Deirdre A. Hurley

The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review

It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population.

Objective measurements of sleep for non‐laboratory settings as alternatives to polysomnography – a systematic review

Sleep disturbance influences human health. To examine sleep patterns, it is advisable to utilize valid subjective and objective measures. Laboratory‐based polysomnography (PSG) is deemed the gold standard to measure sleep objectively, but is impractical for long‐term and home utilization (e.g. resource‐demanding, difficult to use). Hence, alternative devices have been developed. This study aimed to review the literature systematically, providing an overview of available objective sleep measures in non‐laboratory settings as an alternative to PSG. To identify relevant articles, a specific search strategy was run in EMBASE, PubMed, CINAHL, PsycInfo and Compendex (Engineering Village 2). In addition, reference lists of retrieved articles were screened and experts within this research field were contacted. Two researchers, using specified in/exclusion criteria, screened identified citations independently in three stages: on title, abstract and full text. Data from included articles were extracted and inserted into summarizing tables outlining the results. Of the 2217 electronically identified citations, 35 studies met the inclusion criteria. Additional searches revealed eight papers. Psychometric characteristics of nine different objective measures of sleep pattern alternatives to PSG [(bed) actigraphy, observation, bed sensors, eyelid movement‐ and non‐invasive arm sensors, a sleep switch and a remote device] were evaluated. Actigraphy is used widely and has been validated in several populations. Alternative devices to measure sleep patterns are becoming available, but most remain at prototype stage and are validated insufficiently. Future research should concentrate on the development and further validation of non‐invasive, inexpensive and user‐friendly sleep measures for non‐laboratory settings.

Objective and subjective assessment of sleep in chronic low back pain patients compared with healthy age and gender matched controls: a pilot study.

BackgroundWhile approximately 70% of chronic low back pain (CLBP) sufferers complain of sleep disturbance, current literature is based on self report measures which can be prone to bias and no objective data of sleep quality, based exclusively on CLBP are available. In accordance with the recommendations of The American Sleep Academy, when measuring sleep, both subjective and objective assessments should be considered as the two are only modestly correlated, suggesting that each modality assesses different aspects of an individuals sleep experience. Therefore, the purpose of this study was to expand previous research into sleep disturbance in CLBP by comparing objective and subjective sleep quality in participants with CLBP and healthy age and gender matched controls, to identify correlates of poor sleep and to test logistics and gather information prior to a larger study.Methods15 CLBP participants (mean age = 43.8 years (SD = 11.5), 53% female) and 15 healthy controls (mean age = 41.5 years (SD = 10.6), 53% female) consented. All participants completed the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Pittsburgh Sleep Diary and the SF36v2. CLBP participants also completed the Oswestry Disability Index. Sleep patterns were assessed over three consecutive nights using actigraphy. Total sleep time (TST), sleep efficiency (SE), sleep latency onset (SL) and number of awakenings after sleep onset (WASO) were derived. Statistical analysis was conducted using unrelated t-tests and Pearsons product moment correlation co-efficients.ResultsCLBP participants demonstrated significantly poorer overall sleep both objectively and subjectively. They demonstrated lower actigraphic SE (p = .002) and increased WASO (p = .027) but no significant differences were found in TST (p = .43) or SL (p = .97). Subjectively, they reported increased insomnia (p =< .001), lower SE (p =< .001) and increased SL (p =< .001) but no difference between TST (p = .827) and WASO (p = .055). Statistically significant associations were found between low back pain (p = .021, r = -.589), physical health (p = .003, r = -.713), disability levels (p = .025, r = .576), and subjective sleep quality in the CLBP participants but not with actigraphy.ConclusionCLBP participants demonstrated poorer overall sleep, increased insomnia symptoms and less efficient sleep. Further investigation using a larger sample size and a longer period of sleep monitoring is ongoing.

A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain

Study Design. A multicenter assessor-blinded randomized clinical trial was conducted. Objectives. To investigate the difference in effectiveness of manipulative therapy and interferential therapy for patients with acute low back pain when used as sole treatments and in combination. Summary of Background Data. Both manipulative therapy and interferential therapy are commonly used treatments for low back pain. Evidence for the effectiveness of manipulative therapy is available only for the short-term. There is limited evidence for interferential therapy, and no study has investigated the effectiveness of manipulative therapy combined with interferential therapy. Methods. Consenting subjects (n = 240) recruited following referral by physicians to physiotherapy departments in the (government-funded) National Health Service in Northern Ireland were randomly assigned to receive a copy of the Back Book and either manipulative therapy (MT; n = 80), interferential therapy (IFT; n = 80), or a combination of manipulative therapy and interferential therapy (CT; n = 80). The primary outcome was a change in functional disability on the Roland Morris Disability Questionnaire. Follow-up questionnaires were posted at discharge and at 6 and 12 months. Results. The groups were balanced at baseline for low back pain and demographic characteristics. At discharge all interventions significantly reduced functional disability (Roland Morris scale, MT: −4.53; 95% CI, −5.7 to −3.3 vs. IFT: −3.56; 95% CI, −4.8 to −2.4 vs. CT: −4.65; 95% CI, −5.8 to −3.5; P = 0.38) and pain (McGill questionnaire, MT: −5.12; 95% CI, −7.7 to −2.5 vs. IFT: −5.87; 95% CI, −8.5 to −3.3 vs. CT: −6.64; 95% CI, −9.2 to −4.1; P = 0.72) and increased quality of life (SF-36 Role-Physical, MT: 28.6; 95% CI, 18.3 to 38.9 vs. IFT: 31.4; 95% CI, 21.2 to 41.5 vs. CT: 30; 95% CI, 19.9 to 40; P = 0.93) to the same degree and maintained these improvements at 6 and 12 months. No significant differences were found between groups for reported LBP recurrence, work absenteeism, medication consumption, exercise participation, or healthcare use at 12 months (P > 0.05). Conclusions. For acute low back pain, there was no difference between the effects of a combined manipulative therapy and interferential therapy package and either manipulative therapy or interferential therapy alone.

Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review

&NA; The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n = 3) and quantitative (n = 12) methodologies. Themes that emerged included doctors’ attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors’ specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors’ specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors’ attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient‐care, and reduce costs to health services.

Laser therapy in the treatment of achilles tendinopathy: a pilot study.

OBJECTIVE To test the feasibility of a randomized controlled trial to assess the clinical effectiveness of low-level laser therapy (LLLT) when used in addition to eccentric exercise in the management of Achilles tendinopathy. BACKGROUND DATA LLLT has emerged as a possible treatment modality for tendon injuries. Over the past 20 years only three human studies have investigated LLLT for Achilles tendinopathy. MATERIALS AND METHODS Twenty patients were randomized into an active laser or placebo group; all patients, therapists, and investigators were blinded to allocation. All patients were given a 12-week eccentric exercise program and irradiated three times per week for 4 wk with either an active or placebo laser at standardized points over the affected tendons. Irradiation parameters in the active treatment group were: 810 nm, 100 mW, applied to six points on the tendon for 30 s, for a total dose of 3 J per point and 18 J per session. Outcome measures were the VISA-A questionnaire, pain, and isokinetic strength. Patients were measured before treatment and at 4 and 12 wk. Analysis of covariance was used to analyze data, using the effects of baseline measurements as a covariate. RESULTS Within groups, there were significant improvements (p < 0.05) at 4 and 12 wk for all outcome measures, except eccentric strength for the placebo group at 4 wk (p = 0.11). Based on the results of the current study, recruitment of 20 subjects per group would be required to perform an adequately powered study based on minimally important clinical differences in VISA-A scale. CONCLUSION This study has demonstrated the feasibility of undertaking a randomized controlled trial of LLLT for Achilles tendinopathy. Conclusions regarding effectiveness cannot be made due to the low statistical power of this pilot study.

Adherence of Irish general practitioners to European guidelines for acute low back pain: A prospective pilot study

There are no national low back pain (LBP) clinical guidelines in Ireland, and neither the level of adherence of General Practitioners (GPs) to the European guidelines, nor the cost of LBP to the patient and the state, have been investigated.

Pedometer-driven walking for chronic low back pain A feasibility randomized controlled trial

Objectives:To evaluate the feasibility of an RCT of a pedometer-driven walking program and education/advice to remain active compared with education/advice only for treatment of chronic low back pain (CLBP). Methods:Fifty-seven participants with CLBP recruited from primary care were randomly allocated to either: (1) education/advice (E, n=17) or (2) education/advice plus an 8-week pedometer-driven walking program (EWP, n=40). Step targets, actual daily step counts, and adverse events were recorded in a walking diary over the 8 weeks of intervention for the EWP group only. All other outcomes (eg, functional disability using the Oswestry Disability Questionnaire (ODQ), pain scores, physical activity (PA) measurement etc.) were recorded at baseline, week 9 (immediately post-intervention), and 6 months in both groups. Results:The recruitment rate was 22% and the dropout rate was lower than anticipated (13% to 18% at 6 mo). Adherence with the EWP was high, 93% (n=37/40) walked for ≥6 weeks, and increased their steps/day (mean absolute increase in steps/d, 2776, 95% confidence interval [CI], 1996-3557) by 59% (95% CI, 40.73%-76.25%) from baseline. Mean percentage adherence with weekly step targets was 70% (95% CI, 62%-77%). Eight (20%) minor-related adverse events were observed in 13% (5/40) of the participants. The EWP group participants demonstrated an 8.2% point improvement (95% CI, −13 to −3.4) on the ODQ at 6 months compared with 1.6% points (95% CI, –9.3 to 6.1) for the E group (between group d=0.44). There was also a larger mean improvement in pain (d=0.4) and a larger increase in PA (d=0.59) at 6 months in EWP. Discussion:This preliminary study demonstrated that a main RCT is feasible. EWP was safe and produced a real increase in walking; CLBP function and pain improved, and participants perceived a greater improvement in their PA levels. These improvements require confirmation in a fully powered RCT.

Utility of the RT3 triaxial accelerometer in free living: An investigation of adherence and data loss

There is strong evidence for the protective effects of physical activity on chronic health problems. Activity monitors can objectively measure free living occupational and leisure time physical activity. Utility is an important consideration when determining the most appropriate monitor for specific populations and environments. Hours of activity data collected, the reasons for activity hours not being recorded, and how these two factors might change over time when using an activity monitor in free living are rarely reported. This study investigated user perceptions, adherence to minimal wear time and loss of data when using the RT3 activity monitor in 21 healthy adults, in a variety of occupations, over three (7 day) repeated weeks of measurement in free living. An activity diary verified each day of monitoring and a utility questionnaire explored participant perceptions on the usability of the RT3. The RT3 was worn for an average of 14 h daily with 90% of participants having complete data sets. In total 6535.8 and 6092.5h of activity data were collected from the activity diary and the RT3 respectively. An estimated 443.3h (6.7%) of activity data were not recorded by the RT3. Data loss was primarily due to battery malfunction (45.2%). Non-adherence to wear time accounted for 169.5h (38.2%) of data loss, of which 14 h were due to occupational factors. The RT3 demonstrates good utility for free living activity measurement, however, technical issues and strategies to manage participant adherence require consideration with longitudinal and repeated measures studies.

Communication style and exercise compliance in physiotherapy (CONNECT). A cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients’ adherence to physiotherapists’ recommendations: study rationale, design, and methods

BackgroundPhysical activity and exercise therapy are among the accepted clinical rehabilitation guidelines and are recommended self-management strategies for chronic low back pain. However, many back pain sufferers do not adhere to their physiotherapist’s recommendations. Poor patient adherence may decrease the effectiveness of advice and home-based rehabilitation exercises. According to self-determination theory, support from health care practitioners can promote patients’ autonomous motivation and greater long-term behavioral persistence (e.g., adherence to physiotherapists’ recommendations). The aim of this trial is to assess the effect of an intervention designed to increase physiotherapists’ autonomy-supportive communication on low back pain patients’ adherence to physical activity and exercise therapy recommendations.Methods/DesignThis study will be a single-blinded cluster randomized controlled trial. Outpatient physiotherapy centers (N =12) in Dublin, Ireland (population = 1.25 million) will be randomly assigned using a computer-generated algorithm to either the experimental or control arm. Physiotherapists in the experimental arm (two hospitals and four primary care clinics) will attend eight hours of communication skills training. Training will include handouts, workbooks, video examples, role-play, and discussion designed to teach physiotherapists how to communicate in a manner that promotes autonomous patient motivation. Physiotherapists in the waitlist control arm (two hospitals and four primary care clinics) will not receive this training. Participants (N = 292) with chronic low back pain will complete assessments at baseline, as well as 1 week, 4 weeks, 12 weeks, and 24 weeks after their first physiotherapy appointment. Primary outcomes will include adherence to physiotherapy recommendations, as well as low back pain, function, and well-being. Participants will be blinded to treatment allocation, as they will not be told if their physiotherapist has received the communication skills training. Outcome assessors will also be blinded.We will use linear mixed modeling to test between arm differences both in the mean levels and the rates of change of the outcome variables. We will employ structural equation modeling to examine the process of change, including hypothesized mediation effects.DiscussionThis trial will be the first to test the effect of a self-determination theory-based communication skills training program for physiotherapists on their low back pain patients’ adherence to rehabilitation recommendations.Trial RegistrationCurrent Controlled Trials ISRCTN63723433