Developing, testing and refining a physiotherapy model of care for acute low back pain

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.This thesis is concerned with the physiotherapy management of acute low back pain. Various national guidelines contain conflicting views regarding the role of physiotherapy in the management of acute low back pain. The discrepancies involve primarily the content and timing of physiotherapy intervention. There is a need to place the physiotherapy management of acute low back pain on a more firm research base. A comprehensive literature review was undertaken to develop a best practice model of care for acute low back pain. This model was tested in a randomised controlled trial. Subjects involved in the treatment model demonstrated significantly better short-term outcomes than subjects given advice only. Furthermore, subjects treated early demonstrated significantly better long-term outcome than subjects who waited six weeks for their treatment. Changes in pain and physical function were found to be the factors most closely associated with good outcome in the short-term. Good outcome in the long term was associated with improvement in a number of physical and psychological variables. It is recommended that changes be made to the treatment model to facilitate improvement in pain relief and maintenance of physical and social function to further enhance treatment effectiveness.This study was funded by a grant from the NHS R&D committee

Predicting outcome in acute low back pain using different models of patient profiling

Study Design: Prospective observational study of prognostic indicators, utilising data from a randomised, controlled trial of physiotherapy care of acute low back pain (ALBP) with follow up at 6 weeks, 3 months and 6 months. Objective: To evaluate which patient profile offers the most useful guide to long-term outcome in ALBP. Summary of Background Data: The evidence used to inform prognostic decision-making is derived largely from studies where baseline data is used to predict future status. Clinicians often see patients on multiple occasions so may profile patients in a variety of ways. It is worth considering if better prognostic decisions can be made from alternative profiles. Methods: Clinical, psychological and demographic data were collected from a sample of 54 ALBP patients. Three clinical profiles were developed from information collected at baseline, information collected at 6 weeks, and the change in status between these two time points. A series of regression models were used to determine the independent and relative contributions of these profiles to the prediction of chronic pain and disability. Results: The baseline profile predicted long-term pain only. The 6-week profile predicted both long-term pain and disability. The change profile only predicted long-term disability (p \u3c 0.01). When predicting long-term pain, after the baseline profile had been added to the model, the 6-week profile did not add significantly when forced in at the second step (p \u3e 0.05). A similar result was obtained when the order of entry was reversed. When predicting long-term disability, after the 6-week profile was entered at the first step, the change profile was not significant when forced in at the second step. However, when the change profile was entered at the first step and the 6-week clinical profile was forced in at the second step, a significant contribution of the 6-week profile was found. Conclusions: The profile derived from information collected at 6 weeks provided the best guide to long-term pain and disability. The baseline profile and change in status offered less predictive value

Tactile Thresholds are Preserved yet Cortical Sensory Function is Impaired in Chronic Non-Specific Low Back Pain Patients

Introduction: A substantial amount of evidence points to an alteration in brain structure and function patients with chronic non-specific low back pain (CNSLBP) [1-6]. One interpretation of these findings is that the observed brain changes may represent a disruption of the brain’s representations of the body part and the resultant body perception disturbance may underpin this clinical problem. The current study aimed to investigate sensory dysfunction in CNSLBP. Specifically we aimed to distinguish cortically mediated sensory dysfunction from peripheral dysfunction by comparing simple tactile thresholds with more complex cortically mediated sensory tests Methods: We investigated tactile thresholds (TTH), two point discrimination (TPD) and graphaesthesia over the lumbar spine of 19 CLBP patients and 19 age and sex matched healthy controls as a way of investigating whether CLBP patients present with a perceptual disturbance of their lumbar spine. Differences in performance of the sensory tests was explored using the Mann Whitney U Test and one-way between groups multivariate analysis of variance. Results: We found no difference in tactile threshold between the two groups (P=.0.751). There was a statistically significant difference between controls and LBP for TPD: F(1,36)=10.15, p=.003 and letter error rate: F(1, 36)=6.54 p=0.015. The data indicate that LBP patients had a larger lumbar TPD distance and a greater letter recognition error rate. Discussion: Both TPD and graphaesthesia are dependant on the integrity of the primary sensory cortex [7]. These data support existing findings of perceptual abnormality in chronic back pain [8] and the preservation of tactile thresholds is suggestive of cortical rather than peripheral sensory dysfunction. Amelioration of these abnormalities may present a target for therapeutic intervention

Chronic Lower Back Pain: A Maladaptive Perceptions Model

High quality evidence suggests that current approaches to the management of CLBP show only limited effectiveness; one explanation of this finding is that current models of management are misdirected or incomplete. This talk proposes a model of CLBP underpinned by data on the psychological contributors to the LBP experience and recent evidence of neuroplastic changes in the brains of people with CLBP (see below). The model suggests that maladaptive cognitive perception about the nature of the back problem and future consequences drive behaviours that might bring about maladaptive neuroplastic changes. These central nervous system changes may enhance sensitivity, influence normal attentional processing and potentially create a state of maladaptive self perception of the back, in terms of how the back feels to the individual, the control they feel they have over their back and the meaning of sensory information from the back. Maladaptive cognitive perception and maladaptive self perception are potentially mutually reinforcing and contribute to the maintenance of the CLBP experience. Identification of these issues in the clinical setting and the implications of this model to the rehabilitation of people with CLBP will also be discussed

International low back pain guidelines: A comparison of two research based models of care for the management of acute low back pain.

Evidence based guidelines for the management of acute low back pain (ALBP) have been formulated by numerous countries. There are discrepancies between guidelines regarding physiotherapy treatment. The aim of this study was to compare two research based models derived from international LBP guidelines. A single-blind randomised controlled trial was undertaken in a physiotherapy outpatients department. Subjects with ALBP were randomly allocated to an ‘assess/advise/treat’ group (n = 50) or an ‘assess/advise/wait’ group (n = 52). The primary outcome measure was the Roland and Morris Disability Questionnaire (RMDQ). Secondary outcome measures of pain (VAS, usual pain intensity) depressive symptoms (MZSRDS) somatic distress (MSPQ) anxiety (STAIS) quality of life (SF36) and general health (EuroQol) were also obtained. Outcomes were assessed at 6-weeks, 3-months and 6-months. At 6-weeks subjects in the assess/advise/treat group demonstrated less LBP related disability (p = 0.02) and depressive symptoms (p = 0.01), as well as better general health (p = 0.006, p = 0.05), vitality (p \u3c 0.001), social functioning (p = 0.004) and mental health (p = 0.002). At long-term assessment (3 and 6 months) subjects in the assess/advise/treat group were less distressed (p = 0.004), anxious (p = 0.01) and had fewer depressive symptoms (p = 0.001), as well as reporting better general health (p = 0.009, p = 0.05), emotional role (p = 0.03) and mental health (p = 0.04). Active physiotherapy produces better short-term outcomes than advice. Delaying treatment has no long-term consequences on pain or disability, but affects the development of psychosocial features

Transcutaneous Electrical Nerve Stimulation (TENS) for neuropathic pain in adults (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the analgesic effectiveness of TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults

Grip and muscle strength dynamometry in acute burn injury: Evaluation of an updated assessment protocol

External stabilization is reported to improve reliability of hand held dynamometry, yet this has not been tested in burns. We aimed to assess the reliability of dynamometry using an external system of stabilization in people with moderate burn injury and explore construct validity of strength assessment using dynamometry. Participants were assessed on muscle and grip strength three times on each side. Assessment occurred three times per week for up to four weeks. Within session reliability was assessed using intraclass correlations calculated for within session data grouped prior to surgery, immediately after surgery and in the sub-acute phase of injury. Minimum detectable differences were also calculated. In the same timeframe categories, construct validity was explored using regression analysis incorporating burn severity and demographic characteristics. Thirty-eight participants with total burn surface area 5 – 40% were recruited. Reliability was determined to be clinically applicable for the assessment method (intraclass correlation coefficient \u3e0.75) at all phases after injury. Muscle strength was associated with sex and burn location during injury and wound healing. Burn size in the immediate period after surgery and age in the sub-acute phase of injury were also associated with muscle strength assessment results. Hand held dynamometry is a reliable assessment tool for evaluating within session muscle strength in the acute and sub-acute phase of injury in burns up to 40% total burn surface area. External stabilization may assist to eliminate reliability issues related to patient and assessor strength

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II (Review)

Background: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery. When it occurs, it is associated with significant pain and disability. It is thought to arise and persist as a consequence of a maladaptive pro-inflammatory response and disturbances in sympathetically-mediated vasomotor control, together with maladaptive peripheral and central neuronal plasticity. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified, and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS, although their effectiveness is not known. Objectives: To determine the effectiveness of physiotherapy interventions for treating the pain and disability associated with CRPS types I and II. Search methods: We searched the following databases from inception up to 12 February 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments, without language restrictions, for randomised controlled trials (RCTs) of physiotherapy interventions for treating pain and disability in people CRPS. We also searched additional online sources for unpublished trials and trials in progress. Selection criteria: We included RCTs of physiotherapy interventions (including manual therapy, therapeutic exercise, electrotherapy, physiotherapist administered education and cortically directed sensory-motor rehabilitation strategies) employed in either a stand-alone fashion or in combination, compared with placebo, no treatment, another intervention or usual care, or of varying physiotherapy interventions compared with each other in adults with CRPS I and II. Our primary outcomes of interest were patient-centred outcomes of pain intensity and functional disability. Data collection and analysis: Two review authors independently evaluated those studies identified through the electronic searches for eligibility and subsequently extracted all relevant data from the included RCTs. Two review authors independently performed ’Risk of bias’ assessments and rated the quality of the body of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results: We included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions. Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I. Most included trials were at ’high’ risk of bias (15 trials) and the remainder were at ’unclear’ risk of bias (three trials). The quality of the evidence was very low or low for all comparisons, according to the GRADE approach. We found very low quality evidence that graded motor imagery (GMI; two trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) −21.00, 95% CI −31.17 to −10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95% CI 1.12 to 3.48), at long-term (six months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multimodal physiotherapy (one trial, 135 participants) may be useful for improving ’impairment’ at long-term (12 month) follow-up compared to a minimal ’social work’ intervention; and very low quality evidence that mirror therapy (two trials, 72 participants) provides clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95% CI −4.71 to −2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD −2.3, 95% CI −2.88 to −1.72) at long-term (six month) follow-up in people with CRPS I post stroke compared to placebo (covered mirror). There was low to very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-termin people with CRPS I. Laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I. Adverse events were only rarely reported in the included trials. No trials including participants with CRPS II met the inclusion criteria of this review. Authors’ conclusions: The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear. Large scale, high quality RCTs are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II. Implications for clinical practice and future research are considered