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.
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
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 ) ?