Mary O’Keeffe

Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study

QUESTIONnWhat are physiotherapists perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training?nnnDESIGNnQualitative study design using semi-structured interviews to explore physiotherapists perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training.nnnPARTICIPANTSnThirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package.nnnRESULTSnFour main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors.nnnCONCLUSIONnPhysiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, OKeeffe M, Bunzli S, Dankaerts W, OSullivan P, Robinson K, OSullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study.Journal of Physiotherapy62: 215-221].

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

&NA; Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individuals disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

The efficacy of interventions for low back pain in nurses: A systematic review

OBJECTIVESnTo investigate the efficacy of interventions for the prevention and treatment of low back pain in nurses.nnnDESIGNnSystematic review.nnnDATA SOURCESnThe review was registered on the PROSPERO database (CRD42015026941) and followed the PRISMA statement guidelines. A two phase approach was used. In phase one, all randomised controlled trials included in the systematic review of Dawson et al. (2007) which reviewed interventions for low back pain in nurses until 2004 were selected. In phase two, relevant randomised controlled trials and cluster randomised controlled trials published from 2004 until December 2015 were identified by an electronic search of nine databases (Embase, CINAHL, SPORTDiscus, PsycARTICLES, Cochrane Library, Web of Science, PEDro, Scopus and MEDLINE). To be eligible, trials had to examine the efficacy of interventions either for the prevention or treatment of low back pain in nurses. Primary outcomes of interest were any measure of pain and/or disability.nnnREVIEW METHODSnThree reviewers independently assessed eligibility and two reviewers independently conducted a risk of bias assessment (Cochrane Back and Neck Group).nnnRESULTSnFour studies were retrieved from phase one. In phase two, 15,628 titles and abstracts were scanned. From these, 150 full-text studies were retrieved and ten were eligible. Fourteen studies (four from phase one, ten from phase two) were eligible for risk of bias assessment. The included trials were highly heterogeneous, differing in pain and disability outcome measures, types of intervention, types of control group and follow-up durations. Only four of the included studies (n=644 subjects) had a low risk of bias (≥6/12). Manual handling training and stress management in isolation were not effective in nurses with and without low back pain (risk of bias, 7/12, n=210); the addition of a stretching exercise intervention was better than only performing usual activities (risk of bias, 6/12, n=127); combining manual handling training and back school was better than passive physiotherapy (risk of bias, 7/12, n=124); and a multidimensional intervention (risk of bias, 7/12, n=183) was not superior to a general exercise program in reducing low back pain in nurses.nnnCONCLUSIONSnOnly four relevant low risk of bias randomised controlled trials were found. At present there is no strong evidence of efficacy for any intervention in preventing or treating low back pain in nurses. Additional high quality randomised controlled trials are required. It may be worth exploring the efficacy of more individualised multidimensional interventions for low back pain in the nursing population.

Unlocking the potential of physical activity for back health

Physical activity is central to achieving better back health. Engaging in some forms of physical activity may increase the risk of low back pain (LBP), but in general a physically active lifestyle seems to be protective for LBP.1 The only known effective prevention method is exercise alone or exercise with education.2 Most guidelines for acute LBP focus on advice to increase physical activity. For persistent LBP, most effective treatments have physical activity at their core, either where it is the main component (eg, aerobic exercise) or where there is greater use of psychological principles (eg, graded exposure).nnIn our view, the potential value of physical activity for back health is not being realised. We address four key issues.nn1.xa0Preoccupation with the right physical activity could be holding us back nnWhile many clinicians confidently preach the benefits of physical activity for general health, this confidence seems to be replaced with a pause or panic when advising a patient who has …

NICE low back pain guidelines: opportunities and obstacles to change practice

The National Institute for Health and Care Excellence recently updated its low back pain (LBP) guidelines,1 with the associated infographic developed to assist interpretation of the recommendations. The guidelines are more consistently aligned with Cochrane systematic reviews than the previous version. The guidelines contain several key directives, which, if widely implemented, could significantly impact on the care of individuals with LBP. Established evidence-based messages, including the need for more cautious referral for some investigations and treatments including imaging, medication and surgery, are reinforced, with a clear emphasis on facilitating self-management strategies. Considering psychosocial factors at an early stage is also advocated, rather than waiting for usual care to fail. There is a timely shift to targeting care based on a person’s multidimensional risk profile, rather than merely symptom duration.nn1. Which treatment option for whom?

Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review

QUESTIONnWhat are staff and patients perceptions of physiotherapists working in the emergency department (ED)?nnnDESIGNnSystematic review of qualitative studies.nnnPARTICIPANTSnStaff working in EDs and patients presenting to the ED and managed by ED physiotherapists.nnnOUTCOME MEASURESnPerceptions of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction, grouping (codes), and abstraction of findings.nnnRESULTSnEight studies, which had sought the perceptions of 138 patients and 122 ED staff members, were included. Three main themes emerged: role of physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education, non-pharmacological pain management and activity resumption, especially through exercise therapy. Having broad knowledge to assess and treat different health conditions was seen as facilitating the work of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal communication skills. ED staff expressed concerns regarding the additional time that physiotherapists spent with patients. Some patients felt that performing exercises in the ED was inappropriate and painful.nnnCONCLUSIONSnED physiotherapists were mostly well accepted by patients and ED staff, and their work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira GE, Traeger AC, OKeeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy 64: 229-236].

Advice to athletes with back pain—get active! Seriously?

The recent Lancet low back pain (LBP) series1–3 recommended exercise and physical activity, particularly for persistent and debilitating pain. Given a dearth of clinical trials for LBP among athletes, is encouraging activity justifiable for athletes with LBP when they are often already highly active? This editorial teases out the role of exercise and activity for LBP among athletes.nnThe evidence that athletes get LBP because they are excessively active is limited. For example, there are data that LBP intensity among rowers is higher during intense training periods,4 and that highly active teenagers develop more future LBP.5 However, these studies either did not always examine how meaningful or disabling the LBP was4 5 or several other factors were also implicated. What is clear is that being consistently active is associated with less pain and injury. In other words, being active might be a good thing to reduce pain, including LBP, as long as the rate of increase in activity is managed appropriately and other relevant factors (eg, sleep, mood, relationships) are also addressed.nnIt is worth remembering that many factors linked with …

The Lancet series on low back pain: reflections and clinical implications

The Lancet series of papers on low back pain (LBP)1–3 received considerable academic and media attention, and helpfully reinforced key messages from international guidelines. Box 1 highlights some of the series’ key messages. The series illustrated international, multidisciplinary consensus on management of LBP. The series provides the reader with a comprehensive review of the most promising solutions, ranging from stratified care according to clinical risk profiling, through integrated health and occupational care, changes to payment systems and legislation, as well as public health and prevention strategies. This is important as all too often, guidelines and systematic reviews focus on the effectiveness, or lack thereof, of particular treatment options in isolation, without considering the broader context within which treatments are delivered. Here, we reflect on three issues from the series and discuss the clinical implications. Box 1 n### Lessons from the Lancet low back series

Psychosocial factors in low back pain: letting go of our misconceptions can help management

The Lancet low back pain (LBP) series1 highlighted the important role of psychosocial factors in LBP and its associated disability. It is worth reflecting on what psychosocial factors are, and are not, in order to optimise management.nnNot all psychosocial factors are indicative of a mental health disorder which requires assessment and treatment by a dedicated mental health provider. For example, fear of movement is NOT necessarily a mental health disorder unless the individual meets the criteria for phobic disorder. While we need to competently identify patients with comorbid mental health disorders, such cases are the exception, not the rule. As such, many psychosocial factors (eg, fear of movement, distress about scan findings, depression related to a loss of valued activities, anxiety about the future, social stress) can be within the scope of musculoskeletal clinicians.nnWe contend that the way we have categorised interventions for LBP into ‘physical’ or ‘psychological’ has created boundaries for what clinicians deem to be within their scope.2 We …

Evidence-based physiotherapy needs evidence-based marketing

Just over 20 years ago, an editorial titled ‘Now is the time for evidence based physiotherapy’ highlighted the need for high-quality research on the effectiveness of physiotherapy treatments.1 Today, we arguably have sufficient evidence to allow physiotherapists to choose an evidence-based approach to clinical practice. For example, the Physiotherapy Evidence Database (PEDro) indexes nearly 40u2009000 randomised controlled trials, systematic reviews and clinical practice guidelines. More recently, physiotherapy associations have dramatically increased the marketing of physiotherapy services. This reflects a rapidly expanding workforce and more jurisdictions allowing the public to directly access physiotherapy without the need for medical referral.nnMarketing of physiotherapy sometimes draws on evidence but at other times makes claims for physiotherapist roles and services that are not supported by evidence. This couldxa0mislead the publicxa0and could draw attention away from the strong evidencexa0base within physiotherapy. Consider these examples of marketing from the websites of physiotherapy associations and leading physiotherapy journals from the USA, Australia and UK.nnRecent marketing that early physical therapy could help …