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Study design: Systematic review with meta-analysis and meta-regression.
Background and objectives: We systematically reviewed and delineated the existing evidence on sustainability effects of motor control exercises on pain intensity and disability in chronic low back pain patients when compared with an inactive or passive control group or with other exercises. Secondary aims were to reveal whether moderating factors like the time after intervention completion, the study quality, and the training characteristics affect the potential sustainability effects.
Methods: Relevant scientific databases (Medline, Web of Knowledge, Cochrane) were screened. Eligibility criteria for selecting studies: All RCTs und CTs on chronic (≥ 12/13 weeks) nonspecific low back pain, written in English or German and adopting a longitudinal core-specific/stabilizing sensorimotor control exercise intervention with at least one pain intensity and disability outcome assessment at a follow-up (sustainability) timepoint of ≥ 4 weeks after exercise intervention completion.
Results and conclusions: From the 3,415 studies that were initially retrieved, 10 (2 CTs & 8 RCTs) on N = 1081 patients were included in the review and analyses. Low to moderate quality evidence shows a sustainable positive effect of motor control exercise on pain (SMD = -.46, Z = 2.9, p < .001) and disability (SMD = -.44, Z = 2.5, p < .001) in low back pain patients when compared to any control. The subgroups’ effects are less conclusive and no clear direction of the sustainability effect at short versus mid versus long-term, of the type of the comparator, or of the dose of the training is given. Low quality studies overestimated the effect of motor control exercises.
Vibroarthrography measures joint sounds caused by sliding of the joint surfaces over each other. and can be affected by joint health, load and type of movement. Since both warm-up and muscle fatigue lead to local changes in the knee joint (e.g., temperature increase, lubrication of the joint, muscle activation), these may impact knee joint sounds. Therefore, this study investigates the effects of warm-up and muscle fatiguing exercise on knee joint sounds during an activity of daily living. Seventeen healthy, physically active volunteers (25.7 ± 2 years, 7 males) performed a control and an intervention session with a wash-out phase of one week. The control session consisted of sitting on a chair, while the intervention session contained a warm-up (walking on a treadmill) followed by a fatiguing exercise (modified sit-to-stand) protocol. Knee sounds were recorded by vibroarthrography (at the medial tibia plateau and at the patella) at three time points in each session during a sit-to-stand movement. The primary outcome was the mean signal amplitude (MSA, dB). Differences between sessions were determined by repeated measures ANOVA with intra-individual pre-post differences for the warm-up and for the muscle fatigue effect. We found a significant difference for MSA at the medial tibia plateau (intervention: mean 1.51 dB, standard deviation 2.51 dB; control: mean -1.28 dB, SD 2.61 dB; F = 9.5; p = .007; η2 = .37) during extension (from sit to stand) after the warm-up. There was no significant difference for any parameter after the muscle fatiguing exercise (p > .05). The increase in MSA may mostly be explained by an increase in internal knee load and joint friction. However, neuromuscular changes may also have played a role. It appears that the muscle fatiguing exercise has no impact on knee joint sounds in young, active, symptom-free participants during sit to stand.
Aim: The aim of the study was to identify common orthopedic sports injury profiles in adolescent elite athletes with respect to age, sex, and anthropometrics.
Methods: A retrospective data analysis of 718 orthopedic presentations among 381 adolescent elite athletes from 16 different sports to a sports medical department was performed. Recorded data of history and clinical examination included area, cause and structure of acute and overuse injuries. Injury-events were analyzed in the whole cohort and stratified by age (11–14/15–17 years) and sex. Group differences were tested by chi-squared-tests. Logistic regression analysis was applied examining the influence of factors age, sex, and body mass index (BMI) on the outcome variables area and structure (α = 0.05).
Results: Higher proportions of injury-events were reported for females (60%) and athletes of the older age group (66%) than males and younger athletes. The most frequently injured area was the lower extremity (47%) followed by the spine (30.5%) and the upper extremity (12.5%). Acute injuries were mainly located at the lower extremity (74.5%), while overuse injuries were predominantly observed at the lower extremity (41%) as well as the spine (36.5%). Joints (34%), muscles (22%), and tendons (21.5%) were found to be the most often affected structures. The injured structures were different between the age groups (p = 0.022), with the older age group presenting three times more frequent with ligament pathology events (5.5%/2%) and less frequent with bony problems (11%/20.5%) than athletes of the younger age group. The injured area differed between the sexes (p = 0.005), with males having fewer spine injury-events (25.5%/34%) but more upper extremity injuries (18%/9%) than females. Regression analysis showed statistically significant influence for BMI (p = 0.002) and age (p = 0.015) on structure, whereas the area was significantly influenced by sex (p = 0.005).
Conclusion: Events of soft-tissue overuse injuries are the most common reasons resulting in orthopedic presentations of adolescent elite athletes. Mostly, the lower extremity and the spine are affected, while sex and age characteristics on affected area and structure must be considered. Therefore, prevention strategies addressing the injury-event profiles should already be implemented in early adolescence taking age, sex as well as injury entity into account.
Background: To facilitate access to evidence-based care for back pain, a German private medical insurance offered a health program proactively to their members. Feasibility and long-term efficacy of this approach were evaluated.
Methods: Using Zelen’s design, adult members of the health insurance with chronic back pain according to billing data were randomized to the intervention (IG) or the control group (CG). Participants allocated to the IG were invited to participate in the comprehensive health program comprising medical exercise therapy and life style coaching, and those allocated to the CG to a longitudinal back pain survey. Primary outcomes were back pain severity (Korff’s Chronic Pain Grade Questionnaire) as well as health-related quality of life (SF-12) assessed by identical online questionnaires at baseline and 2-year follow-up in both study arms. In addition to analyses of covariance, a subgroup analysis explored the heterogeneity of treatment effects among different risks of back pain chronification (STarT Back Tool).
Results: Out of 3462 persons selected, randomized and thereafter contacted, 552 agreed to participate. At the 24-month follow-up, data on 189 of 258 (73.3%) of the IG were available, in the CG on 255 of 294 (86.7%). Significant, small beneficial effects were seen in primary outcomes: Compared to the CG, the IG reported less disability (1.6 vs 2.0; p = 0.025; d = 0.24) and scored better at the SF-12 physical health scale (43.3 vs 41.0; p < 0.007; d = 0.26). No effect was seen in back pain intensity and in the SF-12 mental health scale. Persons with medium or high risk of back pain chronification at baseline responded better to the health program in all primary outcomes than the subgroup with low risk at baseline.
Conclusions: After 2 years, the proactive health program resulted in small positive long-term improvements. Using risk screening prior to inclusion in the health program might increase the percentage of participants deriving benefits from it.
Background: The Musculoskeletal Health Questionnaire (MSK-HQ) has been developed to measure musculoskeletal health status across musculoskeletal conditions and settings. However, the MSK-HQ needs to be further evaluated across settings and different languages.
Objective: The objective of the study was to evaluate and compare measurement properties of the MSK-HQ across Danish (DK) and English (UK) cohorts of patients from primary care physiotherapy services with musculoskeletal pain.
Methods: MSK-HQ was translated into Danish according to international guidelines. Measurement invariance was assessed by differential item functioning (DIF) analyses. Test-retest reliability, measurement error, responsiveness and minimal clinically important change (MCIC) were evaluated and compared between DK (n = 153) and UK (n = 166) cohorts.
Results: The Danish version demonstrated acceptable face and construct validity. Out of the 14 MSK-HQ items, three items showed DIF for language (pain/stiffness at night, understanding condition and confidence in managing symptoms) and three items showed DIF for pain location (walking, washing/dressing and physical activity levels). Intraclass Correlation Coefficients for test-retest were 0.86 (95% CI 0.81 to 0.91) for DK cohort and 0.77 (95% CI 0.49 to 0.90) for the UK cohort. The systematic measurement error was 1.6 and 3.9 points for the DK and UK cohorts respectively, with random measurement error being 8.6 and 9.9 points. Receiver operating characteristic (ROC) curves of the change scores against patients’ own judgment at 12 weeks exceeded 0.70 in both cohorts. Absolute and relative MCIC estimates were 8–10 points and 26% for the DK cohort and 6–8 points and 29% for the UK cohort.
Conclusions: The measurement properties of MSK-HQ were acceptable across countries, but seem more suited for group than individual level evaluation. Researchers and clinicians should be aware that some discrepancy exits and should take the observed measurement error into account when evaluating change in scores over time.
Background: The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations.
Objective: To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity.
Methods: A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models.
Results: The participants’ (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%.
Conclusions: The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.
Background: Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation.
Methods: A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology.
Results: Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient’s learning journey, trusting the therapist and needing conviction. Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients’ trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use.
Conclusion: Key barriers identified are the patients’ treatment expectations and physiotherapists’ adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients’ trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research.
Stratified care for low back pain (LBP) has been shown to be clinically- and cost-effective in the UK, but its transferability to the German healthcare system is unknown. This study explores LBP patients’ perspectives regarding future implementation of stratified care, through in-depth interviews (n = 12). The STarT-Back-Tool was completed by participants prior to interviews. Interview data were analysed using Grounded Theory. The overarching theme identified from the data was ‘treatment-success’, with subthemes of ‘assessment and treatment planning’, ‘acceptance of the questionnaire’ and ‘contextual factors’. Patients identified the underlying cause of pain as being of great importance (whereas STarT-Back allocates treatment based on prognosis). The integration of the STarT-Back-Tool in consultations was considered helpful as long as it does not disrupt the therapeutic relationship, and was acceptable if tool results are handled confidentially. Results indicate that for patients to find STarT-Back acceptable, the shift from a focus on identifying a cause of pain and subsequent diagnosis, to prediction-orientated treatment planning, must be made clear. Patient ‘buy in’ is important for successful uptake of clinical interventions, and findings can help to inform future strategies for implementing STarT-Back in the Germany, as well as having potential implications for transferability to other similar healthcare systems.
Background: Stratified care is an up-to-date treatment approach suggested for patients with back pain in several guidelines. A comprehensively studied stratification instrument is the STarT Back Tool (SBT). It was developed to stratify patients with back pain into three subgroups, according to their risk of persistent disabling symptoms. The primary aim was to analyse the disability differences in patients with back pain 12 months after inclusion according to the subgroups determined at baseline using the German version of the SBT (STarT-G). Moreover, the potential to improve prognosis for disability by adding further predictor variables, an analysis for differences in pain intensity according to the STarT-Classification, and discriminative ability were investigated.
Methods: Data from the control group of a randomized controlled trial were analysed. Trial participants were members of a private medical insurance with a minimum age of 18 and indicated as having persistent back pain. Measurements were made for the risk of back pain chronification using the STarT-G, disability (as primary outcome) and back pain intensity with the Chronic Pain Grade Scale (CPGS), health-related quality of life with the SF-12, psychological distress with the Patient Health Questionnaire-4 (PHQ-4) and physical activity. Analysis of variance (ANOVA), multiple linear regression, and area under the curve (AUC) analysis were conducted.
Results: The mean age of the 294 participants was 53.5 (SD 8.7) years, and 38% were female. The ANOVA for disability and pain showed significant differences (p < 0.01) among the risk groups at 12 months. Post hoc Tukey tests revealed significant differences among all three risk groups for every comparison for both outcomes. AUC for STarT-G’s ability to discriminate reference standard ‘cases’ for chronic pain status at 12 months was 0.79. A prognostic model including the STarT-Classification, the variables global health, and disability at baseline explained 45% of the variance in disability at 12 months.
Conclusions: Disability differences in patients with back pain after a period of 12 months are in accordance with the subgroups determined using the STarT-G at baseline. Results should be confirmed in a study developed with the primary aim to investigate those differences.
Background: The STarT-Back-Approach (STarT: Subgroups for Targeted Treatment) was developed in the UK and has demonstrated clinical and cost effectiveness. Based on the results of a brief questionnaire, patients with low back pain are stratified into three treatment groups. Since the organisation of physiotherapy differs between Germany and the UK, the aim of this study is to explore German physiotherapists’ views and perceptions about implementing the STarT-Back-Approach.
Methods: Three two-hour think-tank workshops with physiotherapists were conducted. Focus groups, using a semi-structured interview guideline, followed a presentation of the STarT-Back-Approach, with discussions audio recorded, transcribed and qualitatively analysed using content analysis.
Results: Nineteen physiotherapists participated (15 female, mean age 41.2 (SD 8.6) years). Three main themes emerged, each with multiple subthemes: 1) the intervention (15 subthemes), 2) the healthcare context (26 subthemes) and 3) individual characteristics (8 subthemes). Therapists’ perceptions of the extent to which the STarT-Back intervention would require changes to their normal clinical practice varied considerably. They felt that within their current healthcare context, there were significant financial disincentives that would discourage German physiotherapists from providing the STarT-Back treatment pathways, such as the early discharge of low-risk patients with supported self-management materials. They also discussed the need for appropriate standardised graduate and post-graduate skills training for German physiotherapists to treat high-risk patients with a combined physical and psychological approach (e.g., communication skills).
Conclusions: Whilst many German physiotherapists are positive about the STarT-Back-Approach, there are a number of substantial barriers to implementing the matched treatment pathways in Germany. These include financial disincentives within the healthcare system to early discharge of low-risk patients. Therapists also highlighted the need for solutions in respect of scalable physiotherapy training to gain skills in combined physical and psychological approaches.