Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Beliefs About Low Back Pain in the Norwegian General Population: Are They Related to Pain Experiences and Health Professionals? A 2-year prospective longitudinal study on low back pain in primary school children Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: secondary analyses of three randomized clinical trials Spinal Manipulative Therapy Has an Immediate Effect on Thermal Pain Sensitivity in People With Low Back Pain: A Randomized Controlled Trial Does physical activity change predict functional recovery in low back pain? Protocol for a prospective cohort study Work factors as predictors of intense or disabling low back pain; a prospective study of nurses’ aides Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's 'high-risk' intervention (StarT Back; ISRCTN 37113406). Physiotherapists' use of advice and exercise for the management of chronic low back pain: a national survey. Identification of Modifiable Personal Factors That Predict New-onset Low Back Pain: A Prospective Study of Female Nursing Students Does physiotherapy management of low back pain change as a result of an evidence-based educational programme? Does a patient’s physical activity predict recovery from an episode of acute low back pain? A prospective cohort study Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol It's time for change with the management of non-specific chronic low back pain A walking programme and a supervised exercise class versus usual physiotherapy for chronic low back pain: a single-blinded randomised controlled trial. (The Supervised Walking In comparison to Fitness Training for Back Pain (SWIFT) Trial) Physical Therapy Treatment of Back Complaints on Children and Adolescents The causality field (extrinsic and intrinsic factors) in industrial subacute low back pain patients. Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Low back pain in Australian adults. health provider utilization and care seeking. Psychosocial Factors in the Workplace‐Do They Predict New Episodes of Low Back Pain?: Evidence From the South Manchester Back Pain Study Prediction model for unsuccessful return to work after hospital-based intervention in low back pain patients
Background . The IMPaCT Back study ( IMplementation to improve Patient Care through Targeted treatment for Back pain ) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain ( LBP ) in primary care . This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aim ed at equipping clinicians to deliver it . The subgrouping and targeted treatment system . This system differs from ‘ one-size fits all ’ usual practice as it suggests that first contact health care practitioners should systematic ally allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity . Patients in each subgroup ( those at low , medium or high risk of chronicity ) are then managed according to a targeted treatment system of increasing complexity . The subgrouping tools . Subgrouping tools help guide clinical decision-making about treatment and onward referral . Two subgrouping tools have been used in the IMPaCT Back study , a 9-item version used by participating physiotherapists and a 6-item version used by GPs . The targeted treatments . The targeted treatments include a minimal intervention delivered by GPs ( for those patients at low risk of poor outcome ) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability  ( for those at medium risk ) and additional cognitive-behavioural approaches to help address  psychological and social obstacles to recovery  ( for those at high risk ) . The training packages . Building on previous interventions for other pilot studies and r and omized trials , we have developed and delivered clinical training and support programmes for GPs and physiotherapists . Discussion . This paper describes in detail the IMPaCT Back study ’s subgrouping for targeted treatment system and the training and mentoring packages aim ed at equipping clinicians to deliver it , within the IMPaCT Back study . Study registration . IS RCT N55174281 Study Design . A baseline study of the general population and the health care providers in 3 Norwegian counties . Objective . To investigate if beliefs about low back pain ( LBP ) are related to personal experiences and profession sought for care . Summary of Background Data . Myths about LBP that are ab and oned by health professionals are still alive in the public . Such myths represent pain avoidance beliefs and passive coping strategies that may hinder normal spontaneous recovery from an episode of LBP . Methods . A sample of 1502 r and omly selected people was interviewed  by telephone , and all the 1105 physicians , physiotherapists , and chiropractors in the area were sent a question naire in April 2002 . All respondents gave their responses in terms of degree of agreement to 6 statements reflecting beliefs about LBP . Results . Personal back pain experiences were important for beliefs about LBP . People with a history of previous back pain had more faith in the 2 statements “ Back pain recovers best by itself ” ( 52.2 % ) and “ In most cases back pain recovers by itself in a couple of weeks ” ( 32.5 % ) than those with current pain ( 36.9 % and 20.9 % , respectively , P < 0.000 ) . There were significant differences in beliefs between physicians and the chiropractors concerning the same 2 statements , and these differences were also reflected in the beliefs of patients treated by the different professional groups . Conclusions . Belief in spontaneous recovery from LBP seems to be positively correlated to previous experience with LBP without current pain . Patients of the various health care providers seem to have a faith in spontaneous recovery similar to that of their health care provider . These differences may frustrate the public and patients who visit more than one provider , and hinder collaboration among professional groups Abstract . There is increasing evidence that non-specific low back pain ( LBP ) is common among children and adolescents , but there are few longitudinal studies on this subject . This is a longitudinal prospect i ve study aim ed at finding factors associated with the prediction of low back pain in schoolchildren aged 9–12 years , which is a younger age group than has previously been studied . This study was performed on school children in the city of Antwerp , Belgium . A total of 287 children filled out a question naire  and were examined at the beginning of the study ( T1 ) and 2 years later ( T2 ) . The question naire asked about back pain , general health , health perceptions , quality of life perceptions , sports , leisure , daily life , school life ( weight of satchel ... ) and some issues related to parents ( smoking , LBP ) . The question naire reliability was tested . Logistic regression was used to analyse the data . No predictors for LBP in children could be identified . Using logistic regression techniques , we analysed the children who reported no lifetime episode of LBP at both T1 and T2 , the children who did report a lifetime episode at both T1 and T2 and also those who reported a history of LBP at T2 only ( New LBP ) . At T2 there were 51 children ( 17.8 % ) reporting suffering at least one lifetime episode of LBP who had not reported such an episode at T1 . Only one parameter showed a statistical difference : New LBP was observed significantly more frequently in children who do not walk to school ( P<0.0001 ) . An interesting point of this study is that a number of children who had reported a history of LBP at T1 did not do so at T2 . It may be that LBP in children is so benign and its natural history so favourable that the memory of the episode fades away . It is extremely interesting to note that among the few significant variables , those related to general well-being and self-perception of health , are prominent . It appears , therefore , that psychological factors play a role in the experience of LBP in a similar way to what has been reported in adults . Poor self-perception of health ( health belief ) could be a factor behind the reporting of LBP . Some variables linked to consequences of LBP ( absence from school or from gym and visit to a doctor ) play a significant role in reporting LBP , which suggests that those " health care " factors may reinforce a feeling of disease severity The objective of this study was to report on secondary analyses of a merged trial data set aim ed at exploring the potential importance of patient factors associated with clinical ly relevant improvements in non-acute , non-specific low back pain ( LBP ) . From 273 predominantly male army workers ( mean age 39 ± 10.5 years , range 20–56 years , 4 women ) with LBP who were recruited in three r and omized clinical trials , baseline individual patient factors , pain-related factors , work-related psychosocial factors , and psychological factors were evaluated as potential prognostic variables in a short-term ( post-treatment ) and a long-term logistic regression model ( 6 months after treatment ) . We found one dominant prognostic factor for improvement directly after treatment as well as 6 months later : baseline functional disability , expressed in Rol and –Morris Disability Question naire scores . Baseline fear of movement , expressed in Tampa Scale for Kinesiophobia scores , had also significant prognostic value for long-term improvement . Less strongly associated with the outcome , but also included in our final models , were supervisor social support and duration of complaints ( short-term model ) , and co-worker social support and pain radiation ( long-term model ) . Information about initial levels of functional disability and fear-avoidance behaviour can be of value in the treatment of patient population s with characteristics comparable to the current army study population ( e.g. , predominantly male , physically active , working , moderate but chronic back problems ) . Individuals at risk for poor long-term LBP recovery , i.e. , individuals with high initial level of disability and prominent fear-avoidance behaviour , can be distinguished that may need additional cognitive-behavioural treatment Background Current evidence suggests that spinal manipulative therapy ( SMT ) is effective in the treatment of people with low back pain ( LBP ) ; however , the corresponding mechanisms are unknown . Hypoalgesia is associated with SMT and is suggestive of specific mechanisms . Objective The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP . A secondary purpose was to determine whether the result ing hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception . Design This study was a r and omized controlled trial . Setting A sample of convenience was recruited from community and outpatient clinics . Participants Thirty-six people ( 10 men , 26 women ) currently experiencing LBP participated in the study . The average age of the participants was 32.39 ( SD=12.63 ) years , and the average duration of LBP was 221.79 ( SD=365.37 ) weeks . Intervention and Measurements Baseline demographic and psychological measurements were obtained , followed by quantitative sensory testing to assess temporal summation and Aδ fiber – mediated pain perception . Next , participants were r and omly assigned to ride a stationary bicycle , perform low back extension exercises , or receive SMT . Finally , the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity . Results Hypoalgesia to Aδ fiber – mediated pain perception was not observed . Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed . Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT , but not in those who rode a stationary bicycle or performed low back extension exercises . Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT . Limitations Only immediate effects of SMT were measured , so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect . Furthermore , the authors are unable to comment on the relationship between their findings and changes in clinical pain . Conclusions Inhibition of Aδ fiber – mediated pain perception was similar for all groups . However , inhibition of temporal summation was observed only in participants receiving SMT , suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area Background Activity advice and prescription are commonly used in the management of low back pain ( LBP ) . Although there is evidence for advising patients with LBP to remain active , facilitating both recovery and return to work , to date no research has assessed whether objective measurements of free living physical activity ( PA ) can predict outcome , recovery and course of LBP . Methods An observational longitudinal study will investigate  PA  levels in a cohort of community-dwelling working age adults with acute and sub-acute LBP . Each participant 's  PA level , functional status , mood , fear avoidance behaviours , and levels of pain , psychological distress and occupational activity  will be measured on three occasions during for 1 week periods at baseline , 3 months , and 1 year .  Physical activity levels  will be measured by self report , RT3 triaxial accelerometer , and activity recall question naires . The primary outcome measure of functional recovery will be the Rol and Morris Disability Question naire ( RMDQ ) . Free living PA levels and changes in functional status will be quantified in order to look at predictive relationships between levels and changes in free living PA and functional recovery in a LBP population . Discussion This research will investigate levels and changes in activity levels of an acute LBP cohort and the predictive relationship to LBP recovery . The results will assess whether occupational , psychological and behavioural factors affect the relationship between free living PA and LBP recovery . Results from this research will help to determine the strength of evidence supporting international guidelines that recommend restoration of normal activity in managing LBP.Trial registration [ Clinical Trial Registration Number , ACTRN12609000282280 Aims : To identify the work factors that predict  intense low back pain ( LBP ) and LBP related sick leaves in nurses ’ aides . Methods : The sample comprised 4266 r and omly selected Norwegian nurses ’ aides , not bothered or only a little bothered by LBP during the previous three months , and not on sick leave when completing a mailed question naire in 1999 . Of these , 3808 ( 89.3 % ) completed a second question naire 3 months later and 3651 ( 85.6 % ) completed a third question naire 15 months later . Intensity of low back symptoms and certified sick leaves attributed to LBP during the observation period were assessed by self reports at the follow ups . Results : After adjustments for LBP during the three months prior to baseline , baseline health complaints , demographic and familial factors , and a series of physical , psychological , and social work factors , logistic regression analyses revealed the following associations : intense low back symptoms were predicted by frequent positioning of patients in bed , perceived lack of support from immediate superior , and perceived lack of pleasant and relaxing culture in the work unit . LBP related sick leaves were predicted by frequent h and ling of heavy objects , medium level of work dem and s , perceived lack of supportive and encouraging culture in the work unit , working night shifts , and working in a nursing home . Long term LBP related sick leaves were associated with changes of work or work tasks during the observation period that result ed in a perceived reduction of support and encouragement at work . Conclusions : Not only frequent mechanical exposures , but also organisational , psychological , and social work factors , such as night shift work , perceived lack of support from superior , and perceived lack of a pleasant and relaxing or supporting and encouraging culture in the work unit , are associated with an increased risk of intense low back symptoms and LBP related sick leaves in nurses ’ aides Background Brief intervention programs for subacute low back pain ( LBP ) result in significant reduction of sick leave compared to treatment as usual . Although effective , a substantial proportion of the patients do not return to work . This study investigates predictors of return to work in LBP patients participating in a r and omized controlled trial comparing a  brief intervention program ( BI ) with BI and physical exercise . Methods Predictors for not returning to work was examined in 246 patients sick listed 8 - 12 weeks for low back pain . The patients had participated in a r and omized controlled trial , with BI ( n = 122 ) and BI + physical exercise ( n = 124 ) . There were no significant differences between the two intervention groups on return to work . The groups were therefore merged in the analyses of predictors . Multiple logistic regression analysis was used to identify predictors for non return to work at 3 , 12 , and 24 months of follow-up . Results At 3 months of follow-up , the strongest predictors for not returning to work were pain intensity while resting ( OR = 5.6 ; CI = 1.7 - 19 ) , the perception of constant back strain when working ( OR = 4.1 ; CI = 1.5 - 12 ) , negative expectations for return to work ( OR = 4.2 ; CI = 1.7 - 10 ) , and having been to a physiotherapist prior to participation in the trial ( OR = 3.3 ; CI = 1.3 - 8.3 ) . At 12 months , perceived reduced ability to walk far due to the complaints ( OR = 2.6 ; CI = 1.3 - 5.4 ) , pain during activities ( OR = 2.4 ; CI = 1.1 - 5.1 ) , and having been to a physiotherapist prior to participation in the trial ( OR = 2.1 ; CI = 1.1 - 4.3 ) were the strongest predictors for non return to work . At 24 months age below 41 years ( OR = 2.9 ; CI = 1.4 - 6.0 ) was the only significant predictor for non return to work . Conclusion It appears that return to work is highly dependant on individual and cognitive factors . Patients not returning to work after the interventions were characterized by negative expectations , perceptions about pain and disability , and previous physiotherapy treatment . This is the first study reporting that previous treatment by physiotherapists is a risk factor for long-term sick leave . This has not been reported before and is an interesting finding that deserves more scrutiny Background Low Back Pain ( LBP ) remains a common and costly problem . Psychological obstacles to recovery have been identified , but psychological and behavioural interventions have produced only moderate improvements . Review s of trials have suggested that the interventions lack clear theoretical basis , are often compromised by low dose , lack of fidelity , and delivery by non-experts . In addition , interventions do not directly target known risk mechanisms . We identified a theory driven intervention ( Contexual Cognitive Behavioural Therapy , CCBT ) that directly targets an evidence -based risk mechanism ( avoidance and ensured dose and delivery were optimised . This feasibility study was design ed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients , and to test recruitment , delivery of the intervention and response rates prior to moving to a full definitive trial . Methods A r and omised controlled feasibility trial with patients r and omised to receive CCBT or physiotherapy . CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions . Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based .  Patients were eligible to take part if they had back pain for more than 3 months , and scored above a threshold indicating fear avoidance , catastrophic beliefs and distress . Results 89 patients were recruited .  Uptake rates were above those predicted . Scores for credibility and acceptability of the interventions met the set criteria . Response rates at three and six months fell short of the 75 % target . Problems associated with poor response rates were identified and successfully resolved , rates increased to 77 % at 3 months , and 68 % at 6 months . Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity . Numbers were too small for formal analysis . Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy ( increase of 7.9 versus 5.1 ) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group , these findings should be interpreted with caution . Conclusions CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery . Trial registration IS RCT N43733490 , registered 15/12/2010 A new r and omised controlled trial of intervention in low back pain has been described recently . In this trial , a screening and targeted approach was found to be more effective and cost-effective than current best practice . Nested within the intervention arm were three different interventions targeting patients identified as ' low ' , ' medium ' or ' high ' risk dependent on the presence of ( mainly ) psychosocial risk factors . In this paper , the development and content of the STarT Back trial 's ' high-risk ' intervention is described . It offers a systematic approach , termed ' psychologically informed practice ' , to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists . The term ' disability ' is used to refer to self-reported pain-associated functional limitations , and ' psychological ' is used to refer to the beliefs/expectations , emotional responses and behavioural responses associated with low back pain The objective of the study was to establish the specific use of advice and exercise by physiotherapists , for the management of  chronic low back pain ( LBP ) . A question naire was mailed to a r and om sample of 600 members of the Irish Society of Chartered Physiotherapists . Open and closed questions were used to obtain information on treatments provided to chronic LBP patients . Respondents ' treatment goals were also investigated , along with the typical methods used to assess treatment outcome . Four hundred and nineteen of the sample returned the question naire ; 280/419 ( 67 % ) indicated that they currently treated LBP of which 76 % ( n=214 ) were senior grade therapists .  Advice and exercise  , respectively , were the treatments most frequently used for chronic LBP : advice was most commonly delivered as part of an exercise programme , with strengthening ( including core stability ) the most frequently used exercise type .  Supervision of exercise and follow-up advice  were underutilised with respect to the recommendations of relevant clinical guidelines . Pain relief was an important treatment goal . Emphasis on exercise programme  supervision , incorporating reassurance that its safe to stay active and ' hurt does not mean harm ' , must be more effectively disseminated and promoted in practice . The influence of follow-up advice on  exercise adherence warrants further investigation Objectives Prevention of occupational low back pain ( LBP ) in nurses is a research priority . Recent research suggests intervening before commencing nursing employment is ideal ; however , identification of modifiable risk factors is required . The objective of this study was to investigate modifiable personal characteristics that predicted new-onset LBP in nursing students . Methods This prospect i ve study was conducted on female nursing students ( n=117 ) without LBP at baseline to predict new-onset LBP ( an episode of significant LBP during the follow-up period ) . At the 12-month follow-up , participants with ( n=31 ) and without new-onset LBP ( n=76 ) were compared across baseline social or lifestyle , psychologic ( distress , back pain beliefs , coping strategies , and catastrophising ) , and physical ( spinal postures and spinal kinematics in functional tasks , leg and back muscle endurance , spinal repositioning error , and cardiovascular fitness ) characteristics . Results Participants response rate at follow-up was excellent ( 91 % ) . After controlling for earlier LBP , age , and BMI , regression analysis showed that modifiable social or lifestyle , psychologic and physical characteristics ( namely , smoking , increased physical activity , higher stress , reduced back muscle endurance , greater posterior pelvic rotation in slump sitting , and more accurate spinal repositioning in sitting ) were significant and independent predictors of new-onset LBP at follow-up . Inclusion of these factors in multivariate logistic regression analysis , with significant new-onset LBP as the outcome , result ed in a substantial model R2 of 0.45 . Discussion Modifiable personal characteristics across multiple domains are associated with new-onset LBP in female nursing students . These findings may have implication s for the development of prevention and management interventions for LBP in nurses RATIONALE The concept of evidence -based medicine is important in providing efficient health care . The process uses research findings as the basis for clinical decision making . Evidence -based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide . Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence . The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed . AIMS The aim of this study was to investigate if physiotherapists ' clinical management of patients with low back pain would change following an evidence -based education package , which utilized local opinion leaders and delivered the best evidence . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work , to two groups . The intervention group received an evidence -based programme on the management of low back pain , including advice regarding increasing activity levels and return to normal activity and challenging patients ' fears and beliefs about their pain . The control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' clinical management of patients with low back pain was measured prior to training and 6 months post training . Outcome measures were based on physiotherapists completing ' discharge summary ' question naires , which included information relating to the use and importance of therapies for treating their low back pain patients . RESULTS There were few significant differences in treatment options between the intervention and control groups post training . Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain , there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention . CONCLUSIONS Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain . This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice . Whilst there were some limitations in the overall size of the study , the results help to give an insight into the challenges faced by the health care system and research ers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care Background Advice to remain active and normalisation of activity are commonly prescribed in the management of low back pain ( LBP ) . However , no research has assessed whether objective measurements of physical activity predict outcome and recovery in acute low back pain . Method The aims of this study were to assess the predictive relationship between activity and disability at 3 months in a sub-acute LBP population . This prospect i ve cohort study recruited 101 consenting patients with sub-acute LBP ( < 6 weeks ) who completed the Rol and Morris Disability Question naire ( RMDQ ) , the Visual Analogue Scale , and resumption of full ‘ normal ’ activity question ( Y/N ) , at baseline and 3 months .  Physical activity  was measured for 7 days at both baseline and at 3 months with an RT3 accelerometer and a recall question naire . Results Observed and self-reported measures of physical activity at baseline and change in activity from baseline to 3 months were not independent predictors of RMDQ ( p > 0.05 ) or RMDQ change ( p > 0.05 ) over 3 months . A self-report of a return to full ‘ normal ’ activities was significantly associated with greater RMDQ change score at 3 months ( p < 0.001 ) . Paired t-tests found no significant change in activity levels measured with the RT3 ( p = 0.57 ) or the recall question naire ( p = 0.38 ) from baseline to 3 months . Conclusions These results question the predictive role of physical activity in LBP recovery , and the assumption that activity levels change as LBP symptoms resolve . The importance of a patient ’s perception of activity limitation in recovery from acute LBP was also highlighted . Trial registration Clinical Trial Registration Number , Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Low back pain ( LBP ) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health re sources spent on LBP disorders , the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies , opiod medications , spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach , and evidence that only 8–15 % of patients with LBP have an identified patho-anatomical diagnosis , result ing in the majority being diagnosed as having non-specific LBP.3 Of this population , a small but significant group becomes chronic and disabled , labelled non-specific chronic low back pain ( NSCLBP ) , consuming a disproportionate amount of healthcare re sources .4 1 . Over the past decade , the traditional biomedical view of LBP has been greatly challenged . This is a result of : the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8 ; 2 . the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9 ; 3 . the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments , conflicting diagnoses , lost hope and ongoing suffering10 ; 4 . the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder , where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12 ; 5 . positive outcomes in r and omised controlled trials ( RCTs ) are best predicted by changes in psychological distress , fear avoidance beliefs , self-efficacy in Background Chronic low back pain ( CLBP ) is a persistent disabling condition with rising significant healthcare , social and economic costs . Current research supports the use of exercise-based treatment approaches that encourage people with CLBP to assume a physically active role in their recovery . While international clinical guidelines and systematic review s for CLBP support supervised group exercise as an attractive first-line option for treating large numbers of CLBP patients at low cost , barriers to their delivery include space and time restrictions in healthcare setting s and poor patient attendance . The European Clinical Guidelines have identified the need for research in the use of brief/minimal contact self-activation interventions that encourage participation in physical activity for CLBP . Walking may be an ideally suited form of individualized exercise prescription as it is easy to do , requires no special skills or facilities , and is achievable by virtually all ages with little risk of injury , but its effectiveness for LBP is unproven . Methods and design This study will be an assessor-blinded r and omized controlled trial that will investigate the difference in clinical effectiveness and costs of an individualized walking programme and a supervised general exercise programme compared to usual physiotherapy , which will act as the control group , in people with chronic low back pain . A sample of 246 patients will be recruited in Dublin , Irel and through acute general hospital outpatient physiotherapy departments that provide treatment for people with CLBP . Patients will be r and omly allocated to one of the three groups in a concealed manner . The main outcomes will be functional disability , pain , quality of life , fear avoidance , back beliefs , physical activity , satisfaction and costs , which will be evaluated at baseline , and 3 , 6 and 12 months [ follow-up by pre-paid postage ] . Qualitative telephone interviews and focus groups will be embedded in the research design to obtain feedback about participants ' experiences of the interventions and trial participation , and to inform interpretation of the quantitative data . Planned analysis will be by intention to treat ( quantitative data ) and thematic analysis ( qualitative data ) Discussion The trial will evaluate the effectiveness of a walking programme and a supervised general exercise programme compared to usual physiotherapy in people with CLBP.Trial registration Current controlled trial IS RCT Study Design . A r and omized controlled trial was performed . Objectives . To evaluate how 2 different treatment options affect perception of health , pain , and physical functioning over time among children and adolescents with low back pain ( LBP ) . Summary of Background Data . LBP among children and adolescents has increased . The literature shows that children with LBP also suffer from this condition as adults . Thus , it is important to prevent and treat LBP in children and adolescents . Methods . Forty-five children and adolescents were consecutively r and omized into one of 2 treatment groups and were studied for 12 weeks . Group 1 was given individualized physical therapy and exercise and a st and ardized self-training program and back education . Group 2 was given self-training program and back education but no individualized therapy . The children and adolescents were tested before and after the treatment period .  Child Health Question naire Child Form 87 , Rol and & Morris Disability Question naire , Painometer , Back Saver Sit and Reach , and test of trunk muscle endurance  were used to evaluate the interventions . Results . Both groups improved statistically significant in most parameters over time . On comparison between the groups the physical function measured by Rol and & Morris Disability Question naire and the duration of pain measured by Painometer improved statistically significant in Group 1 . Conclusion . An individual assessment by a knowledgeable physiotherapist and an active treatment model improve how children and adolescents experience their back problems with respect to health and physical function , pain , strength , and mobility , regardless of whether treatment consists of a home exercise program with follow-up or home exercise combined with exercise and treatment supervised by a physiotherapist In a prospect i ve , r and omized study , primarily design ed to test the efficacy of activation on consecutive blue-collar workers sick-listed for 6 weeks due to subacute low back pain , 25 % of the workers were excluded for medical reasons . In the intervention study ( n = 103 ) , only a minority of cases ( 6 % ) had ' true ' subacute complaints , i.e. no prior history of low back pain .  Subjective reports on general well-being , health status and work-related ergonomic factors were significantly lower or worse in patients than in reference sample s. The r and omized intervention study could establish a significant effect of grade d activation on work return , but the effect seemed to be restricted to patients moderately disabled , i.e. one-third of the subacute low back pain patients included . A predictive four-factor model on work return increased the possibility of identifing nonresponders ( chronic low back pain ) more than threefold with a specificity ( 91 % ) and sensitivity ( 74 % ) comparable to that of clinical disc herniation . The history of a prolonged disablement process , cognitive factors , pain behavior and mentally straining ergonomic factors seemed to be of importance . Psychological reactions , or ' barriers to recovery ' , were slightly different in treatment and control groups but the type of intervention did not significantly alter the predictive model , suggesting that subsets of the study sample may benefit from other optional functional approaches . Descriptive characteristics of the study sample emphasized that subacute low back pain patients can not be conceptualized as a homogeneous group . Four sub-groups could be identified : ( a ) specific medical disorders ; ( b ) spontaneous recovery group ; ( c ) moderately disabled back pain patients ; and ( d ) nonresponders . The results support proposals that treatment should be tailored according to individual needs and that better case management should have priority for those belonging to the nonresponder group OBJECTIVE For long-term treatment effects , patients with subacute back pain need to adhere to treatment recommendations beyond the prescribed exercise treatment . Adherence rates are as low as 30 % , so we developed a cognitive-behavioural training programme to enhance patients ' self-efficacy , maximise severity perceptions and reduce barrier perceptions . METHOD A 2 x 4 ( group x time ) repeated measurement design was applied . Forty-seven patients with non-specific , subacute back pain were r and omly assigned to a training group ( exercise treatment plus cognitive-behavioural training programme ) or a control group ( exercise treatment only ) . RESULTS Repeated measures ANOVA revealed significant main and interaction effects ; the training group reported enhanced self-efficacy and severity perceptions , reduced barrier perceptions , and self-reported that they exercised more often than the control group over time . However , no group differences regarding pain intensity emerged . CONCLUSION Our findings demonstrate that a short and inexpensive cognitive-behavioural training programme is an effective tool to enable back pain patients to follow treatment recommendations on a regular basis . PRACTICE IMPLICATION S The short and simple intervention can easily be conducted by personnel , other than psychologists , i.e. , physiotherapists OBJECTIVE To determine the characteristics of Australian adults who seek care for low back pain ( LBP ) , including the type of care they choose and any factors associated with making those choices . DESIGN A population -based mailed survey . SUBJECTS An age , gender , and state stratified r and om sample of 2768 Australian adults selected from the Electoral Roll . METHODS A self-administered , fully structured question naire included a series of questions relating to care seeking for LBP , choice of provider , and types of treatment received . In addition , a series of questions were asked relating to demographic characteristics , socioeconomic variables , severity of LBP , cigarette smoking , anthropometric variables , perceived cause of LBP , lifetime emotional distress , job satisfaction , lifetime physical fitness , past 5-year health status , and fear of LBP causing future impairment . RESULTS The response rate was 69.1 % . The sample proved to be similar to the Australian adult population . The majority of respondents with LBP in the past 6 months did not seek care for it ( 55.5 % ) . Factors that increased care seeking were higher grade s of pain and disability severity , fear of the impact of pain on future work and life , and female sex . Factors decreasing the likelihood for seeking care were identified as the cause of pain being an accident at home and also never being married . General medical practitioners and chiropractors are the most popular providers of care . CONCLUSION This study shows that a majority of people did not seek care for their LBP . The reasons for care seeking proved to be independent of social or economic status Study Design . A prospect i ve , population ‐based cohort study of working adults . Objectives . To determine whether work‐related psychosocial factors and social status predict the occurrence of new episodes of low back pain and influence consultation behavior . Summary and Background Data . Dissatisfaction with work and social status has been associated with low back pain in several studies ; few of these studies have been prospect i ve or population based . Methods . An initial postal survey  was returned by 4,501 ( 59 % ) adults ( 18‐75 years old ) registered with two primary care practice s. From this , a cohort of 1,412 people currently in employment and free of low back pain was identified , and baseline information on work‐related psychosocial factors and psychologic distress was obtained . Social class was derived from current occupation using a st and ardized classification . New episodes of low back pain occurring in the next 12 months were identified by continuous monitoring of primary care consulters and by mailing a second question naire a year later to identify occurrences of low back pain for which no consultation was sought . Results . The baseline cross‐sectional survey showed modest but significant associations between low back pain and perceived inadequacy of income ( risk ratio 1.3 ) , dissatisfaction with work ( risk ratio 1.4 ) and social class IV/V ( risk ratio 1.2 ) . In the follow‐up year , the risk of reporting low back pain for which no consultation was sought doubled in those dissatisfied with their work . Both perceived inadequacy of income ( odds ratio 3.6 ) and social class IV/V ( odds ratio 4.8 ) were strongly associated with consulting with a new episode of low back pain during the follow‐up year , an association more marked in women . The associations with work dissatisfaction and perceived adequacy of income were not explained by general psychologic distress or social status . Conclusion . People dissatisfied with work are more likely to report low back pain for which they do not consult a physician , whereas lower social status and perceived inadequacy of income are independent risks for working people to seek consultation because of low back pain Background Many studies on low back pain ( LBP ) have identified prognostic factors , but prediction models for use in secondary health care are not available . The purpose of this cohort study , based on a r and omised clinical study , was to identify risk factors for unsuccessful return to work ( U-RTW ) in sick-listed LBP patients with or without radiculopathy and to vali date a prediction model for U-RTW . Methods 325 sick-listed LBP patients with or without radiculopathy were included in an intervention study and followed for one year . Afterwards , 117 other LBP patients were recruited similarly , included in a validation study and also followed for one year . All patients were subjected to identical procedures and interventions and received a brief intervention by the same rehabilitation doctor and physiotherapist . Half of them received case manager guidance within a multidisciplinary setting . At baseline , they completed a question naire and went through a clinical low-back examination . Sciatica was investigated by magnetic resonance imaging ( MRI ) . U-RTW was registered in a national data base both initially and at 1-year . Results Neither initial U-RTW ( 24.0 % ) nor one-year U-RTW ( 38.2 % ) were statistically significantly different in the two intervention groups nor in patients with and without radiculopathy . Multivariate logistic regression analysis identified two clinical and five psychosocial baseline predictors for one-year U-RTW ( primary outcome ) . The clinical predictors included pain score ( back+leg pain ) and side-flexion . The five psychosocial predictors included ‘ bodily distress ’ ‘ low expectations of RTW ’ , ‘ blaming the work for pain ’ , ‘ no home ownership ’ and ‘ drinking alcohol less than once/month ’ . These predictors were not statistically significantly different in patients with and without radiculopathy , and they also predicted initial U-RTW ( secondary outcome ) . Obesity and older age were only supplementary predictors in patients with radiculopathy . A prediction model was established and tested in the validation study group . The model predicted one-year U-RWT in patients with intermediate and high risk , but only partially in patients with low risk . The model predicted all three risk categories in initial U-RTW . Conclusions A prediction model combining baseline clinical and psychosocial risk factors predicted patients with low , intermediate and high risk for unsuccessful return to work , both initially and at 1-year
Physiotherapists partially recognised cognitive , psychological and social factors in people with LBP .
Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP , and some stigmatised the behaviours suggestive of cognitive , psychological and social contributions to LBP .
Physiotherapists perceived that neither their initial training , nor currently available professional development training , instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP .
QUESTION What are physiotherapists ' perceptions about identifying and managing the cognitive , psychological and social factors that may act as barriers to recovery for people with low back pain ( LBP ) ?