logistic regression models measured the association between biopsychosocial classifications and 3 and 12 months postoperative outcomes (back/leg pain intensity, disability and quality of life), adjusting for covariates. Three classes were identified based on 19 a priori biopsychosocial factors and were characterised as 'high-risk' (15%), 'physical-/social health-risk' (44%) and 'low-risk' (41%). The high-risk class demonstrated increased odds of failing to recover post-operatively compared to the other classes. Similarly, the physical-/social-risk class demonstrated increased odds of failing to recover in all outcomes and time points compared to the low-risk class. Biopsychosocial factors with higher prevalence in the high versus low-risk class were depression (92.5% vs. 10.6%), multiple morbidities (55.3% vs. 25.7%) and obesity (59.5% vs. 37.2%). This study introduces novel non-recovery phenotypes for older adults undergoing lumbar surgery and may lead to the development of tailored interventions to improve clinical care and outcomes for this population.

OBJECTIVE For individuals with severe disability requiring spine surgery, appropriate discharge destination is a challenging and complex decision. Past studies have found associations between discharge destination and postoperative outcomes but were limited by biases in sampling characteristics. The purpose of this study was to explore whether there is an association between discharge destination and odds of worse postoperative outcomes in high-risk individuals with severe/crippling/bedbound disability who received lumbar spine surgery. METHODS This was an observational study using the Quality Outcomes Database Spine Registry. Subjects were limited to age ≥18 years, primary lumbar spine surgery, and severe disability at baseline (Oswestry Disability Index [ODI] ≥50%). Discharge destination was dichotomized to home or healthcare institution. RESULTS Of the 13,050 patients, 11,859 patients (90.9%) were discharged home and 1191 (9.1%) patients were discharged to a healthcare institution. Individuals who were discharged to a healthcare institution were older (68.6 vs 56.9 p

Objectives:(1) To identify baseline variables associated with patients that sought no additional care during the 12 months following a single self-management education session for low back pain (LBP), and (2) in those who sought care, to determine whether the same variables were associated with low versus high downstream LBP-related healthcare utilization.Design:An observational cohort.Setting:Single large military hospital.Participants:A total of 733 patients with LBP.Intervention:Single self-management education session.Main outcomes:Eleven variables were explored in two distinct logistic regression models: (1) no additional care versus additional care, and (2) low versus high number of additional visits in the additional care group.Results:In the first model, not being on active duty service (odds ratio (OR) = 1.98, 95% confidence interval (CI) = 1.37–2.86), low baseline disability (OR = 1.02, 95% CI = 1.00–1.04), low baseline fear-avoidance related to work (OR = 1.02, 95% CI = 1.00–1.03), and, in the last year, no opioid prescriptions (OR = 1.44, 95% CI = 1.00–2.07), physical therapy (OR = 1.63, 95% CI = 1.00–2.65), or sleep disorder diagnosis (OR = 1.62, 95% CI = 1.05–2.51) significantly increased the odds that patients would not seek any additional care. In the second model, not being on active duty service (OR = 2.18, 95% CI = 1.38–3.46), low baseline disability (OR = 1.04, 95% CI = 1.02–1.06), and no opioid prescriptions in the prior year (OR = 2.19, 95% CI = 1.42–3.37) increased the odds that patients would have less visits (⩽2 visits).Conclusion:Our study found several variables that helped determine whether patients would seek little or no additional care during the 12 months following a self-management education class for LBP.

Background The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy. Methods The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data. Results Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7–40.72% with a positive finding and a pretest probability of 31.7–20.33% with a negative finding. Discussion The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

Background Postpartum runners report musculoskeletal pain with running. Because of inadequate research, little is known about the origin and pain-related classification. Through expert consensus, this study is the first attempt to understand the musculoskeletal impairments that these runners present with. The objective of this survey was to gather expert consensus on characteristics of reported impairments in postpartum runners that have musculoskeletal pain. Methods A web-based Delphi survey was conducted and was composed of five categories: strength, range of motion, alignment and flexibility impairments, as well as risk factors for pain in postpartum runners. Results A total of 117 experts were invited. Forty-five experts completed round I and forty-one completed rounds II and III. The strength impairments that reached consensus were abdominal, hip and pelvic floor muscle weakness. The range of motion impairments that reached consensus were hip extension restriction, anterior pelvic tilt and general hypermobility. The alignment impairments that reached consensus were a Trendelenburg sign, dynamic knee valgus, lumbar lordosis, over-pronation and thoracic kyphosis. The flexibility impairments that reached consensus were abdominal wall laxity, and tightness in hip flexors, lumbar extensors, iliotibial band and hamstrings. The risk factors for pain in postpartum runners were muscular imbalance, poor lumbopelvic control, too much too soon, life stressors, pain during pregnancy and pelvic floor trauma. Conclusion This study presents a framework for clinicians to understand pain in postpartum runners and that can be investigated in future cohort studies. Level of evidence 5

Background: Previous studies have shown that the rates of complications associated with revision spine surgery are higher than those of primary spine surgery. However, there is a lack of research exploring the difference in magnitude of risk of poor outcomes between primary and revision lumbar spine surgeries. Purposes: We sought to compare the risks of poor outcomes for primary and revision lumbar spine surgeries and to analyze different measures of risk to better understand the true differences between the 2 forms of surgery. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Spine Surgical Registry from 2012 to 2018. We included individuals who received primary or revision surgery due to degenerative lumbar disorders. Outcome variables collected were complications within 30 days of surgery and 3 destination variables, specifically, (1) 30-day hospital readmission, (2) 30-day return to operating room, and (3) revision surgery within 3 months. Measures of risk considered were odds ratio (OR), relative risk (RR), relative risk increase (RRI), and absolute risk increase (ARI). Results: There were 31,843 individuals who received primary surgery and 7889 who received revision surgery. After controlling for baseline descriptive variables and comorbidities, revision surgery increased the odds of 4 complications and all 3 destination variables. Risk ratios reflected smaller magnitudes but similar findings as the statistically significant ORs. Conclusion: Revision surgery is related to higher overall risks than primary surgery, but the true magnitudes of these risks are very small. RRI and ARI should be included when reporting ORs to better clarify the significance.

This is an observational study on the measurement properties of the Oswestry Disability Index (ODI) version 1.0.To (1) determine the construct validity of the tool, specifically structural validity; (2) analyze the criterion validity of the tool, specifically concurrent validity against proxy measures of pain, function, and quality of life and predictive validity of each item to proxy measures of disability; and (3) reliability of the tool, specifically internal consistency.We endeavored to investigate the measurement properties of the ODI on a spine surgery population to test the assumption that a more disabled population may influence the properties of the tool.Data were pulled from the Quality Outcomes Database (QOD) Spine Registry. A total of 57,199 participants who underwent primary or revision lumbar spine surgeries were included. Structural validity was assessed by exploratory and confirmatory factor analysis, concurrent validity, predictive validity by odds ratios, and internal consistency by Cronbach alpha. The Visual Analog Scale for back pain, two standard open questions, and the EuroQol 5 Dimension/Visual Analogue Scale were included as proxy measures of pain, function, and quality of life, respectively. Hospital readmission, return to operating room for treatment and revision surgery (all within 30 days) were included as proxy measures of disability to assess the predictive validity of each ODI item.The ODI demonstrated a two-factor structural solution, which explained 54.9% of the total variance. Fair internal consistency (0.74-0.77), and fair criterion validity (concurrent) and significant findings with predictive validity (P 0.01) substantiated the use of each item of the ODI as well as the summary score and ODI thresholds.Our study lends value to a burgeoning repository of evidence that suggests the ODI is a useful tool for capturing outcomes in clinical practice. We recommend its continued use in clinical practice.Level of Evidence: 4.

PurposeTo systematically review the literature in order to evaluate the effects of health coaching on patients' reduction of opioid usage and opioid discontinuation. In addition, this systematic review investigated the effects of health coaching on pain intensity, physical function, and quality of life.MethodsFour electronic databases (PubMed, Embase, Scopus, and PsychINFO) were searched from inception to December 2019. Randomized controlled trials assessing the effects of health coaching interventions in adult patients currently using opioids were included. We considered trials if they included any of the four defined key constructs of health coaching adopted in this review: motivational interviewing, positive psychology, the transtheoretical model, and self-determination theory Independent reviewers screened and selected studies, extracted data, and assessed risk of bias using Revised Cochrane risk-of-bias tool for randomized trials (RoB2) and quality of evidence using Grading, Recommendation, Assessment, Development, and Evaluation (GRADE). The review is registered in the International Prospective Register of Systematic Reviews (PROSPERO) databased as CRD42019136201. It was not possible to perform a meta-analysis due to heterogeneity between included trials.ResultsEleven studies met our inclusion criteria (n = 4,516 participants). No study assessed all four constructs of health coaching. All eleven studies utilized only one of the constructs, brief motivational interviewing. Thus, we reported our results in terms of motivational interviewing. There is conflicting and very low quality of evidence that brief motivational interviewing may or may not be more effective than education to reduce opioid usage. There is very low quality of evidence that brief motivational interviewing is more effective than educational monthly diaries to reduce opioid use. There is very low to low quality of evidence that brief motivational interviewing is not more effective than no behavioral intervention to reduce opioid use at 6 months follow-up, treatment as usual (TAU) to improve overdose risk behaviors, and TAU to improve physical and psychological health.ConclusionThere is no direct evidence related to the effect of health coaching on opioid reduction. There is limited, low quality evidence to conclude brief motivational interviewing reduces opioid usage in opioid-dependent patients. Future research should focus on the impact of high theoretical health coaching interventions on opioid usage.

Objectives This overview of reviews aimed to identify (1) aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system, and (2) which mechanisms are used to measure aspects of the patient experience. Data sources Four databases were searched from inception to December 20th, 2019. Review methods Systematic or scoping reviews examining patient experience in seeking care for musculoskeletal from healthcare providers and the healthcare system were included. Independent authors screened and selected studies, extracted data, and assessed the methodological quality of the reviews. Patient experience concepts were compiled into five themes from a perspective of a) relational and b) functional aspects. A list of mechanisms used to capture the patient experience was also collected. Results Thirty reviews were included (18 systematic and 12 scoping reviews). Relational aspects were reported in 29 reviews and functional aspects in 25 reviews. For relational aspects, the most prevalent themes were “information needs” (education and explanation on diseases, symptoms, and self-management strategies) and “understanding patient expectations” (respect and empathy). For functional aspects, the most prevalent themes were patient’s “physical and environmental needs,” (cleanliness, safety, and accessibility of clinics), and “trusted expertise,” (healthcare providers’ competence and clinical skills to provide holistic care). Interviews were the most frequent mechanism identified to collect patient experience. Conclusions Measuring patient experience provides direct insights about the patient’s perspectives and may help to promote better patient-centered health services and increase the quality of care. Areas of improvement identified were interpersonal skills of healthcare providers and logistics of health delivery, which may lead to a more desirable patient-perceived experience and thus better overall healthcare outcomes. Trial registration Systematic review registration: PROSPERO (CRD42019136500).

The purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery.This study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery.Of the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p 0.01) compared to those who did not experience improvement in depression or anxiety.Depression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Background Different outcome measures can be used to assess pain and disability in individuals with Greater Trochanteric Pain Syndrome (GTPS), including the Victorian Institute of Sports Assessment for Gluteal Tendinopathy (VISA-G), Oswestry Disability Index (ODI), Patient Specific Functional Scale (PSFS) and Global Perceived Effect (GPE). Objective To translate, cross-culturally adapt and validate VISA-G to Brazilian Portuguese and to evaluate the measurement properties of the VISA-G.BR, ODI, GPE, and PSFS in individuals with GTPS. Design This is a longitudinal clinimetric study. Methods Sixty-eight individuals with GTPS participated in this study. The questionnaires VISA-G.BR, ODI, PSFS, and GPE were administered to participants at the initial assessment, 24–48 h and 30 days after the initial assessment. Internal consistency and construct validity for the VISA-G.BR were assessed. Reliability, agreement, ceiling and floor effect, and responsiveness were described for all instruments. Results The Cronbach Alpha for internal consistency value for VISA-G.BR was 0.65. The construct validity analysis showed a strong correlation value between ODI and VISA-G.BR (r = −0.77). The agreement analysis performed for all questionnaires showed standard error of measurement values ranging from 0.64 (PSFS) to 4.2 (VISA-G.BR). GPE scale had a floor effect. The responsiveness analysis performed for all questionnaires showed low values of effect size ranging from −0.07 to 0.3. Conclusion The VISA-G.BR is a valid and reliable instrument to assess the disability of individuals with GTPS. The ODI and PSFS instruments can also be used in the evaluation of this population.

Background The STarT Back Screening Tool (SBST) is used to stratify care. It is unclear if the SBST approach works as well for patients in low- and medium-income countries as for patients from high-income countries. Objectives (1) To investigate whether patients with chronic low back pain (LBP) stratified by the SBST are different at baseline; (2) to describe the clinical course for each SBST subgroup; (3) to investigate the SBST utility to predict clinical outcomes; and (4) to determine which SBST subgroup show greater clinical improvement. Design This is a secondary analysis of data derived from a previously published clinical trial. Methods 148 patients with chronic nonspecific LBP were included. Pain intensity, disability, global perceived effect, and the SBST were assessed at baseline and at 5, 12, and 24 weeks after baseline. Descriptive data were provided and ANOVA, unadjusted and adjusted regression models, and linear mixed models were used for data analysis. Results Duration of symptoms, use of medication, pain, disability, and global perceived effect were different between SBST subgroups. Clinical improvements over a 6-month period were consistently greater in patients classified as high risk. The SBST was able to predict disability but this predictability decreased when the analysis was adjusted for possible confounders. Conclusion Clinical outcomes were different between SBST subgroups over 6 months. Adjusting for confounders influenced the predictability of SBST. Patients classified as high risk presented higher improvements in terms of disability.

Background In patients who receive spine surgery, pain is relational to disability and quality of life, but exactly how this influence is mediated is not fully understood. Mediation analyses allow an understanding of a known relationship by exploring the underlying mechanism or processes by which one variable influences another. Objectives To determine the mediating influence of psychological, mobility, and satisfaction variables on the relationship between preoperative back pain intensity and 12-month disability and quality of life in individuals who underwent lumbar spine surgery. Design This mediation analysis study used data from the Quality Outcomes Database (QOD) Lumbar Spine Surgical Registry. Methods There were included individuals who received lumbar spine surgery for degenerative spine conditions. The exposure variable was preoperative back pain intensity. Mediator variables were depression/anxiety, mobility, and satisfaction. Outcomes included disability and quality of life. Separate multiple mediator models were conducted using the Hayes PROCESS, Model 4 with bias-corrected bootstrapping (5000 samples) to predict disability and quality of life. Results 26,130 individuals (n = 13,740 males, mean age 60.2 [SD = 13.8) were included. We observed a significant indirect effect through the mediators (anxiety/depression, mobility and satisfaction), for both disability (b = 0.31, 95%CI = 0.26, 0.35) and quality of life (b = −0.44, 95%CI = −0.48, −0.41). Conclusion Our study suggests that the relationship between preoperative back pain intensity (exposure) and long-term disability and quality of life (outcomes) is partially mediated by anxiety/depression, mobility, and patient satisfaction in individuals who received lumbar spine surgery.

Objectives To provide a comprehensive overview of the measurement properties of patient-reported outcome measures (PROMs) used to assess sleep quality in adult patients with prevalent pain-related conditions. Methods Without language restrictions PubMed, Scopus, and Embase were searched from their inception to January 2020. Independent reviewers screened and selected studies, extracted data, assessed the methodological quality using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) Risk of Bias checklist, and performed an evidence synthesis for each measurement property. The results were classified as sufficient, insufficient, inconsistent, or indeterminate, and quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Nineteen studies were included investigating twelve PROMs and six pain-related conditions. Reliability, internal consistency, structural and construct validity were the most prevalent measurement properties investigated across the studies. Three questionnaires were investigated in more than one study (Jenkins Sleep Scale [JSS] and Pittsburgh Sleep Quality Scale [PSQI] and the Medical Outcomes Study–Sleep Scale [MOS-SS]). High-quality evidence was reported for sufficient content validity in the JSS and indeterminate responsiveness in the MOS-SS. Moderate to high evidence was reported for sufficient structural validity in the MOS-SS and PSQI and sufficient and insufficient construct validity in the JSS And MOS-SS. Low to high evidence was reported for sufficient internal consistency in the MOS-SS and PSQI, while low to moderate evidence for sufficient reliability in the JSS, MOS-SS, and PSQI. Conclusion Studies reporting the most measurement properties included the JSS, MOS-SS, and PSQI in multiple prevalent pain-related conditions. Given this, not all measurement properties have been reported for these as well as other questionnaires, and much investigation is needed to ensure the quality of these questionnaires within high prevalence chronic pain conditions. Prospero CRD42019136623.

OBJECTIVEObese body habitus is a challenging issue to address in lumbar spine surgery. There is a lack of consensus on the long-term influence of BMI on patient-reported outcomes and satisfaction. This study aimed to examine the differences in patient-reported outcomes over the course of 12 and 24 months among BMI classifications of patients who underwent lumbar surgery.METHODSA search was performed using the Quality Outcomes Database (QOD) Spine Registry from 2012 to 2018 to identify patients who underwent lumbar surgery and had either a 12- or 24-month follow-up. Patients were categorized based on their BMI as normal weight (≤ 25 kg/m2), overweight (25–30 kg/m2), obese (30–40 kg/m2), and morbidly obese (> 40 kg/m2). Outcomes included the Oswestry Disability Index (ODI) and the visual analog scale (VAS) for back pain (BP) and leg pain (LP), and patient satisfaction was measured at 12 and 24 months postoperatively.RESULTSA total of 31,765 patients were included. At both the 12- and 24-month follow-ups, those who were obese and morbidly obese had worse ODI, VAS-BP, and VAS-LP scores (all p < 0.01) and more frequently rated their satisfaction as “I am the same or worse than before treatment” (all p < 0.01) compared with those who were normal weight. Receiver operating characteristic curve analysis revealed that the BMI cutoffs for predicting worsening disability and surgery dissatisfaction were 30.1 kg/m2 and 29.9 kg/m2 for the 12- and 24-month follow-ups, respectively.CONCLUSIONSHigher BMI was associated with poorer patient-reported outcomes and satisfaction at both the 12- and 24-month follow-ups. BMI of 30 kg/m2 is the cutoff for predicting worse patient outcomes after lumbar surgery.

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OBJECTIVE The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that assesses patient satisfaction, which is an important measure of the quality of hospital care and ultimately the overall hospital rating (OHR). However, the survey covers several elements of patient satisfaction beyond the patient-surgeon interaction. In this study, authors investigated which admission and experience factors had the highest impact on the OHR. METHODS This was a retrospective cohort analysis of HCAHPS surveys from patients who, in the period between August 1, 2016, and January 31, 2018, had been discharged from the neurosurgical or orthopedic service at three hospitals serving a single metropolitan area. The top-box score was defined as the highest rating obtainable for each survey question. Baseline admission attributes were obtained, and multivariate logistic regression was used to determine predictors of the top-box OHR. RESULTS After application of the inclusion and exclusion criteria, 1470 patients remained in the analysis. Categories on the HCAHPS included OHR, communication, education, environment, pain management, and responsiveness. After excluding identifying questions from the survey and adjusting for subspecialty and hospital, 7 of 17 HCAHPS survey items were significant predictors of OHR. Only 2 of these were related to the surgeon: 1) discharge, “Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” (OR 5.93, 95% CI 2.52–13.94); and 2) doctor, “Did doctors explain things in a way you could understand?” (OR 2.78, 95% CI 1.73–4.46). The top three strongest correlating items were 1) discharge; 2) nursing, “Did nurses treat you with courtesy and respect?” (OR 3.86, 95% CI 2.28–6.52); and 3) hospital environment, “Were your room and bathroom kept clean?” (OR 2.86, 95% CI 1.96–4.17). CONCLUSIONS The study findings demonstrated that there are several nonmodifiable factors (i.e., specialty, experience) and items that are not under the direct purview of the neurosurgeon (e.g., nursing communication, hospital environment) that are significant influences on overall inpatient satisfaction on the HCAHPS survey. Furthermore, components of the survey that ultimately influence the OHR vary across different hospitals. Hence, HCAHPS survey results should be broadly interpreted as a way to make health systems more aware of the overall hospital factors that can improve quality of care and patient experience.

Objectives This study aimed to report compliance with stepped care management of patellofemoral pain and determine whether adherence to stepped care results in decreased recurrence and lower health care utilization. Methods A total of 60,730 participants were included, using data from the Military Health System Data Repository, a large single-payer government health system. Outcomes included total knee-related care visits and costs, knee surgeries, opioid prescriptions, and 2-year recurrence. Stepped care was based on interventions delivered within the appropriate timing and in the appropriate order (low risk/cost before high risk/cost). Results A total of 54,460 (89.7%) participants received adherent Step 1 care, 10,964 (18.1%) received step 2, and 4168 (6.9%) received step 3. A total of 32.0% and 50.8%, respectively, of all patients in Step 2 and Step 3 care were adherent. Of the 2385 participants (3.9% of cohort) that received both Step 2 and Step 3 care, 24.8% of participants received adherent care. For participants receiving both Step 2 and Step 3 care, adherence resulted in cost savings (mean difference [MD] $1708; 95% confidence interval [CI]: $1241, 2175), fewer knee-related visits (MD 3.4; 95% CI 2.2, 4.7), fewer episodes of knee pain (MD 0.7; 95% CI 0.5, 0.8), fewer knee surgeries (adjusted odds ratio 0.4; 95% CI 0.3, 0.5), and fewer opioid prescriptions (adjusted odds ratio 0.6; 95% CI 0.5, 0.8). Conclusion These findings demonstrate the value of following stepped care guidelines for pain management in patients with patellofemoral pain.

Mechanical Diagnosis and Therapy (MDT) is a treatment-based classification system founded on 3 core principles: classification into diagnostic syndromes, classification-based intervention, and appropriate application of force. Many randomized controlled trials have investigated the efficacy of MDT for low back pain; however, results have varied. The inconsistent delivery of MDT across trials may explain the different findings.To compare treatment effect sizes for pain or disability between trials that delivered MDT consistent with the core principles of the approach and trials that met some or none of these principles.In this systematic review, databases were searched from inception to June 2018 for studies that delivered MDT compared to nonpharmacological, conservative control interventions in patients with low back pain and reported outcomes of pain or disability. Studies were classified as "adherent" (meeting the core principles of MDT) or "nonadherent" (using some or none of the principles of MDT). Data were extracted by 2 independent reviewers. Meta-regression procedures were used to analyze the effect of delivery mode on clinical outcomes, adjusting for covariates of symptom duration (less than or greater than 3 months) and control intervention (minimal or active).Studies classified as adherent to the MDT approach showed greater reductions in pain and disability of 15.0 (95% confidence interval: 7.3, 22.7) and 11.7 (95% confidence interval: 5.4, 18.0) points, respectively, on a 100-point scale compared to nonadherent trials.This review provides preliminary evidence that treatment effects of MDT are greater when the core principles are followed.Therapy, level 1a. J Orthop Sports Phys Ther 2019;49(4):219-229. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8734.

Objectives To determine the reliability, internal consistency, measurement error, convergent validity, and floor and ceiling effects of three quality assessment tools commonly used to evaluate the quality of diagnostic test accuracy studies in physical therapy. A secondary aim was to describe the quality of a sample of diagnostic accuracy studies. Study design and setting 50 studies were randomly selected from a comprehensive database of physical therapy-relevant diagnostic accuracy studies. Two reviewers independently rated each study with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Diagnostic Accuracy Quality Scale (DAQS) tools in random sequence. Results Only 7% of QUADAS items, 14% of QUADAS-2 items, and 33% of DAQS items had at least moderate inter-rater reliability (kappa > 0.40). Internal consistency and convergent validity measures were acceptable (>0.70) in 33% and 50% of cases respectively. Floor or ceiling effects were not present in any tool. The quality of studies was mixed: most avoided case–control sampling strategies and used the same reference standard on all subjects, but many failed to enroll a consecutive or random sample of subjects or provide confidence intervals about estimates of diagnostic accuracy. Conclusion The QUADAS, QUADAS-2 and DAQS tools provide unreliable estimates of the quality of studies of diagnostic accuracy in physical therapy.

To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings. An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and −LR) and posttest probabilities (+PTP and −PTP) with 95% confidence intervals were summarized. Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS. Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS. These slides can be retrieved under Electronic Supplementary Material.

Background The choice of outcome success thresholds may influence clinical management, pay-for-performance, and assessment of value-based care. Objective To evaluate outcomes success thresholds in older adults using two different methods: 1) Minimal clinically important differences (MCIDs) of the Quick-DASH and 2) Dichotomization of the Quick-DASH based on low disability rating at discharge Design An observational design (retrospective database study). Setting Dataset of 1109 patients with shoulder disorders. Participants 297 older adults patients who were diagnosed with rotator cuff related shoulder disorders and were managed through physical therapy treatment. Main outcome measures We categorized and calculated how many patients met 8.0 and 16.0 point changes on the Quick-DASH. To evaluate outcomes success thresholds using dichotomization, patients who discharge score of ≤20 on the Quick-DASH were considered positive responders with successful outcomes. Results The percentage of positive responders who met the MCID thresholds for the Quick-DASH were 63.3% using MCID of 8.0 points, 39.7% using the MCID of 16.0 points, and 46.12% who met discharge score of ≤ 20 on the Quick-DASH. 39.0% met both MCID of 8.0 points and discharge score of ≤ 20 on the Quick-DASH. Only 28% met both MCID of 16.0 points and discharge score of = 20 on the Quick-DASH. Conclusion Three different success threshold derivations classified patients into three very different assessments of success. Quick-DASH scores of ≤ 20 represent low levels of self-report disability at discharge and can be a stable clinical option for a measure of success to capture whether a treatment results in meaningful improvement.

Objectives Our objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables. Methods This observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery—a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery. Results Stepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH. Discussion Collective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.

Introduction As patient-reported outcome measures (PROMs) continue to evolve as vital measures of patient status, it may be useful to identify efficiently, Single Assessment Numeric Evaluation (SANE) scores that are valid and related to the patient's specific functional needs. Objective To evaluate the concurrent validity between SANE scores and commonly used body region-specific functional PROMs, functional percentage change scores, and total visits in patients with musculoskeletal (MSK) disorders. Methods 479 patients completed the SANE and one of the following PROMs at physical therapy discharge: Modified Low Back Pain Disability Questionnaire [MDQ], Neck Disability Index [NDI], Penn Shoulder Score [PSS], International Knee Documentation Committee [IKDC], Lower Extremity Functional Scale [LEFS]. Pearson correlation coefficients were used to assess the relationship between SANE and the aforementioned outcomes and total visits. Results The SANE was moderately negatively correlated with the MDQ and NDI at discharge. There were high positive correlations between SANE and PSS and IKDC and moderate positive correlation between SANE and LEFS. The SANE and MDQ and IKDQ demonstrated low positive correlation for functional percentage change scores, and the SANE and NDI demonstrated moderate positive correlation for functional percentage change scores. For total visits outcome, there was a negligible negative correlation between SANE and MDQ and NDI at discharge. Conclusion The SANE exhibits acceptable concurrent validity across all investigated PROMs at physical therapy discharge. However, inconsistent relationships across body regions for functional percentage change and total visits suggest differences in these values as compared to raw discharge scores.

BackgroundConsequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline.ObjectiveOur primary purpose was to improve overall understanding of the harms and benefits associated with oral opioid interventions prescribed for treatment of acute or chronic back pain. Our second goal was to evaluate pain intensity and to compare and contrast these data with the harms. Our last objective was to evaluate conflicts of interest among the study authors and the findings.Design/data/eligibility criteriaStudies incorporating oral prescription opioid management of non-surgical LBP were evaluated. After systematic assessment, no studies that met inclusion included participants with specifically acute LBP. Therefore, extracted data reflects only populations with subacute and chronic LBP. Data on reported harms, severe harms, pain outcomes and withdrawal rates were extracted and meta-analyses were completed for opioid versus placebo trials and opioids versus non-opioid trials.ResultsFourteen studies met inclusion/exclusion requirements. All trials involved short-term management with limited follow-up. A high percentage of harms were identified across most studies. Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms).ConclusionThis review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of subacute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of subacute or chronic LBP.Trial registration numberCRD42017070914

An updated summary of the evidence for the reliability of the Mechanical Diagnosis and Therapy (MDT) system in patients with spinal pain is needed.To investigate the evidence on the intrarater and interrater reliability of MDT in patients with spinal pain.Searches in MEDLINE, CINAHL, Embase, PEDro, and Scopus were conducted for this systematic review. We included any study design as long as reliability of the MDT method was tested in patients with spinal pain. We collected data on the reliability of MDT to identify main and subsyndromes, directional preference, the centralization phenomenon, and lateral shift. The methodological quality of studies was assessed using the Quality Appraisal of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement Studies checklists.Twelve studies were included (8 studies on back pain, pooled n = 2160 patients; 3 studies on neck pain, pooled n = 45 patients; and 3 studies recruited mixed spinal conditions, pooled n = 389 patients). Studies investigating patients with back pain reported kappa estimates ranging from 0.26 to 1.00 (main and subsyndromes), 0.27 to 0.90 (directional preference), and 0.11 to 0.70 (centralization phenomenon). Kappa estimates for studies investigating neck pain ranged from 0.47 to 0.84 (main and subsyndromes) and 0.46 (directional preference). In mixed populations, kappa estimates ranged from 0.56 to 0.96 (main and subsyndromes).The MDT system appears to have acceptable interrater reliability for classifying patients with back pain into main and subsyndromes when applied by therapists who have completed the credentialing examination, but unacceptable reliability in other therapists. We found conflicting evidence regarding the reliability of the MDT system in patients with neck pain or mixed pain locations. J Orthop Sports Phys Ther 2018;48(12):923-933. Epub 22 Jun 2018. doi:10.2519/jospt.2018.7876.

Objective To identify potential prognostic factors that may predict clinical improvement of patients treated with different physical therapy interventions in the short-term. Methods This is a prospective cohort study. A total of 616 patients with chronic non-specific low back pain treated with interventions commonly used by physical therapists were included. These patients were selected from five randomized controlled trials. Multivariate linear regression models were used to verify if sociodemographic characteristics (age, gender, and marital status), anthropometric variables (height, body mass, and body mass index), or duration of low back pain, pain intensity at baseline, and disability at baseline could be associated with clinical outcomes of pain intensity and disability four weeks after baseline. Results The predictive variables for pain intensity were age (β = 0.01 points, 95% CI = 0.00 to 0.03, p = 0.03) and pain intensity at baseline (β = 0.23 points, 95% CI = 0.13 to 0.33, p = 0.00), with an explained variability of 4.6%. Similarly, the predictive variables for disability after four weeks were age (β = 0.03 points, 95% CI = 0.00 to 0.06, p = 0.01) and disability at baseline (β = 0.71 points, 95% CI = 0.65 to 0.78, p = 0.00), with an explained variability of 42.1%. Conclusion Only age, pain at baseline and disability at baseline influenced the pain intensity and disability after four weeks of treatment. The beta coefficient for age was statistically significant, but the magnitude of this association was very small and not clinically important.

BackgroundThe McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP.MethodsThis was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment.ResultsThe MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) −1.00, 95% CI −2.09 to −0.01) but not for disability (MD −0.84, 95% CI −2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events.ConclusionWe found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times.Trial registration numberClinicalTrials.gov (NCT02123394)

BACKGROUND: Chronic non-specific low back pain is both a health and a socio-economic problem which is associated with disability as well as with emotional distress. The Mckenzie and Back School’s techniques have been shown to be effective in the treatment of this condition. OBJECTIVES: to perform a preliminary analysis of the effects of these treatments in patients with chronic non specific low back pain for the following outcomes: pain, disability and trunk flexion range of motion and to test the feasibility of randomized controlled trial testing these interventions on this population. METHODS: the participants were assessed by a blinded assessor and randomly assigned into one of the treatment groups. The data analysis was performed in only 18 patients and the study is still ongoing, so the results are restricted to these patients, as a single group. RESULTS: the patients improved for the outcomes pain intensity (mean difference of 2.4 points and 95% CI 0.84 to 3.93) and disability (5.2 points and 95% CI 2.55 to 7.78), but no improvement in range of motion in flexion was observed (7.2 degrees 95% CI -1.82 to 16.29). CONCLUSION:the Mckenzie and Back School’s approaches may be beneficial for the treatment of patients with chronic non specific low back pain for the outcomes pain intensity and disability. We also concluded that the study is feasible and we will continue performing the current study without any adjustments of the original research protocol. This study was prospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12610000435088.CONTEXTUALIZAÇÃO: A dor lombar crônica não-específica é um problema de saúde associado à redução do desempenho funcional e a alterações emocionais. Os métodos Back School e Mckenzie têm se mostrado eficazes no tratamento desse sintoma. OBJETIVOS: Realizar uma análise preliminar da eficácia dessas técnicas em pacientes com dor lombar crônica não-específica para os desfechos intensidade da dor, desempenho funcional e amplitude de movimento (ADM) de flexão de coluna e testar a viabilidade da condução de um estudo controlado aleatorizado utilizando essas intervenções nessa população. MÉTODOS: Os indivíduos foram avaliados por um examinador cego e distribuídos aleatoriamente para os grupos de tratamento. A análise dos dados foi realizada em 18 pacientes, e o estudo continua em andamento, portanto os resultados apresentados se referem a esses pacientes como sendo de um só grupo. RESULTADOS:Os pacientes obtiveram melhora nos desfechos intensidade da dor (média das diferenças de 2,4 pontos e IC a 95% - 0,84 a 3,93) e desempenho funcional (5,2 pontos e IC 95% - 2,55 a 7,78), mas não para a ADM de flexão de coluna (7,2 graus e IC 95% - 1,82 a 16,29). CONCLUSÃO: Os métodos Back School e Mckenzie podem ser benéficos no tratamento de indivíduos com dor lombar crônica não-específica. Além disso, concluiu-se que o estudo é viável e continua sem alterações no projeto inicial. Estudo previamente registrado no Australian New Zealand Clinical Trials Registry (ANZCTR) sob o número ACTRN12610000435088.

Background “Mechanical Diagnosis and Therapy” (MDT) (also known as the McKenzie method), like other interventions for low back pain (LBP), has been found to have small effects for people with LBP. It is possible that a group of patients respond best to MDT and have larger effects. Identification of patients who respond best to MDT compared with other interventions would be an important finding. Objective The purpose of the study was to investigate whether baseline characteristics of patients with chronic LBP, already classified as derangement syndrome, can identify those who respond better to MDT compared with Back School. Methods This study was a secondary analysis of data from a previous trial comparing MDT with Back School in 148 patients with chronic LBP. Only patients classified at baseline assessment as being in the directional preference group (n=140) were included. The effect modifiers tested were: clear centralization versus directional preference only, baseline pain location, baseline pain intensity, and age. The primary outcome measures for this study were pain intensity and disability at the end of treatment (1 month). Treatment effect modification was evaluated by assessing the group versus predictor interaction terms from linear regression models. Interactions ≥1.0 for pain and ≥3 for disability were considered clinically important. Results Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment. Limitations The sample (n=140) was powered to detect the main effects of treatment but not to detect the interactions of the potential treatment effect modifiers. Conclusions The results of the study suggest older age may be an important factor that can be considered as a treatment effect modifier for patients with chronic LBP receiving MDT. As the main trial was not powered for the investigation of subgroups, the results of this secondary analysis have to be interpreted cautiously, and replication is needed.

Background The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain. Objective The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain. Design An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted. Setting This study will be conducted in physical therapy clinics in São Paulo, Brazil. Participants The participants will be 148 patients seeking care for chronic nonspecific low back pain. Intervention Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks). Measurements The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor. Limitations Therapists will not be blinded. Conclusions This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.

Evidence-Based Practice (EBP) has been widely implemented in different health-related areas. Several studies investigated important characteristics in EBP by physiotherapists and systematic review is needed. Therefore the aim of this study is to describe the current evidence on EBP knowledge, skills, behaviour, opinions and barriers by physiotherapists. Searches were conducted on MEDLINE, EMBASE, CINAHL, PSYCINFO, LILACS, and SciELO in September 2014. We retrieved quantitative cross-sectional studies that investigated EBP knowledge, skills, behaviour, opinions, and barriers in physiotherapy. Risk of bias was assessed using a scale to evaluate representativeness of the sample, response rate, the accuracy of the data, evidence of power calculation and the instrument used. The search yielded 12,392 potentially eligible studies. Of these, 12 studies were included in the review (pooled sample = 6411 participants). In 3 studies that analysed knowledge, approximately 21–82% of respondents claimed to have received prior information on EBP. In 2 studies that reported skills and behaviour, nearly half of the sample had used databases to support clinical decision-making. In 6 studies that investigated opinions, the majority of the samples considered EBP necessary or important. The barriers most frequently reported were: lack of time, inability to understand statistics, lack of support from employer, lack of resources, lack of interest and lack of generalisation of results. Although the majority of physiotherapists have a positive opinion about EBP, they consider that they need to improve their knowledge, skills and behaviour towards EBP. They also faced barriers that might hinder the implementation of EBP.

Background Back School and McKenzie methods are popular active treatment approaches that include both exercises and information for patients with chronic nonspecific low back pain. Objective The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain. Design The study was a prospectively registered, 2-arm randomized controlled trial with a blinded assessor. Setting The study was conducted in the outpatient physical therapy clinic in São Paulo, Brazil. Patients The study participants were 148 patients with chronic nonspecific low back pain. Interventions The 4-week treatment program (one session/week) was based on the Back School (delivered to the group) or McKenzie (delivered individually) principles. The participants also were instructed to perform a daily set of home exercises. Measurements Clinical outcomes were assessed at follow-up appointments at 1, 3, and 6 months after randomization. Primary outcome measures were pain intensity (measured by the 0–10 pain numerical rating scale) and disability (measured by the 24-item Roland-Morris Disability Questionnaire) 1 month after randomization. Secondary outcome measures were pain intensity and disability at 3 and 6 months after randomization, quality of life (measured by the World Health Organization Quality of Life–BREF instrument) at 1, 3, and 6 months after randomization, and trunk flexion range of motion measured by an inclinometer at 1 month after randomization. The data were collected by a blinded assessor. Results Participants allocated to the McKenzie group had greater improvements in disability at 1 month (mean effect=2.37 points, 95% confidence interval=0.76 to 3.99) but not for pain (mean effect=0.66 points, 95% confidence interval=−0.29 to 1.62). No between-group differences were observed for all secondary outcome measures. Limitations It was not possible to monitor the home exercise program. Therapists and participants were not blinded. Conclusions The McKenzie method (a more resource-intensive intervention) was slightly more effective than the Back School method for disability, but not for pain intensity immediately after treatment in participants with chronic low back pain.

BACKGROUND: Chronic non-specific low back pain is both a health and a socio-economic problem which is associated with disability as well as with emotional distress. The Mckenzie and Back School’s techniques have been shown to be effective in the treatment of this condition. OBJECTIVES: to perform a preliminary analysis of the effects of these treatments in patients with chronic non specific low back pain for the following outcomes: pain, disability and trunk flexion range of motion and to test the feasibility of randomized controlled trial testing these interventions on this population. METHODS: the participants were assessed by a blinded assessor and randomly assigned into one of the treatment groups. The data analysis was performed in only 18 patients and the study is still ongoing, so the results are restricted to these patients, as a single group. RESULTS: the patients improved for the outcomes pain intensity (mean difference of 2.4 points and 95% CI 0.84 to 3.93) and disability (5.2 points and 95% CI 2.55 to 7.78), but no improvement in range of motion in flexion was observed (7.2 degrees 95% CI -1.82 to 16.29). CONCLUSION:the Mckenzie and Back School’s approaches may be beneficial for the treatment of patients with chronic non specific low back pain for the outcomes pain intensity and disability. We also concluded that the study is feasible and we will continue performing the current study without any adjustments of the original research protocol. This study was prospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12610000435088. CONTEXTUALIZAÇÃO: A dor lombar crônica não-específica é um problema de saúde associado à redução do desempenho funcional e a alterações emocionais. Os métodos Back School e Mckenzie têm se mostrado eficazes no tratamento desse sintoma. OBJETIVOS: Realizar uma análise preliminar da eficácia dessas técnicas em pacientes com dor lombar crônica não-específica para os desfechos intensidade da dor, desempenho funcional e amplitude de movimento (ADM) de flexão de coluna e testar a viabilidade da condução de um estudo controlado aleatorizado utilizando essas intervenções nessa população. MÉTODOS: Os indivíduos foram avaliados por um examinador cego e distribuídos aleatoriamente para os grupos de tratamento. A análise dos dados foi realizada em 18 pacientes, e o estudo continua em andamento, portanto os resultados apresentados se referem a esses pacientes como sendo de um só grupo. RESULTADOS:Os pacientes obtiveram melhora nos desfechos intensidade da dor (média das diferenças de 2,4 pontos e IC a 95% - 0,84 a 3,93) e desempenho funcional (5,2 pontos e IC 95% - 2,55 a 7,78), mas não para a ADM de flexão de coluna (7,2 graus e IC 95% - 1,82 a 16,29). CONCLUSÃO: Os métodos Back School e Mckenzie podem ser benéficos no tratamento de indivíduos com dor lombar crônica não-específica. Além disso, concluiu-se que o estudo é viável e continua sem alterações no projeto inicial. Estudo previamente registrado no Australian New Zealand Clinical Trials Registry (ANZCTR) sob o número ACTRN12610000435088.

Background Chronic low back pain is a highly prevalent condition, which is associated with high direct and indirect costs to the society. Although this condition is highly prevalent, it is still extremely difficult to treat. Two potentially useful treatments for patients with chronic low back pain are called the McKenzie and Back School treatment programs. These programs have good biological plausibility, are widely available and have a modest cost. Although these treatments are already available for patients, the evidence that supports their use is largely based on low quality methodological studies. Therefore, a high-quality randomised controlled trial is required to compare, for the first time, the effectiveness of these treatments in patients with chronic low back pain. Methods/design One hundred and forty-eight patients will be randomly allocated to a four-week treatment program based upon the McKenzie or Back School principles. Clinical outcomes (pain intensity, disability, quality of life, and trunk flexion range of motion) will be obtained at follow-up appointments at 1, 3 and 6 months after randomisation. The data will be collected by an assessor who will be blinded to the group allocation. Discussion This will be the first study aimed to compare the McKenzie and Back School approaches in patients with chronic low back pain. The results of this trial may help in the decision-making process of allied health providers for the treatment of chronic low back pain and reduce the health-related costs of this condition. Trial Registration ACTRN12610000435088