Search

Kristian Johnsen,1 Patrick J Owen,1 Scott D Tagliaferri,1 Jessica Van Oosterwijck,2– 4 Bernadette M Fitzgibbon,5 Jon J Ford,6,7 Daniel L Belavy,1,8 Clint T Miller1 1Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia; 2Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; 3Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; 4Research Foundation – Flanders (FWO), Brussels, Belgium; 5School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; 6Advance HealthCare, Boronia, VIC, Australia; 7Low Back Research Team, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC, Australia; 8Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit, Bochum, GermanyCorrespondence: Clint T Miller, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, Tel +61 3 9244 6605, Email c.miller@deakin.edu.auPurpose: This cross-sectional study aimed to investigate whether psychosocial factors were predictive for exercise-induced hypoalgesia (EIH) in pain-free adults.Methods: A sample of 38 pain-free nurses with a mean (SD) age of 26 (6) years were included in this study. Participants completed psychosocial questionnaires prior to physical tests. Pressure pain threshold (PPT) was assessed bilaterally at the calves (local), lower back (semi-local) and forearm (remote) before and immediately after a maximal graded cycling exercise test. Separate linear mixed effects models were used to determine change in PPT before and after cycling exercise (EIH). Multiple linear regression for all psychosocial variables and best subset regression was used to identify predictors of EIH at all locations.Results: The relative mean increase in PPT at the forearm, lumbar, calf, and globally (all sites pooled) was 6.0% (p< 0.001), 10.1% (p< 0.001), 13.9% (p< 0.001), and 10.2% (p=0.013), respectively. Separate best subset multiple linear regression models at the forearm (predictors; Multidimensional Scale of Perceived Social Support (MSPSS) total), lumbar (predictors; MSPSS total, Pain Catastrophizing Scale (PCS) total, Depression Anxiety Stress Scale (DASS) depression), calf (predictors; MSPSS friends, PCS total), and global (predictors; MSPSS friends, PCS total) accounted for 7.5% (p=0.053), 13% (p=0.052), 24% (p=0.003), and 17% (p=0.015) of the variance, respectively.Conclusion: These findings confirm that cycling exercise produced EIH in young nurses and provided preliminary evidence to support the interaction between perceived social support, pain catastrophizing and EIH. Further investigation is required to better understand psychological and social factors that mediate EIH on a larger sample of adults at high risk of developing chronic musculoskeletal pain.Keywords: aerobic exercise, acute exercise, pain pressure threshold, perceived social support, kinesiophobia

Purpose Proximal hamstring tendinopathy (PHT) presents as localised lower buttock pain with tasks such as squatting and sitting. It is a condition that occurs at all ages and levels of sporting participation and can cause disability with sport, work, and activities of daily living. This paper details a pilot trial protocol for investigating the effectiveness of individualised physiotherapy compared to extracorporeal shockwave therapy (ESWT) on pain and strength in people with PHT. Methods The study is an assessor-blinded, pilot randomised controlled trial (RCT). One hundred participants with PHT will be recruited from the local community and sporting clubs. Participants will be randomised to receive six sessions of either individualised physiotherapy or ESWT, with both groups also receiving standardised education and advice. Primary outcomes will be global rating of change on a 7-point Likert scale, and the Victorian Institute of Sport—Hamstring (VISA-H) scale, measured at 0, 4, 12, 26 and 52 weeks. Secondary outcomes will include sitting tolerance, the modified Physical Activity Level Scale, eccentric hamstring strength, modified Tampa scale for kinesiophobia, the Örebro Musculoskeletal Pain Screening Questionnaire Short Form (ÖMPSQ-SF), Numerical Pain Rating Scale (NPRS) for average and worst pain, participant adherence, the Pain Catastrophizing scale, satisfaction scores, and quality of life. Data will be analysed on an intention to treat basis, with between-group effects estimated using linear mixed models for continuous data and Mann Whitney U tests for ordinal data. Conclusions This pilot RCT will compare individualised physiotherapy versus ESWT for PHT. The trial will determine feasibility and estimated treatment effects to inform a definitive trial in the future. Trial registration The trial has been prospectively registered with the Australia & New Zealand Clinical Trials Registry (ACTRN12621000846820), registered 1 July 2021, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373085

Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Background An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice. Purpose This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). Study design Cohort Study. Methods Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy. Results Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain Conclusion In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. Clinical relevance These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.

Muscle, bone and tendon respond anabolically to mechanical forces. Whether the intervertebral disc (IVD) can benefit from exercise is unclear. To examine whether exercise can beneficially affect IVD characteristics. This is a single-blinded 6-month randomised controlled trial (ACTRN12615001270505) in an exercise and physiotherapy clinic. Forty patients with chronic non-specific low back pain (NSCLBP) are included in this study. The primary outcome was lumbar IVD T2 time (MRI). Secondary outcomes included IVD diffusion coefficient and IVD expansion with short-duration lying. Twenty patients progressively loaded their lumbar IVDs (exercise) via an exercise programme involving progressive upright aerobic and resistance exercises targeting the trunk and major muscle groups and were compared to twenty patients who performed motor control training and manual therapy (control). Testing occurred at baseline, 3 months and 6 months. Seventeen exercise and fifteen control patients completed the interventions. There were no group-by-time differences in T2 time of the entire IVD (exercise 94.1 ± 10.0 ms vs. control 96.5 ± 9.3 ms, p = 0.549). Exercise patients had shorter T2 time in the posterior annulus at 6 months (82.7 ± 6.8 ms vs. 85.1 ± 8.0 ms, p = 0.028). Exercise patients showed higher L5/S1 apparent diffusion coefficients and decreased IVD height at 3 months (both p ≤ 0.050). After adjustments for multiple comparisons, differences lost statistical significance. Per-protocol and intent-to-treat analyses yielded similar findings. This trial found that 6 months of exercise did not benefit the IVD of people with NSCLBP. Based on this index study, future studies could investigate the effect of exercise on IVD in different populations, with different types, durations and/or intensities of exercise, and using different IVD markers. These slides can be retrieved under Electronic Supplementary Material.

ObjectiveTo explore a protection motivation theory screening tool for predicting rehabilitation adherence.DesignAnalysis of a randomised controlled trial.SettingAn exercise physiology and physiotherapist clinic.ParticipantsPatients with chronic low back pain (n=40).InterventionsGeneral strength and conditioning (GSC) compared with motor control and manual therapy. Primary and secondary outcome measures: predicting patient adherence to supervised sessions and dropout using the Sports Injury Rehabilitation Beliefs Scale, seven-item barriers checklist and Positive and Negative Affect Schedule and Sports Injury Rehabilitation Adherence Scale.ResultsAverage attendance was 77% (motor control and manual therapy) and 60% (GSC) with eight dropouts. No Sports Injury Rehabilitation Adherence Scale values other than 5 across all three components were recorded. Treatment efficacy (p=0.019), self-efficacy (p=0.001), rehabilitation value (p=0.028) and injury severity (p=0.002) positively correlated with susceptibility (the extent of vulnerability to having health problems from not taking action). Rehabilitation value positively correlated with self-efficacy (p=0.005). Injury severity positively correlated with rehabilitation value (p=0.011). The final model for number of cancellations included rehabilitation value only and accounted for approximately 12% of variance (p=0.033).ConclusionsPerceived value of rehabilitation should be considered by clinicians in the rehabilitation setting to improve treatment adherence in patients with chronic low back pain.Trial registration numberACTRN12615001270505.

IntroductionChronic low back pain disorders (CLBDs) present a substantial societal burden; however, optimal treatment remains debated. To date, pairwise and network meta-analyses have evaluated individual treatment modes, yet a comparison of a wide range of common treatments is required to evaluate their relative effectiveness. Using network meta-analysis, we aim to evaluate the effectiveness of treatments (acupuncture, education or advice, electrophysical agents, exercise, manual therapies/manipulation, massage, the McKenzie method, pharmacotherapy, psychological therapies, surgery, epidural injections, percutaneous treatments, traction, physical therapy, multidisciplinary pain management, placebo, ‘usual care’ and/or no treatment) on pain intensity, disability and/or mental health in patients with CLBDs.Methods and analysisSix electronic databases and reference lists of 285 prior systematic reviews were searched. Eligible studies will be randomised controlled/clinical trials (including cross-over and cluster designs) that examine individual treatments or treatment combinations in adult patients with CLBDs. Studies must be published in English, German or Chinese as a full-journal publication in a peer-reviewed journal. A narrative approach will be used to synthesise and report qualitative and quantitative data, and, where feasible, network meta-analyses will be performed. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, including the network meta-analysis extension (PRISMA-NMA). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for network meta-analysis will be implemented for assessing the quality of the findings.Ethics and disseminationEthical approval is not required for this systematic review of the published data. Findings will be disseminated via peer-reviewed publication.PROSPERO registration numberPROSPERO registration number CRD42020182039.

Purpose The Oswestry Disability Index (ODI) is a common aggregate measure of disability for people with Low Back Pain (LBP). Scores on individual items and the relationship between items of the ODI may help understand the complexity of low back disorders and their response to treatment. In this study, we present a network analysis to explore how individualised physiotherapy or advice might influence individual items of the ODI, and the relationship between those items, at different time points for people with LBP. Methods Data from a randomised controlled trial (n = 300) comparing individualised physiotherapy versus advice for low back pain were used. A network analysis was performed at baseline, 5, 10, 26 and 52 weeks, with the 10 items of the Oswestry Disability Index modelled as continuous variables and treatment group (Individualised Physiotherapy or Advice) modelled as a dichotomous variable. A Mixed Graphical Model was used to estimate associations between variables in the network, while centrality indices (Strength, Closeness and Betweenness) were calculated to determine the importance of each variable. Results Individualised Physiotherapy was directly related to lower Sleep and Pain scores at all follow-up time points relative to advice, as well as a lower Standing score at 10-weeks, and higher Lifting and Travelling scores at 5-weeks. The strongest associations in the network were between Sitting and Travelling at weeks 5 and 26, between Walking and Standing at week 10, and between Sitting and Standing scores at week 52. ODI items with the highest centrality measures were consistently found to be Pain, Work and Social Life. Conclusion This study represents the first to understand how individualised physiotherapy or advice differentially altered disability in people with LBP. Individualised Physiotherapy directly reduced Pain and Sleep more effectively than advice, which in turn may have facilitated improvements in other disability items. Through their high centrality measures, Pain may be considered as a candidate therapeutic target for optimising LBP management, while Work and Socialising may need to be addressed via intermediary improvements in lifting, standing, walking, travelling or sleep. Slower (5-week follow-up) improvements in Lifting and Travelling as an intended element of the Individualised Physiotherapy approach did not negatively impact any longer-term outcomes. Trials registration ACTRN12609000834257.

Animal and human cross-sectional data suggest that bone marrow adipose tissue (MAT) may respond to mechanical loads and exercise. We conducted the first randomised controlled trial of exercise on MAT modulations in humans.Forty patients with chronic non-specific low back pain (NSCLBP) were enrolled in a six-month single-blinded randomised controlled trial (ACTRN12615001270505). Twenty patients loaded their spines via progressive upright aerobic and resistance exercises targeting major muscle groups (Exercise). Twenty patients performed non-weightbearing motor control training and manual therapy (Control). Testing occurred at baseline, 3-months (3mo) and 6-months (6mo). Lumbar vertebral fat fraction (VFF) was measured using magnetic resonance imaging axial mDixon sequences.When compared to baseline (percent change), lumbar vertebral fat fraction (VFF; measured using magnetic resonance imaging axial mDixon sequences) was lower in Exercise at 3mo at L2 (-3.7[6.8]%, p = 0.033) and L4 (-2.6[4.1]%, p = 0.015), but not in Control. There were no between-group effects. The effects of Exercise on VFF were sex-specific, with VFF lower in men at L2, L3, L4 at 3mo and at L1, L2, L3 and L4 at 6mo (p all ≤ 0.05), but not in women. Leg and trunk lean mass were increased at 3mo in Exercise. Changes in VFF correlated significantly with changes in total fat (ρ = 0.40) and lean (ρ = -0.41) masses, but not with lumbar BMD (ρ = -0.10) or visceral adipose tissue volume (ρ = 0.23).This trial provided first prospective evidence in humans that a moderate exercise intervention may modulate lumbar VFF as a surrogate measure of MAT at 3mo, yet not 6mo. The effect of exercise on MAT may be more prominent in males than females.

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

Background: The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire, pain, muscle strength, scapular upward rotation, scapular coordinates, global rating of change, satisfaction scales, limiting angle in abduction range, limiting factor in abduction range, and incidence of dislocation. Primary analysis was by intention to treat based on linear mixed models. Results: Between-group differences showed significant effects favoring the Watson program for the WOSI (effect size [ES], 11.1; 95% CI, 1.9-20.2; P = .018) and for the limiting factor in abduction (ES, 0.1; 95% CI, 0.0-1.6; P = .023) at 12 weeks, and for the WOSI (ES, 12.6; 95% CI, 3.4-21.9; P =. 008), MISS (ES, 15.4; 95% CI, 5.9-24.8; P = .002), and pain (ES, -2.0; CI: -2.3 to -0.7, P = .003) at 24 weeks. Conclusion: For people with MDI, 12 sessions of the Watson MDI program were more effective than the Rockwood program at 12- and 24-week follow-up. Registration: ACTRN12613001240730 (Australian New Zealand Clinical Trials Registry).

Objectives To evaluate the effectiveness of individualised functional restoration plus guideline-based advice compared to advice alone in people with non-reducible discogenic pain (NRDP). Design Subgroup analysis within a multicentre, parallel group randomised controlled trial. Setting Fifteen primary care physiotherapy clinics. Participants Ninety-six participants with clinical features indicative of NRDP (6 week to 6 month duration of injury). Interventions Over a 10 week period physiotherapists provided 10 sessions of individualised functional restoration plus guideline-based advice or two sessions of advice alone Main outcome measures Primary outcomes were back and leg pain (separate numerical rating scales) and activity limitation (Oswestry Disability Index). Results Between-group differences favoured individualised functional restoration over advice for back pain (1.1, 95% CI 0.1 to 2.1), leg pain (1.5, 95% CI 0.4 to 2.6) and Oswestry (6.3, 95% CI 1.3 to 11.4) at 10 weeks as well as Oswestry at 26 weeks (6.6, 95% CI 1.4 to 11.8). Secondary outcomes and responder analyses also favoured physiotherapy functional restoration suggesting the differences were clinically important. Conclusions In people with NRDP of ≥6 weeks and ≤6 months duration, individualised functional restoration was more effective than advice for all primary outcomes at 10 weeks and sustained at 26 weeks for activity limitation. Our results suggest that for people with NRDP not recovering after 6 weeks, an individualised physiotherapy functional restoration program should be considered. Contribution of paper (1) A physiotherapist delivered functional restoration program individualised to pathoanatomical, psychosocial and neurophysiological barriers and incorporating guideline-based advice was more effective than advice alone in people with non-reducible discogenic low back pain of ≥6 weeks and ≤6 months duration. (2) This trial differs significantly from other studies on individualised physiotherapy, as it investigates a conservative management program that specifically targets the pathoanatomical subgroup non-reducible discogenic pain. ACTRN numbers: ACTRN12609000412235; ACTRN12609000834257.

Multidirectional instability of the shoulder is a type of glenohumeral joint shoulder instability. There are discrepancies in the definition and classification of this condition, which can make diagnosis and treatment selection challenging. Knowledge of contributing factors, the typical clinical presentation, and current best evidence for treatment options can assist in the diagnosis and appropriate treatment selection for this pathology. The purpose of this article is to present an overview of the current literature regarding the etiology, classification, assessment, and management of multidirectional instability of the glenohumeral joint.

A cost-utility analysis within a randomized controlled trial was conducted from the health care perspective.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).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.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.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.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.2.

We thank Travers et al 1 for highlighting the results of the Specific Treatment of Problems of the Spine (STOPS) trial.2 However, a number of their assertions are factually wrong, and we strongly disagree with their interpretation of our results. Travers et al argue that the recovery trajectory of the STOPS comparison group (guideline-based advice) was worse than for participant data from a meta-analysis of cohort studies by Costa et al .3 They propose the reason for this was our advice group receiving a pathoanatomical explanation as a component of the advice intervention, which may have had a negative effect. Travers et al conclude that the lower than expected recovery trajectory for the STOPS advice group renders our statistically and likely clinically important results favouring the STOPS primary intervention (individualised physiotherapy) over advice as potentially invalid. Practitioners4 and researchers5 understand that the validity and utility of research for clinical practice are influenced by the complexity of low back disorders (LBD).6 It is therefore essential that interpretation and comparison of research data are conducted using the principle of ‘apples for apples’. Travers et al suggest that the participants in the Costa et al meta-analysis were ‘broadly comparable’ with those in the STOPS trial. A closer analysis reveals that this is not the case. Travers et al compare the Costa et al recovery trajectories for ‘acute/subacute’ LBD with the STOPS participants. However, this comparison is based on the authors’ erroneous assertion that the Costa et al ’s acute group had a symptom duration of 0–12 …

Muscle, bone and tendon respond anabolically to mechanical forces. Whether the intervertebral disc (IVD) can benefit from exercise is unclear.To examine whether exercise can beneficially affect IVD characteristics.This is a single-blinded 6-month randomised controlled trial (ACTRN12615001270505) in an exercise and physiotherapy clinic.Forty patients with chronic non-specific low back pain (NSCLBP) are included in this study.The primary outcome was lumbar IVD T2 time (MRI). Secondary outcomes included IVD diffusion coefficient and IVD expansion with short-duration lying.Twenty patients progressively loaded their lumbar IVDs (exercise) via an exercise programme involving progressive upright aerobic and resistance exercises targeting the trunk and major muscle groups and were compared to twenty patients who performed motor control training and manual therapy (control). Testing occurred at baseline, 3 months and 6 months.Seventeen exercise and fifteen control patients completed the interventions. There were no group-by-time differences in T2 time of the entire IVD (exercise 94.1 ± 10.0 ms vs. control 96.5 ± 9.3 ms, p = 0.549). Exercise patients had shorter T2 time in the posterior annulus at 6 months (82.7 ± 6.8 ms vs. 85.1 ± 8.0 ms, p = 0.028). Exercise patients showed higher L5/S1 apparent diffusion coefficients and decreased IVD height at 3 months (both p ≤ 0.050). After adjustments for multiple comparisons, differences lost statistical significance. Per-protocol and intent-to-treat analyses yielded similar findings.This trial found that 6 months of exercise did not benefit the IVD of people with NSCLBP. Based on this index study, future studies could investigate the effect of exercise on IVD in different populations, with different types, durations and/or intensities of exercise, and using different IVD markers. These slides can be retrieved under Electronic Supplementary Material.

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

ObjectivesExercise can be used as a treatment for depressive symptoms in the general population. However, little is known as to whether exercise has mental health benefits for adults experiencing chronic low back pain (CLBP). The aim of this study was to examine the feasibility of two intervention protocols commonly used in clinical practice for treating chronic low back pain, but with differing exercise dose, on depressive symptoms.MethodsForty men and women (mean age = 35) experiencing chronic persistent (>3 months), non-specific low back pain were recruited into a randomised clinical trial during 2015-2016. Participants were randomised to receive motor control (low-dose exercise) and manual therapy (n = 20), or general strength and conditioning training (moderate-dose exercise) (n = 20). Depressive symptoms were assessed fortnightly throughout a 6-month follow-up period using the Centre for Epidemiologic Studies Depression Scale (CES-D 10). Linear mixed models were used to examine within-group and between-group changes in depressive symptoms.ResultsMean CES-D 10 score at baseline was 9.17 (SD = 4.32). There was evidence of a small decrease in average depressive symptoms over time (β -0.19 per fortnight, 95% CI = -0.34, -0.02). However, there was no evidence that change over time was dependent on treatment group.ConclusionsReduction in depressive symptoms amongst adults with CLBP occurred with both treatment methods (motor control [low-dose exercise] and manual therapy; or general strength and conditioning [moderate-dose exercise]). Further interventions including a true control group are needed to draw conclusions as to the effectiveness of each of these treatment methods on depressive symptoms amongst adults with CLBP.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12615001270505. Registered on 20 November 2015.

BackgroundProximal hamstring tendinopathy (PHT) is a condition that occurs at all ages and levels of sporting participation. Presenting as localised lower buttock pain with tasks such as squatting and sitting, it can cause disability with sport, work and other activities of daily living. Recent research has investigated the effect of isometric exercise on pain and strength with a range of tendinopathies but there are no published studies on PHT. This protocol paper details a study investigating the effectiveness of isometric compared with isotonic exercise on pain and strength in people with PHT.Methods/DesignThe study is a prospective, cross-over randomised controlled trial (RCT). Twenty participants with PHT, recruited from the local community and sporting clubs will be recruited for the study. Participants will receive one session of isotonic hamstring strength exercises and one session of isometric hamstring exercise, with random allocation to the order of intervention.Primary outcomes will be hamstring strength measured with a dynamometer and pain with a functional task, assessed immediately following and 45 min after intervention. A secondary outcome will be pain with sitting assessed 24 hours after intervention.The effect of isotonic versus isometric exercise on hamstring pain and strength will be determined using a repeated measures linear mixed model. Further analyses will determine the proportion of patients with clinically important pain and strength improvements, using relative risks, χ2 testing and number needed to treat.DiscussionThis RCT protocol will investigate the effect of isometric compared with isotonic exercise for PHT.

Background Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach. Purpose The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP. Study design Systematic review Methods Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted. Results Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention. Conclusions This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.

Exercise and spinal manipulative therapy are commonly used for the treatment of chronic low back pain (CLBP) in Australia. Reduction in pain intensity is a common outcome, however, it is only one measure of intervention efficacy in clinical practice. Therefore, we evaluated the effectiveness of two common clinical interventions on physical and self-report measures in CLBP. Participants were randomized to a 6‑month intervention of general strength and conditioning (GSC, n = 20, up to 52 sessions) or motor control exercise plus manual therapy (MCMT, n =20, up to 12 sessions). Pain intensity was measured at baseline and fortnightly throughout the intervention. Trunk extension and flexion endurance, leg muscle strength and endurance, paraspinal muscle volume, cardio‑respiratory fitness and self-report measures of kinesiophobia, disability and quality of life were assessed at baseline and 3- and 6-month follow-up. Pain intensity differed favoring MCMT between-groups at week 14 and 16 of treatment (both, p = 0.003), but not at 6-month follow‑up. Both GSC (mean change (95%CI): &minus, 10.7 (&minus, 18.7, &minus, 2.8) mm, p = 0.008) and MCMT (&minus, 19.2 (&minus, 28.1, &minus, 10.3) mm, p &lt, 0.001) had within-group reductions in pain intensity at six months, but did not achieve clinically meaningful thresholds (20mm) within- or between‑group. At 6-month follow-up, GSC increased trunk extension (mean difference (95% CI): 81.8 (34.8, 128.8) s, p = 0.004) and flexion endurance (51.5 (20.5, 82.6) s, p = 0.004), as well as leg muscle strength (24.7 (3.4, 46.0) kg, p = 0.001) and endurance (9.1 (1.7, 16.4) reps, p = 0.015) compared to MCMT. GSC reduced disability (&minus, 5.7 (‑11.2, &minus, 0.2) pts, p = 0.041) and kinesiophobia (&minus, 6.6 (&minus, 9.9, &minus, 3.2) pts, 0.001) compared to MCMT at 6‑month follow-up. Multifidus volume increased within-group for GSC (p = 0.003), but not MCMT or between-groups. No other between-group changes were observed at six months. Overall, GSC improved trunk endurance, leg muscle strength and endurance, self-report disability and kinesiophobia compared to MCMT at six months. These results show that GSC may provide a more diverse range of treatment effects compared to MCMT.

Background The most commonly recommended treatment for multidirectional instability (MDI) is exercise-based management, followed by surgery if exercise management fails. We aimed to evaluate the effectiveness of exercise-based management compared with surgery in patients with MDI. Secondary aims were to identify effective protocols and any adverse effects associated with exercise or surgery. Method The Cochrane database of systematic reviews, MEDLINE, EMBASE, CINAHL, PEDro, Current Contents, AMED, AMI, Ausport and Clinical Trials Registers were searched for published and unpublished studies from inception date to August 2014, using the key words multidirectional instability, and glenohumeral and exercise and surgery. Selection criteria included all study designs (except case reports and case series) and participants with MDI where both exercise-based management and surgery were compared in the same study. Inclusion criteria were not limited by outcomes. Risk of bias was assessed using Cochrane criteria. The GRADE approach was used to synthesise the evidence. Results 4 non-randomised studies met the inclusion criteria. Risk of bias was high in all 4 studies. GRADE assessment revealed very low-quality evidence that surgery was superior to exercise therapy for impairment outcome measures, and exercise was favoured over surgery for patient-reported outcome measures. Summary The effect of exercise-based management compared with surgery for MDI is difficult to determine due to participant heterogeneity and a high level of bias across included studies.

To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs).Prospective inception cohort study.Primary care private physiotherapy clinics in Melbourne, Australia.Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration.Not applicable.Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale.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.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.

A pre-planned effect modifier analysis of the Specific Treatment of Problems of the Spine (STOPS) randomized controlled trial. 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. 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. The trial involved 300 participants with low back pain and/or referred leg pain (≥6 weeks, ≤6 month 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 Numerical Rating Scale) and activity limitation (Oswestry Disability Index) over a 52-week follow-up. Participants with higher levels of back pain, higher Orebro 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. 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 Orebro scores. Level of Evidence: 2

Background The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise. Methods The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence. Results The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low–quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength. Conclusions The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Over the past decade a wide variety of approaches for the management of low back disorders (LBD) have been developed and evaluated in clinical trials. As a consequence physiotherapists and researchers interested in LBD are faced with a range of issues to do with complexity. These issues will be explored and suggestions made to improve the delivery of high quality research evidence and better patient outcomes.

Objectives The lumbar intervertebral disc is a known source of low back pain (LBP). Various clinical features of discogenic pain have been proposed, but none have been validated. Several subgroups of discogenic pain have been hypothesised, with non-reducible discogenic pain (NRDP) proposed as a relevant clinical subgroup. The objectives of this study were to obtain consensus from an expert panel on the features of discogenic low back pain, the existence of subgroups of discogenic LBP, particularly NRDP, and the associated features of NRDP. Design Three-round Delphi survey. Participants Twenty-one international physiotherapists with expertise in LBP. Methods Panellists listed and ranked features that they believed to be indicative of discogenic pain and NRDP. On completion of Round 3, features with ≥50% agreement between panellists were deemed to have reached consensus. Results After three rounds, 10 features of discogenic LBP were identified. Nineteen of the panellists believed that NRDP was a subgroup of discogenic LBP, and nine features of NRDP were identified. Conclusion This study provides preliminary validation for the features associated with discogenic LBP. It also provides evidence supporting the existence and features of NRDP as a separate clinical subgroup of discogenic LBP.

Over the past decade research into the effectiveness of low back disorders (LBDs) has focused on the classification of subgroups more likely to respond to specific treatment. Much of this research has explicitly excluded a focus on pathoanatomical factors based on a questionable interpretation of the biopsychosocial model. Common justifications and potential issues with this approach are explored with recommendations made for future clinical and research practice.

BACKGROUND: The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology. OBJECTIVES: To determine the effects of PFR for post-acute LBP. DATA SOURCES: Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave. RESULTS: Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence. CONCLUSIONS: Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.

IntroductionThe most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI.Methods and analysisConsenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, symptomatic onset, limiting factor and angle of limiting factor in abduction range, incidence of complete glenohumeral joint dislocation, global rating of change, satisfaction scores, the Orebro Musculoskeletal Pain Questionnaire, adverse events and compliance with the home exercise programme. Data will be analysed on intention-to-treat principles and a per protocol basis.DiscussionThis trial will evaluate whether there are differences in outcomes between the Rockwood and the Watson MDI programmes for participants with MDI.Ethics and disseminationParticipant confidentiality will be maintained with publication of results. Ethics approval: Faculty of Health Sciences (FHEC12/201).Trial registration numberACTRN12613001240730; Pre-results.

Background Context Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population. Purpose To determine the effectiveness of physical therapist-delivered individualized functional restoration as an adjunct to guideline-based advice in people with lumbar disc herniation and associated radiculopathy. Study Design This is a preplanned subgroup analysis of a multicenter parallel group randomized controlled trial. Patient Sample The study included 54 participants with clinical features of radiculopathy (6-week to 6-month duration) and imaging showing a lumbar disc herniation. Outcome Measures Primary outcomes were activity limitation (Oswestry Disability Index) and separate 0–10 numerical pain rating scales for leg pain and back pain. Measures were taken at baseline and at 5, 10, 26, and 52 weeks. Methods The participants were randomly allocated to receive either individualized functional restoration incorporating advice (10 sessions) or guideline-based advice alone (2 sessions) over a 10-week period. Treatment was administered by 11 physical therapists at private clinics in Melbourne, Australia. Results Between-group differences for activity limitation favored the addition of individualized functional restoration to advice alone at 10 weeks (7.7, 95% confidence interval [CI] 0.3–15.1) and 52 weeks (8.2, 95% CI 0.7–15.6), as well as back pain at 10 weeks (1.4, 95% CI 0.2–2.7). There were no significant differences between groups for leg pain at any follow-up. Several secondary outcomes also favored individualized functional restoration over advice. Conclusions In participants with lumbar disc herniation and associated radiculopathy, an individualized functional restoration program incorporating advice led to greater reduction in activity limitation at 10- and 52-week follow-ups compared with guideline-based advice alone. Although back pain was significantly reduced at 10 weeks with individualized functional restoration, this effect was not maintained at later timepoints, and there were no significant effects on leg pain, relative to guideline-based advice.

Background: It has been recommended that clinical trials on people with low back disorders (LBDs) should have a greater focus on subgroup specific treatment in order to increase the likelihood of clinically meaningful effects being demonstrated. Functional restoration is a treatment approach that has demonstrated some evidence of effectiveness in subacute and chronic LBDs. However, most studies to date have not used a clearly defined and appropriately detailed clinical protocol designed for and applied to a homogenous subgroup.Objectives: This paper presents a detailed classification and treatment protocol for people with a LBD and clinical features indicative of multifactorial persistent pain. The treatment is directed at psychosocial and neurophysiological barriers to recovery.Discussion: The classification and treatment components in the clinical protocol are discussed.Conclusion: The described clinical protocol will be used in the specific treatment of problems of the spine (STOPS) trials comp...

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.

Background: It has been widely recommended that clinical trials on people with low back disorders (LBDs) should have a greater focus on subgroup specific treatment in order to increase the likeliho...

Background: It has been widely recommended that clinical trials on people with low back disorders should have a greater focus on subgroup specific treatment in order to increase the likelihood of clinically meaningful effects being demonstrated. The McKenzie approach to assessing and treating patients with a directional preference is a potentially useful and widely used clinical method in providing specific treatment. Studies to date have not used a clearly defined and appropriately detailed clinical protocol for the McKenzie approach that is reproducible in the clinical or research setting.Objectives: This paper presents a detailed classification and treatment protocol for people with clinical features thought to be indicative of reducible discogenic pain with a directional preference that is responsive to mechanical loading strategies.Discussion: A pathoanatomical interpretation of the McKenzie approach, classification principles and particular treatment components in the clinical protocol are d...

Background: It has been widely recommended that clinical trials involving people with low back disorders should identify subgroups and provide specific treatment in order to increase the likelihood of clinically meaningful effects being demonstrated. The Maitland approach to providing manual therapy is an appropriate and widely used clinical method in providing specific treatment. However, few clinical trials have described a detailed clinical protocol that allows replication in clinical and research practice.Objectives: This paper presents a detailed classification and treatment protocol for people with clinical features indicating a likely positive response to specific manual therapy.Conclusion: The presented protocol will be used in the Specific Treatment for Problems of the Spine trials comparing specific physiotherapy to evidence-based advice.

Background and PurposeThe lumbar zygapophyseal joints (LZJs) are thought to be a source of low back pain (LBP); however, no valid or reliable indicators exist. The purpose of this study was to obtain a consensus from an expert panel on the indicators of LZJ pain.SubjectsA multidisciplinary panel of 20 experts in the field of LBP participated in this study.MethodsA 3-round Delphi survey designed to obtain a consensus on the indicators of LZJ pain was completed by use of accepted protocols. Subjects also were asked to justify their selection of each indicator.ResultsFollowing the 3 rounds, consensus was achieved, and 12 indicators were identified. Those that reached the highest levels of consensus were a positive response to facet joint injection, localized unilateral LBP, positive medial branch block, pain upon unilateral palpation of the LZJ or transverse process, lack of radicular features, pain eased by flexion, and pain, if referred, located above the knee. Justifications for the experts’ selection of the indicators, predominantly based on pathoanatomical mechanisms, also were described.Discussion and ConclusionThis Delphi survey identified 12 indicators of LZJ pain, each with an associated pathoanatomical mechanism justifying selection. This survey provides preliminary validation for these indicators, which will be of value in further research into the classification and treatment of LZJ pain.

The classification of low back pain has been proposed as a high research priority due to the possible confounding effect of sample heterogeneity on effect sizes for outcome studies investigating treatment efficacy. However, the literature is unclear regarding methodological criteria for the development and validation of low back pain classification systems. The objectives of this paper were to describe and discuss the methodology used in studies researching the development and validation of low back pain classification systems. A database search for relevant papers was conducted, and data describing the frequency of utilisation of specific methodologies extracted and summarised. Seventy-seven papers were included in the review. Considerable variability in the methodological approaches used was found. Based on the results of the review and a comparison with the theory of classification, recommendations are made for future research into the classification of low back pain.

Background: Successful management of workers on sick leave due to low back pain by the general physician and physiotherapist depends on reliable prognostic information on the course of low back pain and work resumption. Methods: Retrospective cohort study in 194 patients who were compensated because of chronic low back pain and who were treated by a physiotherapy functional restoration program. Patient-reported and clinician based prognostic indicators were assessed at baseline before patients entered the functional restoration program. We investigated the predictive value of these indicators on work status at 6 months. Relationships were studied using logistic regression analysis in a 2-step bootstrap modelling approach and a nomogram was developed. Discrimination and calibration of the nomogram was evaluated internally and the explained variation of the nomogram calculated. Results: Seventy percent of workers were back to work at 6 months. We found that including duration of complaints, functional disability, disc herniation and fear avoidance beliefs resulted in the "best" prognostic model. All these factors delayed work resumption. This model was used to construct a nomogram. The explained variation of the nomogram was 23.7%. Discrimination was estimated by the area under the receiver operating characteristic curve and was 0.76 and for calibration we used the slope estimate that was 0.91. The positive predictive values of the nomogram at different cut-off levels of predicted probability were good. Conclusions: Knowledge of the predictive value of these indicators by physicians and physiotherapists will help to identify subgroups of patients and will thus enhance clinical decision-making. © 2007 Springer Science+Business Media, LLC.

Background Low back disorders are prevalent and directional preference management is a common treatment with mixed evidence for effectiveness. Objectives To determine the effectiveness of individualised directional preference management plus guideline-based advice versus advice alone in participants with reducible discogenic pain of 6-week to 6-month duration. Design Pre-planned secondary analysis of a multicentre, parallel group randomised controlled trial. Methods Participants were randomly allocated to receive a 10-week physiotherapy program of 10-sessions of individualised directional preference management plus guideline-based advice (n = 40) or 2-sessions of advice alone (n = 38). Primary outcomes were back pain, leg pain and activity limitation. Outcomes were taken at baseline and 5, 10, 26, and 52-weeks. Results Between-group differences significantly favoured directional preference management compared with advice for back pain at 5-weeks (1.28; 95% CI 0.34–2.23) and 10-weeks (1.45; 95% CI 0.51–2.40), and leg pain at 10-weeks (1.21; 95% CI 0.04–2.39). These short-term differences were not maintained. There were no significant differences between-groups for activity limitation. Secondary outcomes and responder analyses favoured directional preference management suggesting between-group differences were clinically important. Conclusions In people with reducible discogenic pain, individualised directional preference management plus guideline-based advice resulted in significant and rapid improvement in short-term back and leg pain compared with advice alone. These effects were not maintained at long-term and there were no differences in activity limitation. Individualised directional preference management could be considered for patients with reducible discogenic pain seeking rapid pain relief however further research is indicated.

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.