Lars Morsø

Supervised and non-supervised Nordic walking in the treatment of chronic low back pain: a single blind randomized clinical trial

BackgroundActive approaches including both specific and unspecific exercise are probably the most widely recommended treatment for patients with chronic low back pain but it is not known exactly which types of exercise provide the most benefit. Nordic Walking - power walking using ski poles - is a popular and fast growing type of exercise in Northern Europe that has been shown to improve cardiovascular metabolism. Until now, no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to back pain.MethodsA total of 151 patients with low back and/or leg pain of greater than eight weeks duration were recruited from a hospital based outpatient back pain clinic. Patients continuing to have pain greater than three on the 11-point numeric rating scale after a multidisciplinary intervention were included. Fifteen patients were unable to complete the baseline evaluation and 136 patients were randomized to receive A) Nordic walking supervised by a specially trained instructor twice a week for eight weeks B) One-hour instruction in Nordic walking by a specially trained instructor followed by advice to perform Nordic walking at home as much as they liked for eight weeks or C) Individual oral information consisting of advice to remain active and about maintaining the daily function level that they had achieved during their stay at the backcenter. Primary outcome measures were pain and disability using the Low Back Pain Rating Scale, and functional limitation further assessed using the Patient Specific Function Scale. Furthermore, information on time off work, use of medication, and concurrent treatment for their low back pain was collected. Objective measurements of physical activity levels for the supervised and unsupervised Nordic walking groups were performed using accelerometers. Data were analyzed on an intention-to-treat basis.ResultsNo mean differences were found between the three groups in relation to any of the outcomes at baseline. For pain, disability, and patient specific function the supervised Nordic walking group generally faired best however no statistically significant differences were found. Regarding the secondary outcome measures, patients in the supervised group tended to use less pain medication, to seek less concurrent care for their back pain, at the eight-week follow-up. There was no difference between physical activity levels for the supervised and unsupervised Nordic walking groups. No negative side effects were reported.ConclusionWe did not find statistically significant differences between eight weeks of supervised or unsupervised Nordic walking and advice to remain active in a group of chronic low back pain patients. Nevertheless, the greatest average improvement tended to favor the supervised Nordic walking group and - taking into account other health related benefits of Nordic walking - this form of exercise may potentially be of benefit to selected groups of chronic back pain patients.Trial registrationhttp://www.ClinicalTrials.gov # NCT00209820

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

Background Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. Objective The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). Design and Methods Using the EQUATOR Networks methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. Results There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. Limitations The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. Conclusions The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Nordic Walking and chronic low back pain: design of a randomized clinical trial

BackgroundLow Back Pain is a major public health problem all over the western world. Active approaches including exercise in the treatment of low back pain results in better outcomes for patients, but it is not known exactly which types of back exercises are most beneficial or whether general physical activity provide similar benefits.Nordic Walking is a popular and fast growing type of exercise in Northern Europe. Initial studies have demonstrated that persons performing Nordic Walking are able to exercise longer and harder compared to normal walking thereby increasing their cardiovascular metabolism. Until now no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to low back pain.The primary aim of this study is to investigate whether supervised Nordic Walking can reduce pain and improve function in a population of chronic low back pain patients when compared to unsupervised Nordic Walking and advice to stay active. In addition we investigate whether there is an increase in the cardiovascular metabolism in persons performing supervised Nordic Walking compared to persons who are advised to stay active. Finally, we investigate whether there is a difference in compliance between persons receiving supervised Nordic Walking and persons doing unsupervised Nordic Walking.MethodsOne hundred and fifty patients with low back pain for at least eight weeks and referred to a specialized secondary sector outpatient back pain clinic are included in the study. After completion of the standard back centre treatment patients are randomized into one of three groups: A) Nordic Walking twice a week for eight weeks under supervision of a specially trained instructor; B) Unsupervised Nordic Walking for eight weeks after one training session with an instructor; C) A one hour motivational talk including advice to stay active. Outcome measures are pain, function, overall health, cardiovascular ability and activity level.ResultsNo results available at this point.DiscussionThis study will investigate the effect of Nordic Walking on pain and function in a population of people with chronic LBP.Trial Registrationhttp://www.ClinicalTrials.gov registration # NCT00209820

Are self-reported pain characteristics, classified using the paindetect questionnaire, predictive of outcome in people with low back pain and associated leg pain?

ObjectiveThis study was designed to investigate whether the PainDETECT Questionnaire (PDQ) classification was predictive of outcomes at 3 and 12 months follow-up in low back pain (LBP) patients with associated leg pain. Identification of clinically important subgroups and targeted treatment is believed to be important in LBP care. The PD-Q is designed to classify whether a person has neuropathic pain, based on their self-reported pain characteristics. However, it is unknown whether this classification is a prognostic factor or predicts treatment response. MethodOne hundred forty-five participants were recruited in the secondary care. Inclusion criteria were 3 to 12 months of LBP and related leg pain. Baseline PDQ scores classified participants into 3 groups (“likely” to have neuropathic pain, “uncertain,” and “unlikely”) but did not affect treatment decisions. The outcome measures were LBP, leg pain, activity limitation, and self-reported general health. Scores were compared between those with “likely” neuropathic pain (neuropathic group) and “unlikely” (non-neuropathic group), using Mann-Whitney, Friedman, and &khgr;2 tests. ResultsAt baseline, the neuropathic group had worse scores on all outcome measures, and analgesic use, sick leave, and sense of coherence (P=0.000 to 0.044). At 3 months and 12 months, both groups improved (P=0.001 to 0.032). However, the groups remained different at each time point on all outcome measures (P=0.000 to 0.033) except LBP (P=0.054 to 0.214). Discussion and ConclusionsThe PDQ classification was a prognostic factor but was not predictive of response to treatment that was not targeted to neuropathic pain. Further studies should investigate whether PD-Q groups are predictive of treatment response when targeted to neuropathic pain.

Is the psychosocial profile of people with low back pain seeking care in Danish primary care different from those in secondary care

Differences between the psychosocial risk factors of low back pain (LBP) patients in primary and secondary care are under-investigated. Similarly, differences in the psychosocial profile of people classified into STarT Back Screening Tool (SBT) subgroups in primary and secondary care settings have not been investigated. The aim of the study was to determine: (1) if movement-related fear, catastrophisation, anxiety and/or depression in LBP patients are different between primary and secondary care settings, and (2) if those differences are retained when stratified by SBT subgroup. This study was a cross-sectional comparison of LBP patients in Danish primary settings (405 general practitioner or physiotherapy patients) and a secondary care setting (311 outpatient spine centre patients). Psychosocial factors were measured with the Roland Morris Disability Questionnaire, the Tampa Scale of Kinesiophobia, the Coping Strategies Questionnaire (catastrophisation subscale), and the Hospital Anxiety and Depression Scale. There were significantly higher scores in secondary care for movement-related fear (1.3 points (95%CI .1-2.5) p = .030) and catastrophisation (2.0 (95%CI 1.0-3.0) p < .000), lower scores on anxiety (-1.0 (95%CI -1.0-2.0) p < .000) but no difference for depression. These differences in psychosocial scores were broadly retained when stratified by SBT subgroup. However, questionnaire-specific reported thresholds for important difference scores indicate the size of these differences between the care settings were unlikely to be clinically important from a patient perspective. Longitudinal studies are required to investigate the predictive ability of SBT in secondary care settings and whether treatment targeted to SBT subgroups is effective in secondary care.

Patients' perceived level of social isolation affects the prognosis of low back pain

Perceived social isolation is prevalent among patients with low back pain (LBP) and could be a potential prognostic factor for clinical outcomes following an episode of LBP.

The effectiveness of a stratified care model for non-specific low back pain in Danish primary care compared to current practice: study protocol of a randomised controlled trial

BackgroundPrior studies indicate that stratified care for low back pain results in better clinical outcome and reduced costs in healthcare compared to current practice. Stratified care may be associated with clinical benefits for patients with low back pain at a lower cost, but evidence is sparse. Hence this study aims to evaluate the clinical effects and cost-effectiveness of stratified care in patients with non-specific low back pain compared to current practice.Methods/designThe study is a two-armed randomised controlled trial in primary care in the Regions of Southern and Central Denmark (2.5 million citizens). Patients with non-specific low back will be recruited by paticpating GPs. Patients are randomised to either (1) stratified care or (2) current practice at participating physiotherapy clinics. In the stratified care arm, the intervention is based on the patient’s STarT Back Tool classification and trained accordingly, whereas physiotherapists in the current pratice arm are blinded to the STarT score. Primary outcomes in the trial will be group differences in time off work, improvement in LBP disability measured by the Roland Morris Disability Questionnaire (RMDQ) and patient-reported global change. Secondary measures will be pain intensity, patient satisfaction, data on patient healthcare resource utilisation and quality-adjusted life year based on the EQ-5D-5L.DiscussionStratified care that effectively targets treatment to relevant sub-groups of patients has potentially great impact on the treatment pathways of low back pain. Thus, if effective, this could result in better patient outcomes and at the same time reduce the costs for treatment of low back pain.Trial registrationClinicalTrials.gov, NCT02612467. Registered on 16 November 2015.

Advancing practice for back pain through stratified care (STarT Back)

BACKGROUND Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care. RESULTS The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care. CONCLUSIONS The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

Rehabilitation of discharged patients with Chronic Obstructive Pulmonary Disease: Are new strategies needed?

Background: Rehabilitation after hospital stay implies several benefits for patients with chronic obstructive pulmonary disease (COPD); still few patients are referred and participate in rehabilitation programs. We conducted a case study to investigate the effects of interventions targeting the referral, uptake, and completion for a program of early rehabilitation in the primary health-care sector. Methods: We undertook targeted initiatives to make patients participate in an individualized rehabilitation program with gradual increased intensity. After discharge, primary care COPD nurses and physiotherapists guided patients through progressing exercises in small groups online. Patients proceeded to class-based exercises, patient education and/or leisure activities, or continued telerehabilitation. We evaluated the effects of the intervention by assessing referral rates, completion, and readmission. Results: Sixteen (23% of discharged patients) patients were referred to rehabilitation. In comparison, only 1 (0.8%) in 131 patients from Vejle hospital was referred to Vejle hospital. Twelve patients completed rehabilitation, all having severe COPD. All started the program within 2 weeks and proceeded to the online-guided exercises within 4 weeks. Study data showed that after 30 days, 1 (6.3%) of the 16 patients in the rehabilitation program had been readmitted compared to 8 (14.8%) of 55 patients who were not referred. After 90 days, 2 (12.5%) and 11 (20.0%) patients were readmitted, respectively. The readmission rate showed a nonsignificant decline in patients participating in rehabilitation. Conclusion: This case study showed that the referral rate of patients with COPD to early municipal rehabilitation is extremely low without a targeted effort and still insufficient in spite of a focused intervention. We showed that completion of a municipal rehabilitation program shortly after discharge is possible even for patients with severe COPD. The findings from our pilot study can guide further investigations into the effect of implementation strategies for handovers between health-care sectors to secure early-onset rehabilitation of patients with COPD.

Vertebral Endplate Changes / Modic Changes: An Audit Study Using Antibiotics in 147 Chronic Low Back Pain Patients:

Introduction Vertebral endplate changes/Modic changes (MC) are the MRI-image of inflammatory vertebral endplate damage.1 In patients with chronic back pain, the prevalence of (MC) is 40%.2 MC are most often related to general disc degeneration or herniation.3 However, in a subgroup of patients, disc infection may be involved.4,5 In one high quality RCT more than 50% of patients with persistent pain and prolapsed discs showed clinically significant improvement after treatment with a broad spectrum antibiotic at 6 Month Follow Up (6MFU).6 Material and Methods A cohort study was established to evaluate the effect of treatment with Amoxicillin/ Clavulanic Acid for 3 months. 70 patients were treated with 1 1/2 g per day for one month followed by 3 g per day for 2 months (HighDose). Another 77 patients were treated with 2 g per day for 3 months (LowDose). The clinical profile of the included patients: referred to a secondary care outpatient Spine Centre with persistent low back pain and lumbar MC Type 1 and no effect of other non-surgical treatment forms. Main outcome measures at 6MFU: Patients global assessment (Global), change in spinal pain intensity on a 0–10 numerical rating scale (DeltaPain) and Number of Days with Pain (DaysPain) over a 14 day period. Responders were compared with non-responders. Results 147 patients (95 females) were included. The outcome analysis compares the treatment effect of the responders to the non-responders. Overall, 78/147; 53.01% of the patients stated a positive responder treatment effect after 6 months. DeltaPain in ‘the responder group’ at 6 months follow up was -29.96%[SD 36.2%] and in ‘the non-responder group’ 2.16% [SD 43.3%]. DaysPain decrease in ‘the responder group’ at 6MFU were 22.17% [SD 60.3], and in ‘the non-responder group’ an increase of 28.07%[SD 153.6]. Substantial side effects were noted in 17/70(24%) patients in HighDose and 12/77(16%) in LowDose patients. Minor side effects: 17/70(24%) of patients in HighDose and 14/77(18%) patients in LowDose. No difference in responderrate were seen between HighDose/ LowDose; 52.9%/53.3%. Conclusion The antibiotic treatment regime in this group of low back pain patients represented positive outcome results for 53% of the patients. At 6MFU clinically relevant improvements regar- ding pain intensity were obtained and numbers of days with pain was reduced by 22%. A higher number of side effects was seen using HighDose antibiotics compared with LowDose, but there was no difference in treatment efficacy. References Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988;166(1 Pt 1):193–199 Kjaer P, Korsholm L, Bendix T, Sorensen JS, Leboeuf-Yde C. Modic changes and their associations with clinical findings. Eur Spine J 2006;15(9):1312–1319 Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C. Modic changes, possible causes and relation to low back pain. Med Hypotheses 2008;70(2):361–368 Hongli W, Jianyuan J. Re.: Axial gout is frequently associated with the presence of current tophi, although not with spinal symptoms. Spine 2015;40(8):587 Zhou Z, Chen Z, Zheng Y, et al. Relationship between annular tear and presence of Propionibacterium acnes in lumbar intervertebral disc. Eur Spine J 2015;24(11):2496–2502 Albert HB, Lambert P, Rollason J, et al. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J 2013;22(4):690–696