Publications by authors named "Per Kjaer"

57 Publications

Self-management at the core of back pain care: 10 key points for clinicians.

Braz J Phys Ther 2021 May 24. Epub 2021 May 24.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark; Chiropractic Knowledge Hub, Odense M, Denmark.

Background: A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

Objective: In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

Discussion: People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.
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http://dx.doi.org/10.1016/j.bjpt.2021.05.002DOI Listing
May 2021

'When the picture does not really tell the story'- A qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain.

Patient Educ Couns 2021 May 5. Epub 2021 May 5.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK 5230 Odense M, Denmark; Health Sciences Research Centre, UCL University College, Niels Bohrs Alle 1, DK 5230 Odense M, Denmark.

Objectives: To explore the magnetic resonance imaging (MRI) feedback report as a health care encounter for generating shared diagnostic meaning.

Methods: An exploratory, qualitative case study was conducted using video observation of the MRI report of findings, individual face-to-face and telephonic interviews.

Results: From fourteen distinct encounters, three key themes emerged, these being: 'a powerful shared experience, 'a legacy of biomedical thinking' and 'clinical practice quandaries'. Generally speaking, the MRI encounter was observed to be both an effective and satisfying method for developing shared diagnostic meaning. However, in instances where a structure-based diagnosis could not be reasonably established, clinicians experienced doubts in what to present in a 'soft report'. A feature of these was the communication of speculative causal feedback, based on non-visualised structures and/or incidental findings observed.

Conclusion: Shared diagnostic meaning can result from a 'soft' MRI report of findings. However, the emergence of diagnostic closure is not guaranteed. Further exploration of this phenomenon in the context of shared decision making and the therapeutic alliance is warranted.

Practice Implications: Pre-feedback peer conferences might be considered in order to standardise the information communicated to patients. Clinicians might also consider limiting the MRI scan as a visual aid in 'soft' reports.
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http://dx.doi.org/10.1016/j.pec.2021.04.031DOI Listing
May 2021

The Interexaminer Reproducibility and Prevalence of Lumbar and Gluteal Myofascial Trigger Points in Patients With Radiating Low Back Pain.

Arch Rehabil Res Clin Transl 2020 Jun 30;2(2):100044. Epub 2020 Jan 30.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Objective: To determine the interexaminer reproducibility for judging the presence, number, and location of leg-pain referring myofascial trigger points, and their prevalence in patients with low back pain with and without concomitant leg pain referral.

Design: An interexaminer reproducibility study.

Setting: An outpatient public Hospital Spine Centre in Southern Denmark.

Participants: : experienced examiners (N=2), a chiropractor and a physiotherapist, respectively. : a case mix of patients with low back pain (N=32) with and without leg pain referral.

Interventions: A standardized palpation examination protocol of 4 bilateral lumbosacral muscles performed by each examiner.

Main Outcome Measures: Reproducibility on presence (measured in Cohen's κ), number (difference and limits of agreement), location (distance between matching marks placed by examiners), and prevalence of myofascial trigger points.

Results: Kappa values of the examined muscles were as follows: quadratus lumborum (κ=0.42), gluteus medius (κ=0.83), gluteus minimus (κ=0.74), and piriformis (κ=0.62), with a mean of all examined muscles of kappa=0.66, assessed as substantial agreement. The mean difference in number of trigger points was 0.8, with limits of agreement ranging from -6.4 to 4.9. Mean distance between trigger point locations was 12.9 mm, with 57% only being identified by a single examiner. The prevalence of trigger points was 82.7%, highest in the gluteal region of the painful side.

Conclusions: Inadequate standardization and multiple trigger point sites complicate interexaminer reproducibility on location and number of patients with low back pain and leg pain referral. Nevertheless, substantial interexaminer reproducibility for the trigger point presence appears achievable. Implemented routinely, this relatively simple clinical evaluation procedure could meaningfully enhance diagnostic triage and eventual management.
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http://dx.doi.org/10.1016/j.arrct.2020.100044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853331PMC
June 2020

Strain Elastography and Tendon Response to an Exercise Program in Patients With Supraspinatus Tendinopathy: An Exploratory Study.

Orthop J Sports Med 2020 Dec 16;8(12):2325967120965185. Epub 2020 Dec 16.

Research Unit in Physio- and Occupational Therapy, Lillebaelt Hospital-University Hospital of Southern Denmark, Vejle, Denmark.

Background: Shoulder pain is common, with a lifetime prevalence of up to 67%. Evidence is conflicting in relation to imaging findings and pain in the shoulder. Sonoelastography can be used to estimate tissue stiffness and may be a clinically relevant technique for diagnosing and monitoring tendon healing.

Purpose: To evaluate changes in supraspinatus tendon stiffness using strain elastography (SEL) and associations with changes in patient-reported outcomes, supraspinatus tendon thickness, and grade of tendinopathy after 12 weeks of unilateral shoulder exercises in patients with supraspinatus tendinopathy.

Study Design: Controlled laboratory study.

Methods: A total of 23 patients with unilateral clinical supraspinatus tendinopathy performed 12 weeks of "standard care" exercises. At baseline and follow-up, supraspinatus tendon stiffness was measured bilaterally using SEL and compared with tendinopathy grading on magnetic resonance imaging scans and tendon thickness measured using conventional ultrasound. Patient-reported outcome measures included physical function and symptoms from the Disabilities of the Arm, Shoulder and Hand questionnaire and pain rating (visual analog scale).

Results: No significant changes in SEL within or between groups (asymptomatic vs symptomatic tendon) were seen. All patient-reported outcomes showed significant improvement from baseline to follow-up, but with no change in tendinopathy grading and tendon thickness. No significant differences in the proportion of patients changing above the minimal detectable change in SEL and PROM were seen, except for discomfort while sleeping.

Conclusion: Despite no significant within-group or between-group changes in SEL, significant improvements were found in patient-reported outcomes. An acceptable agreement between patients changing above the minimal detectable change in SEL and patient-reported outcome measure was seen. Further studies should explore the use of SEL to detect changes after tendon repair and long-term training potentially in subgroups of different tendinopathy phases.

Clinical Relevance: In the short term, structural changes in supraspinatus tendons could not be visualized using SEL, indicating that a longer time span should be expected in order to observe structural changes, which should be considered before return to sports. Subgrouping based on stage of tendinopathy may also be important in order to evaluate changes over time with SEL among patients with supraspinatus tendinopathy.

Registration: NCT03425357 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967120965185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747122PMC
December 2020

Motor performance and back pain in children and adolescents: a systematic review and meta-analysis protocol.

Syst Rev 2020 09 14;9(1):212. Epub 2020 Sep 14.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, Odense, Denmark.

Background: The relationship between motor performance and back pain in children and adolescents remains unclear. This article describes the protocol for a systematic review to summarize the knowledge about the association between motor performance, such as agility, flexibility, balance, strength, muscle endurance, and cardiorespiratory fitness, and back pain. Thus, our aim is to identify the influence of motor performance on back pain among children and adolescents.

Methods: Two independent researchers will search MEDLINE, Scopus, Embase, SPORTDiscus, and CINAHL databases, with no period or language restrictions. We will include cross-sectional, cohort, case-control, and controlled clinical trial studies based on the following criteria: (a) participants from 6 to 19 years of age, (b) assessment of motor performance, (c) assessment of back pain, and (d) report measures of associations between motor performance and back pain. Study quality and risk of bias will be assessed using an adapted version of the Downs and Black instrument. Grading of Recommendations, Assessment, Development, and Evaluations will be used to assess the strength of the body of evidence. Meta-analyses of association measures will be performed for each type of motor performance, separately for different study types. The results will be reported using forest to show the pooled effect of findings and funnel plots to assess precision of the data. If studies are not homogeneous, results from the meta-analyses will not be reported. Associations will then be synthesized descriptively using a pragmatic approach.

Discussion: This systematic review will provide critical insights into the association between motor performance and back pain among children and adolescents; this information may help support clinical practice guidelines as well as public health programs.

Ethics And Dissemination: Protocol was written according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

Systematic Review Registration: PROSPERO CRD42020178496.
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http://dx.doi.org/10.1186/s13643-020-01468-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491087PMC
September 2020

Discriminative and convergent validity of strain elastography for detecting tendinopathy within the supraspinatus tendon: a cross-sectional study.

JSES Int 2020 Jun 24;4(2):310-317. Epub 2020 Feb 24.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: We aimed to explore the discriminative validity of ultrasound strain elastography (SEL) between patients with painful supraspinatus tendinopathy and healthy control shoulders, as well as the associations between SEL and magnetic resonance imaging (MRI), conventional ultrasound (tendon thickness), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH).

Methods: Thirty patients with shoulder pain and MRI-verified supraspinatus tendinopathy and 30 healthy control shoulders (no pain) were examined using SEL, MRI, and conventional ultrasound of the supraspinatus tendon. SEL variables included raw data, ratios between the deltoid muscle and supraspinatus tendon (deltoid ratio), color rating, and presence of red/yellow lesions (middle, worst part, and total tendon).

Results: Statistically significant increases in odds ratios for being symptomatic (increased softening) were seen for all raw data variables, corresponding to 3.978 (95% confidence interval [CI], 1.414-11.197) for middle, 4.602 (95% CI, 1.536-13.788) for worst, and 4.865 (95% CI, 1.406-16.836) for total tendon, and 1.260 (95% CI, 1.027-1.545) for the deltoid ratio (worst), adjusted for sex and body mass index (BMI). Tendon thickness was not associated with SEL; however, significantly positive associations were found between raw data variables and MRI (β ≥ 0.58, < .01), and positive associations were found between raw data variables and the DASH score (β = 0.01, ≤ .04), adjusted for sex and BMI.

Conclusions: Raw data variables and the deltoid ratio (worst) discriminated between patients with painful supraspinatus tendinopathy and healthy control shoulders when adjusted for sex and BMI. Associations were statistically significant for raw data variables and MRI or DASH score when adjusted for sex and BMI. Further studies are needed to understand SEL and the role of sex and BMI, including the responsiveness of SEL.
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http://dx.doi.org/10.1016/j.jseint.2019.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256788PMC
June 2020

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population.

BMC Musculoskelet Disord 2020 Apr 17;21(1):253. Epub 2020 Apr 17.

Department of Diagnostic Imaging, Silkeborg Regional Hospital, Silkeborg, Denmark.

Background: Lumbar disc degeneration seen on magnetic resonance imaging (MRI) is defined as loss of signal intensity and/or disc height, alone or in combination with other MRI findings. The MRI findings and thresholds used to define disc degeneration vary in the literature, and their associations with low back pain (LBP) remain uncertain.

Objective: To explore how various thresholds of lumbar disc degeneration alter the association between disc degeneration and self-reported LBP.

Methods: An exploratory, cross-sectional cohort study of a general population. Participants in the cohort 'Backs-on-Funen' had MRI scans and completed questionnaires about LBP at ages 41, 45 and 49 years. The MRI variables, signal intensity (Grades 0-3) and disc height (Grades 0-3), were dichotomised at different thresholds. Logistic regression analyses were used to determine associations. Arbitrarily, a difference in odds ratio (OR) of > 0.5 between thresholds was considered clinically relevant. Receiver Operating Characteristic curves were used to investigate differences between diagnostic values at each threshold.

Results: At age 41, the difference in ORs between signal loss and LBP exceeded 0.5 between the thresholds of ≥2 (OR = 2.02) and = 3 (OR = 2.57). Difference in area under the curves (AUC) was statistically significant (p = 0.02). At ages 45 and 49, the difference in ORs exceeded 0.5 between the thresholds of ≥2 and = 3, but the differences between AUC were not statistically significant. At age 41, the difference in ORs between disc height loss and LBP at the thresholds of ≥1 (OR = 1.44) and ≥ 2 (OR = 2.53) exceeded 0.5. Differences in AUC were statistically significant (p = 0.004). At age 49, differences in ORs exceeded 0.5 (OR = 2.49 at the ≥1 threshold, 1.84 at ≥2 and 0.89 at =3). Differences between AUC were not statistically significant.

Conclusion: The results suggest that the thresholds used to define the presence of lumbar disc degeneration influence how strongly it is associated with LBP. Thresholds at more severe grades of disc signal and disc height loss were more strongly associated with LBP at age 41, but thresholds at moderate grades of disc degeneration were most strongly associated with LBP at ages 45 and 49.
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http://dx.doi.org/10.1186/s12891-020-03268-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165403PMC
April 2020

Cognitive Functional Therapy for People with Nonspecific Persistent Low Back Pain in a Secondary Care Setting-A Propensity Matched, Case-Control Feasibility Study.

Pain Med 2020 10;21(10):2061-2070

School of Physiotherapy and Exercise Science, Curtin University, Australia.

Background: Effective, inexpensive, and low-risk interventions are needed for patients with nonspecific persistent low back pain (NS-PLBP) who are unresponsive to primary care interventions. Cognitive functional therapy (CFT) is a multidimensional behavioral self-management approach that has demonstrated promising results in primary care and has not been tested in secondary care.

Objective: To investigate the effect of CFT and compare it with usual care for patients with NS-PLBP.

Design: Case-control study.

Setting: A secondary care spine center.

Subjects: Thirty-nine patients received a CFT intervention and were matched using propensity scoring to 185 control patients receiving usual care.

Methods: The primary outcome was Roland Morris Disability Questionnaire (0-100 scale) score. Group-level differences at six- and 12-month follow-up were estimated using mixed-effects linear regression.

Results: At six-month follow-up, a statistically significant and clinically relevant difference in disability favored the CFT group (-20.7, 95% confidence interval [CI] = -27.2 to -14.2, P < 0.001). Significant differences also occurred for LBP and leg pain, fear, anxiety, and catastrophizing in favor of CFT. At 12-month follow-up, the difference in disability was smaller and no longer statistically significant (-8.1, 95% CI = -17.4 to 1.2, P = 0.086). Differences in leg pain intensity and fear remained significantly in favor of CFT. Treatment satisfaction was significantly higher in the CFT group at six- (93% vs 66%) and 12-month (84% vs 52%) follow-up.

Conclusions: These findings support that CFT is beneficial for patients with NS-PLBP who are unresponsive to primary care interventions. Subsequent randomized controlled trials could incorporate booster sessions, which may result in larger effects at 12-month follow-up.
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http://dx.doi.org/10.1093/pm/pnaa034DOI Listing
October 2020

An App-Delivered Self-Management Program for People With Low Back Pain: Protocol for the selfBACK Randomized Controlled Trial.

JMIR Res Protoc 2019 Dec 3;8(12):e14720. Epub 2019 Dec 3.

Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP.

Objective: The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP.

Methods: This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months.

Results: The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020.

Conclusions: This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions.

Trial Registration: ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288.

International Registered Report Identifier (irrid): DERR1-10.2196/14720.
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http://dx.doi.org/10.2196/14720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918200PMC
December 2019

Diagnosis and treatment of sciatica.

BMJ 2019 Nov 19;367:l6273. Epub 2019 Nov 19.

Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

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http://dx.doi.org/10.1136/bmj.l6273DOI Listing
November 2019

Electronic measures of movement impairment, repositioning, and posture in people with and without neck pain-a systematic review.

Syst Rev 2019 08 27;8(1):220. Epub 2019 Aug 27.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense M, Denmark.

Background: Neck pain is a major public health problem. Our objective was to describe differences in measures of movement and posture between people with and without neck pain.

Methods: PubMed and Embase were searched before 15 February 2019 for studies comparing people with neck pain with controls using electronic measurements of neck movement and/or posture. Data were extracted on participants, device, test methods, active range of motion (RoM) and quality of motion, joint positioning sense, and posture. Study quality was assessed using the quality assessment of studies of diagnostic accuracy included in systematic reviews (QUADAS) and Guidelines for Reporting Reliability and Agreement Studies (GRRAS) guidelines.

Results: Thirty-six studies were included: 24 studies included measurement of active RoM, 15 quality of motion, 12 joint positioning sense, and 5 cervical spine posture. Measurements and test methods were heterogeneous. The reporting of study populations and methods were poor, whereas devices and statistics were well described. All studies on RoM showed reduced active RoM in people with neck pain when compared with controls, 5 of 10 studies reported reduced movement speed for people with neck pain, and 5 of 9 studies reported significantly greater joint positioning error for people with neck pain compared with controls. Due to heterogeneous test parameters and methods, no conclusion regarding differences in conjunct motion, tracking a motion pattern, and measures of posture could be drawn.

Conclusions: People with neck pain appear to have reduced active RoM, movement speed, and head repositioning accuracy when compared with controls. However, quality of reviewed studies was low and better descriptions of participants and methods are required before firm conclusions can be drawn.
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http://dx.doi.org/10.1186/s13643-019-1125-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6710866PMC
August 2019

GLA:D® Back: group-based patient education integrated with exercises to support self-management of persistent back pain - feasibility of implementing standardised care by a course for clinicians.

Pilot Feasibility Stud 2019 9;5:65. Epub 2019 May 9.

4Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland.

Background: Clinical guidelines for management of low back pain (LBP) are not routinely implemented in practice, and guidelines rarely offer tools for implementation. Therefore, we developed GLA:D® Back, a standardised intervention of patient education and supervised exercises. This pilot study tested the feasibility of implementing GLA:D Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors. It should further inform the planning of an implementation-effectiveness study using a pre-post group design alongside nation-wide implementation.

Methods: Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption and through focus group interviews and a feedback meeting. Patient-level data, including pain, disability, and pain enablement, were collected from (1) LBP patients visiting the clinics during a pre-specified 2-week period 2 months prior to clinicians attending the GLA:D Back course ( = 84), (2) LBP patients consulting during a 2-week period 2 months after the course ( = 77), and (3) those enrolled in GLA:D Back during 4 months after implementation ( = 89). Patient data were collected at baseline and at 4 months.

Results: Clinicians' evaluations of the course were positive and resulted in several modifications. The clinical intervention was adopted by all test sites. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (73% > 3 months) and most had been treated for more than 4 weeks at inclusion. Patients in GLA:D Back were more often retired (30% vs. 16% before implementation) and at high risk of poor prognosis (25% vs. 13%). Procedures for data collection were feasible, and outcomes after implementation, especially with GLA:D Back, were as good as or better than before implementation. Recruiting patients and achieving comparable pre- and post-groups was difficult.

Conclusions: Implementation of the GLA:D Back clinical intervention in Danish primary care physiotherapy and chiropractic clinics was feasible through a 2-day clinician course. Both clinicians and patients were satisfied with the programme, and patient-reported outcomes were slightly better than outcomes in patients registered before implementation. It was not deemed possible to conduct an implementation-effectiveness trial as part of a nation-wide implementation.
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http://dx.doi.org/10.1186/s40814-019-0448-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507160PMC
May 2019

Ultrasonic strain elastography for detecting abnormalities in the supraspinatus tendon: an intra- and inter-rater reliability study.

BMJ Open 2019 05 9;9(5):e027725. Epub 2019 May 9.

Institute of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, Odense, Denmark.

Objectives: The reliability of ultrasonic strain elastography (SEL) used to detect abnormalities in the supraspinatus tendon is unclear. Thus, the aim of this study was to investigate the reliability of SEL in the supraspinatus tendon.

Design: An intra-rater and inter-rater reliability study.

Setting: A single-centre study conducted at the University of Southern Denmark.

Participants: Twenty participants with shoulder pain and MRI-verified supraspinatus tendinosis and 20 asymptomatic participants (no MRI).

Primary And Secondary Outcome Measures: Raw values (RAW) and ratios (deltoid muscle (DELT) and gel pad (GEL) as reference tissues) were calculated and mean values of measurements from three regions of the supraspinatus tendon were reported. Colour scale ratings and number of yellow/red lesions from the three areas were also included.

Results: Intra-rater reliability showed intraclass correlation coefficients (ICCs) for RAW, DELT and GEL: 0.97 (minimal detectable change (MDC): 0.28 (6.36% of the mean)), 0.89 (MDC: 2.91 (20.37%)) and 0.73 (MDC: 1.61 (58.82%)), respectively. The ICCs for inter-rater reliability were 0.89 (MDC: 0.47 (10.53%)), 0.78 (MDC: 3.69 (25.51%)) and 0.70 (MDC: 1.75 (62.63%)), respectively.For colour scale ratings, intra-rater reliability (linear weighted kappa) ranged from 0.76 to 0.79, with the inter-rater reliability from 0.71 to 0.81. For the number of lesions, intra-rater reliability ranged from 0.40 to 0.82 and inter-rater reliability from 0.24 to 0.67.

Conclusions: Intra-rater and inter-rater reliability were excellent for raw values and for ratios with deltoid muscle as the reference tissue, and good for ratios with gel pad as the reference tissue. The reliability of colour scale ratings was substantial-to-almost perfect, and for the number of lesions fair-to-almost perfect.Although high reliability was found, validity and responsiveness of these elastographic methods needs further investigation.

Ethics Approval: The study protocol was approved by the Ethics Committee for the Region of South Denmark (S-20160115) and reported to the Danish Data Protection Agency (2014-41-3266).
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http://dx.doi.org/10.1136/bmjopen-2018-027725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527995PMC
May 2019

The natural course of low back pain from childhood to young adulthood - a systematic review.

Chiropr Man Therap 2019 20;27:10. Epub 2019 Mar 20.

1Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark.

Background: Taking the natural course of recurrent and fluctuating low back pain (LBP) seen in longitudinal studies of adults into consideration, the aetiology and development of LBP in children and adolescents also needs to be reflected in a long-term course. Therefore, a systematic critical literature review was undertaken to assess the natural course of LBP in the general population from childhood through adolescence to young adulthood.

Methods: A systematic literature search was conducted in MEDLINE, EMBASE, CINAHL and PsycINFO with synonyms of search terms for 1) low back pain; 2) natural course; 3) cohort study and 4) children. Records in English, German, French, Danish, Swedish, and Norwegian were included. To assess the methodological quality of the studies, the NIH quality assessment checklist for cohort studies was adapted and risk of bias was assessed on a study level. Two authors independently reviewed selected studies, assessed quality, and extracted data. A synthesis of results in relation to the natural course of LBP was created.

Results: Totally, 3373 records were identified, eight articles were included for quality assessment, and finally, four studies of good to fair quality were included for synthesis of results. Indication of three common patterns of LBP were identified across studies and labelled as 1) ´children and adolescents with no LBP or low probability of LBP´ (49 to 53%), 2) ´children and adolescents with fluctuation of LBP´ (16 to 37%) and 3) ´children and adolescents with repeated reporting of LBP´ (< 1 to 10%).

Conclusion: Although methodological heterogeneity, mainly due to different age ranges, an indication of a natural course of LBP was seen across studies. The majority of children and adolescents repeatedly reporting no or low probability of LBP. With recall periods between one week to three months and sampling rates ranging from one to four years, a very low rate repeatedly reported LBP, and approximately one-fifth to one-third of children and adolescents had fluctuating reports of LBP. A need of future research of LBP trajectories with short reporting period lengths and narrower sampling windows in a long-term perspective is emphasized in order to study childhood influences on the development of LBP throughout life.
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http://dx.doi.org/10.1186/s12998-018-0231-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425623PMC
July 2019

Prevalence of MRI findings in the cervical spine in patients with persistent neck pain based on quantification of narrative MRI reports.

Chiropr Man Therap 2019 6;27:13. Epub 2019 Mar 6.

3Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Previous studies of patients with neck pain have reported a high variability in prevalence of MRI findings of disc degeneration, disc herniation etc. This is most likely due to small and heterogenous study populations. Reasons for only including small study samples could be the high cost and time-consuming procedures of having radiologists coding the MRIs. Other methods for extracting reliable imaging data should therefore be explored.The objectives of this study were 1) to examine inter-rater reliability among a group of chiropractic master students in extracting information about cervical MRI-findings from radiologists´ narrative reports, and 2) to describe the prevalence of MRI findings in the cervical spine among different age groups in patients above age 18 with neck pain.

Method: Adult patients with neck pain (with or without arm pain) seen in a public hospital department between 2011 and 2014 who had an MRI of the cervical spine were identified in the patient registry 'SpineData'. MRI-findings were extracted and quantified from radiologists' narrative reports by second-year chiropractic master students based on a set of coding rules for the process.The inter-rater reliability was quantified with Kappa statistics and the prevalence of the MRI findings were calculated.

Results: In total, narrative MRI reports from 611 patients were included. The patients had a mean age of 52 years (SD 13; range 19-87) and 63% were women. The inter-observer agreement in coding MRI findings ranged from substantial (κ = 0.78, CI: 0.33-1.00) to almost perfect (κ = 0.98, CI: 0.95-1.00).The most prevalent MRI findings were foraminal stenosis (77%), uncovertebral arthrosis (74%) and disc degeneration (67%) while the least prevalent findings were nerve root compromise (2%) and Modic changes type 2 (6%). Modic type 1 was mentioned in 25% of the radiologists' reports. The prevalence of all findings increased with age, except disc herniation which was most prevalent for patients in their forties.

Conclusion: MRI-findings from radiologists' narrative reports can reliably be extracted by chiropractic master students with a minimum of training. Degenerative findings in the cervical spine were most commonly found at levels C5/C6 and C6/C7 and increased with age.
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http://dx.doi.org/10.1186/s12998-019-0233-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402131PMC
July 2019

GLA:D Back: implementation of group-based patient education integrated with exercises to support self-management of back pain - protocol for a hybrid effectiveness-implementation study.

BMC Musculoskelet Disord 2019 Feb 18;20(1):85. Epub 2019 Feb 18.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Reassuring patient education and exercise therapy are widely recommended interventions for back pain in clinical guidelines. However, many patients are offered non-guideline endorsed options, and strategies for effective implementation of guideline-based care have not yet been developed. This protocol outlines the evaluation of a strategy for nationwide implementation of standardised patient education and exercise therapy for people with persistent or recurrent back pain in a hybrid implementation-effectiveness design. The strategy and the evaluation were planned using the framework of the Behaviour Change Wheel.

Methods: The main activity of the implementation strategy is a two-days course for physiotherapists and chiropractors in delivering patient education and exercise therapy that is aimed at supporting patient self-management. This comes with ready-to-use patient education materials and exercise programs. The clinical intervention is a group-based program consisting of two sessions of patient education and 8 weeks of supervised exercises. The program uses a cognitive-behavioural approach and the aim of the exercise component is to restore the patient's ability and confidence to move freely. The implementation process is evaluated in a dynamic process monitoring the penetration, adoption and fidelity of the clinical intervention. The clinical intervention and potential effect mechanisms will be evaluated at the patient-level using measures of knowledge, skills, beliefs, performance, self-efficacy and success in self-management. The education of clinicians will be evaluated via clinician-level outcomes, including the Pain Attitudes and Beliefs Scale, the Practitioner Confidence Scale, and the Determinants of Implementation Behaviour Questionnaire. Effects at a national level will be investigated via data from national registries of health care utilisation and sick-leave.

Discussion: This implementation-effectiveness study is designed to evaluate the process of implementing an evidence-based intervention for back pain. It will inform the development of strategies for implementing evidence-based care for musculoskeletal pain conditions, it will enhance the understanding of mechanisms for developing patient self-management skills, and it will demonstrate the outcomes that are achievable in everyday clinical practice.

Trial Registration: ClinicalTrials.gov NCT03570463 . Registered 27 June 2018.
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http://dx.doi.org/10.1186/s12891-019-2443-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380042PMC
February 2019

GLA:D Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence.

BMC Musculoskelet Disord 2018 Nov 29;19(1):418. Epub 2018 Nov 29.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.

Background: Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

Methods: GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

Results: Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

Conclusion: From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.
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http://dx.doi.org/10.1186/s12891-018-2334-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267880PMC
November 2018

Relationships between paraspinal muscle morphology and neurocompressive conditions of the lumbar spine: a systematic review with meta-analysis.

BMC Musculoskelet Disord 2018 Sep 27;19(1):351. Epub 2018 Sep 27.

Faculty of Kinesiology, University of New Brunswick, 3 Bailey Drive, Fredericton, New Brunswick, E3B 5A3, Canada.

Background: Individual study results have demonstrated unclear relationships between neurocompressive disorders and paraspinal muscle morphology. This systematic review aimed to synthesize current evidence regarding the relationship lumbar neurocompressive disorders may have with lumbar paraspinal muscle morphology.

Methods: Searches were conducted in seven databases from inception through October 2017. Observational studies with control or comparison groups comparing herniations, facet degeneration, or canal stenosis to changes in imaging or biopsy-identified lumbar paraspinal muscle morphology were included. Data extraction and risk of bias assessment were performed by review author pairs independent of one another. Morphological differences between individuals with and without neurocompressive disorders were compared qualitatively, and where possible, standardised mean differences were obtained.

Results: Twenty-eight studies were included. Lumbar multifidus fiber diameter was smaller on the side of and below herniation for type I [SMD: -0.40 (95% CI = -0.70, -0.09) and type II fibers [SMD: -0.38 (95% CI = -0.69, -0.06)] compared to the unaffected side. The distribution of type I fibers was greater on the herniation side [SMD: 0.43 (95% CI = 0.03, 0.82)]. Qualitatively, two studies assessing small angular fiber frequency and fiber type groupings demonstrated increases in these parameters below the herniation level. For diagnostic imaging meta-analyses, there were no consistent differences across the various assessment types for any paraspinal muscle groups when patients with herniation served as their own control. However, qualitative synthesis of between-group comparisons reported greater multifidus and erector spinae muscle atrophy or fat infiltration among patients with disc herniation and radiculopathy in four of six studies, and increased fatty infiltration in paraspinal muscles with higher grades of facet joint degeneration in four of five studies. Conflicting outcomes and variations in study methodology precluded a clear conclusion for canal stenosis.

Conclusions: Based on mixed levels of risk of bias data, in patients with chronic radiculopathy, disc herniation and severe facet degeneration were associated with altered paraspinal muscle morphology at or below the pathology level. As the variability of study quality and heterogeneous approaches utilized to assess muscle morphology challenged comparison across studies, we provide recommendations to promote uniform measurement techniques for future studies.

Trial Registration: PROSPERO 2015: CRD42015012985.
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http://dx.doi.org/10.1186/s12891-018-2266-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6161433PMC
September 2018

Modic changes-Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis.

PLoS One 2018 1;13(8):e0200677. Epub 2018 Aug 1.

The Spine Center of Southern Denmark, Hospital Lillebælt, Middelfart, Denmark.

Background: Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a comprehensive systematic review. Our objectives were to investigate if MCs are associated with non-specific LBP and/or activity limitation and if such associations are modified by other factors.

Methods: A protocol for this review was registered at PROSPERO prior to commencing the work (PROSPERO record: CRD42015017350). The MEDLINE, CINAHL and EMBASE databases were searched for relevant studies from first record to June 15th 2016. Prospective or retrospective cross-sectional cohort studies and case-control studies including people of all ages from general, working and clinical study populations were eligible for inclusion. Risk of bias assessment and data extraction for associations and potential modifiers were completed independently by pairs of reviewers. Meta-analysis was performed for homogeneous studies and presented as odds ratios (OR) with 95% CI.

Results: In all, 5210 citations were identified and 31 studies were included. One study had low risk of bias. Fifteen studies (48%) reported statistically significant positive associations between MCs and LBP and one study found a statistically significant negative association. Meta-analysis performed for studies using concordant pain with provocative discography as the clinical outcome resulted in an OR of 4.01 (1.52-10.61). One of seven studies reported a statistically significant positive association between MCs and activity limitation. Lumbar disc level and disc degeneration were found to modify the association between MCs and LBP.

Conclusions: The results from this comprehensive systematic review indicate that the associations between MCs and LBP-related outcomes are inconsistent. The high risk of bias and the heterogeneity in terms of study samples, clinical outcomes and prevalence estimates of MCs and LBP may explain these findings. It is likely that new studies with low risk of bias will affect the direction and strength of these associations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200677PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6070210PMC
January 2019

The association between subgroups of MRI findings identified with latent class analysis and low back pain in 40-year-old Danes.

BMC Musculoskelet Disord 2018 02 20;19(1):62. Epub 2018 Feb 20.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Research into the clinical importance of spinal MRI findings in patients with low back pain (LBP) has primarily focused on single imaging findings, such as Modic changes or disc degeneration, and found only weak associations with the presence of pain. However, numerous MRI findings almost always co-exist in the lumbar spine and are often present at more than one lumbar level. It is possible that multiple MRI findings are more strongly associated with LBP than single MRI findings. Latent Class Analysis is a statistical method that has recently been tested and found useful for identifying latent classes (subgroups) of MRI findings within multivariable datasets. The purpose of this study was to investigate the association between subgroups of MRI findings and the presence of LBP in people from the general population.

Methods: To identify subgroups of lumbar MRI findings with potential clinical relevance, Latent Class Analysis was initially performed on a clinical dataset of 631 patients seeking care for LBP. Subsequently, 412 participants in a general population cohort (the 'Backs on Funen' project) were statistically allocated to those existing subgroups by Latent Class Analysis, matching their MRI findings at a segmental level. The subgroups containing MRI findings from the general population were then organised into hypothetical pathways of degeneration and the association between subgroups in the pathways and the presence of LBP was tested using exact logistic regression.

Results: Six subgroups were identified in the clinical dataset and the data from the general population cohort fitted the subgroups well, with a median posterior probability of 93%-100%. These six subgroups described two pathways of increasing degeneration on upper (L1-L3) and lower (L4-L5) lumbar levels. An association with LBP was found for the subgroups describing severe and multiple degenerative MRI findings at the lower lumbar levels but none of the other subgroups were associated with LBP.

Conclusion: Although MRI findings are common in asymptomatic people and the association between single MRI findings and LBP is often weak, our results suggest that subgroups of multiple and severe lumbar MRI findings have a stronger association with LBP than those with milder degrees of degeneration.
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http://dx.doi.org/10.1186/s12891-018-1978-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819254PMC
February 2018

Digital Support Interventions for the Self-Management of Low Back Pain: A Systematic Review.

J Med Internet Res 2017 05 21;19(5):e179. Epub 2017 May 21.

General Practice & Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom.

Background: Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health.

Objective: The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes?

Methods: Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively.

Results: Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm.

Conclusions: The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak.
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http://dx.doi.org/10.2196/jmir.7290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466697PMC
May 2017

National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy.

Eur Spine J 2017 09 18;26(9):2242-2257. Epub 2017 May 18.

Evidence, Education and Emergency Services, The Danish Health Authority, Islands Brygge 67, 2300, Copenhagen S, Denmark.

Purpose: To summarise recommendations about 21 selected non-surgical interventions for recent onset (<12 weeks) non-specific neck pain (NP) and cervical radiculopathy (CR) based on two guidelines from the Danish Health Authority.

Methods: Two multidisciplinary working groups formulated recommendations based on the GRADE approach.

Results: Twelve recommendations were based on evidence and nine on consensus. Management should include information about prognosis, warning signs, and advise to remain active. For treatment, guidelines suggest different types of supervised exercise and manual therapy; combinations of exercise and manual therapy before medicine for NP; acupuncture for NP but not CR; traction for CR; and oral NSAID (oral or topical) and Tramadol after careful consideration for NP and CR.

Conclusion: Recommendations are based on low-quality evidence or on consensus, but are well aligned with recommendations from guidelines from North America. The working groups recommend intensifying research relating to all aspects of management of NP and CR.
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http://dx.doi.org/10.1007/s00586-017-5121-8DOI Listing
September 2017

National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy.

Eur Spine J 2018 01 20;27(1):60-75. Epub 2017 Apr 20.

, Hvidkildevej 62, 2400, København NV, Denmark.

Purpose: To summarise recommendations about 20 non-surgical interventions for recent onset (<12 weeks) non-specific low back pain (LBP) and lumbar radiculopathy (LR) based on two guidelines from the Danish Health Authority.

Methods: Two multidisciplinary working groups formulated recommendations based on the GRADE approach.

Results: Sixteen recommendations were based on evidence, and four on consensus. Management of LBP and LR should include information about prognosis, warning signs, and advise to remain active. If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids.

Conclusion: Recommendations are based on low to moderate quality evidence or on consensus, but are well aligned with recommendations from international guidelines. The guideline working groups recommend that research efforts in relation to all aspects of management of LBP and LR be intensified.
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http://dx.doi.org/10.1007/s00586-017-5099-2DOI Listing
January 2018

Clinically acceptable agreement between the ViMove wireless motion sensor system and the Vicon motion capture system when measuring lumbar region inclination motion in the sagittal and coronal planes.

BMC Musculoskelet Disord 2017 03 21;18(1):124. Epub 2017 Mar 21.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Wireless, wearable, inertial motion sensor technology introduces new possibilities for monitoring spinal motion and pain in people during their daily activities of work, rest and play. There are many types of these wireless devices currently available but the precision in measurement and the magnitude of measurement error from such devices is often unknown. This study investigated the concurrent validity of one inertial motion sensor system (ViMove) for its ability to measure lumbar inclination motion, compared with the Vicon motion capture system.

Methods: To mimic the variability of movement patterns in a clinical population, a sample of 34 people were included - 18 with low back pain and 16 without low back pain. ViMove sensors were attached to each participant's skin at spinal levels T12 and S2, and Vicon surface markers were attached to the ViMove sensors. Three repetitions of end-range flexion inclination, extension inclination and lateral flexion inclination to both sides while standing were measured by both systems concurrently with short rest periods in between. Measurement agreement through the whole movement range was analysed using a multilevel mixed-effects regression model to calculate the root mean squared errors and the limits of agreement were calculated using the Bland Altman method.

Results: We calculated root mean squared errors (standard deviation) of 1.82° (±1.00°) in flexion inclination, 0.71° (±0.34°) in extension inclination, 0.77° (±0.24°) in right lateral flexion inclination and 0.98° (±0.69°) in left lateral flexion inclination. 95% limits of agreement ranged between -3.86° and 4.69° in flexion inclination, -2.15° and 1.91° in extension inclination, -2.37° and 2.05° in right lateral flexion inclination and -3.11° and 2.96° in left lateral flexion inclination.

Conclusions: We found a clinically acceptable level of agreement between these two methods for measuring standing lumbar inclination motion in these two cardinal movement planes. Further research should investigate the ViMove system's ability to measure lumbar motion in more complex 3D functional movements and to measure changes of movement patterns related to treatment effects.
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http://dx.doi.org/10.1186/s12891-017-1489-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5361703PMC
March 2017

Outcomes of Patients With Acute Low Back Pain Stratified by the STarT Back Screening Tool: Secondary Analysis of a Randomized Trial.

Phys Ther 2017 03;97(3):330-337

Background: The impact of physical therapy on the outcomes of patients with acute low back pain (LBP) stratified by the STart Back Screening Tool (SBST) is unclear.

Objective: The purpose of this study was to compare the outcomes of patients with acute LBP who were stratified as medium or high risk.

Design: This was a secondary analysis of a randomized trial.

Setting: Patients were recruited between March 2011 and November 2013 from primary care clinics in Salt Lake City, Utah.

Participants: One hundred eighty-one participants with acute LBP who were stratified as medium risk (n = 120) or high risk (n = 61) by the SBST were included. They were aged 18 through 60 years, with duration of symptoms less than 16 days, no symptoms below the knee, no treatment for LBP in the past 6 months, and an Oswestry Disability Index (ODI) score of 20% or greater.

Intervention: After participants received education on how to manage their LBP, they were randomized to receive usual care (n = 97) by their primary care provider or early intervention (n = 84) by a physical therapist.

Measurements: The primary (3-month ODI score) outcome measure was obtained at baseline and at 4 weeks, 3 months, and 1 year.

Results: No differences were detected in the effect of intervention between participants stratified as medium or high risk. For the high-risk subgroup, there was a significant difference between the early intervention and usual care groups for the 3-month ODI (mean difference = -5.87 [95% CI = -11.24, -0.50]) favoring early intervention.

Limitations: The primary study was not designed to examine the SBST.

Conclusions: Patients with acute LBP stratified as high risk seem likely to respond well to one session of education. They may experience additional benefit by 3 months from evidence-based physical therapy treatments. These effects disappear at 1 year.
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http://dx.doi.org/10.2522/ptj.20160298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804017PMC
March 2017

Is the Number of Different MRI Findings More Strongly Associated With Low Back Pain Than Single MRI Findings?

Spine (Phila Pa 1976) 2017 Sep;42(17):1283-1288

Nordic Institute of Clinical Biomechanics, Odense, Denmark.

Study Design: A cross-sectional and longitudinal analysis using two different datasets.

Objective: To investigate if the number of different magnetic resonance imaging (MRI) findings present is more strongly associated with low back pain (LBP) than single MRI findings.

Summary Of Background Data: Most previous studies have investigated the associations between single MRI findings and back pain rather than investigating combinations of MRI findings. If different individuals have different pathoanatomic sources contributing to their pain, then combinations of MRI findings may be more strongly associated with LBP.

Methods: This study used data from two previous studies that investigated the association between single MRI findings and LBP. One study was a cross-sectional population cohort of 412 people of 40 years; the second was a longitudinal cohort of 76 people recently recovered from LBP who were followed for 12 months. The outcome for the cross-sectional study was presence of LBP during the last year. The outcome for the longitudinal study was days to recurrence of activity limiting LBP. In both datasets, we created an aggregate score of the number of different MRI findings present in each individual and assessed the relationship between this aggregate score and LBP.

Results: The risk of LBP outcome increased with increasing numbers of different MRI findings. Compared with those with no MRI findings, those with three MRI findings were at substantially greater risk of LBP in the last year (odd ratio = 14.1; 95% confidence interval, 4.32-49.47) in the cross-sectional study, or of future recurrence of LBP (hazard ratio = 12.2; 95% confidence interval 1.26-118.21) in the longitudinal study.

Conclusion: The aggregate MRI score was more strongly associated with LBP outcomes than single MRI findings in both datasets. Further investigation of this approach is indicated.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002102DOI Listing
September 2017

Individual courses of low back pain in adult Danes: a cohort study with 4-year and 8-year follow-up.

BMC Musculoskelet Disord 2017 01 21;18(1):28. Epub 2017 Jan 21.

Center for Rheumatology and Spine Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

Background: Few longitudinal studies have described the variation in LBP and its impact over time at an individual level. The aims of this study were to: 1) determine the prevalence of LBP in three surveys over a 9-year period in the Danish general population, using five different definitions of LBP, 2) study their individual long-term courses, and 3) determine the odds of reporting subsequent LBP when having reported previous LBP.

Methods: A cohort of 625 men and women aged 40 was sampled from the general population. Questions about LBP were asked at ages 41, 45 and 49, enabling individual courses to be tracked across five different definitions of LBP. Results were reported as percentages and the prognostic influence on future LBP was reported as odds ratios (OR).

Results: Questionnaires were completed by 412 (66%), 348 (56%) and 293 (47%) persons respectively at each survey. Of these, 293 (47%) completed all three surveys. The prevalence of LBP did not change significantly over time for any LBP past year: 69, 68, 70%; any LBP past month: 42, 48, 41%; >30 days LBP past year: 25, 27, 24%; seeking care for LBP past year: 28, 30, 36%; and non-trivial LBP, i.e. LBP >30 days past year including consequences: 18, 20, 20%. For LBP past year, 2/3 remained in this category, whereas four out of ten remained over the three time-points for the other definitions of LBP. Reporting LBP defined in any of these ways significantly increased the odds for the same type of LBP 4 years later. For those with the same definition of LBP at both 41 and 45 years, the risk of also reporting the same at 49 years was even higher, regardless of definition, and most strongly for seeking care and non-trivial LBP (OR 17.6 and 18.4) but less than 11% were in these groups.

Conclusion: The prevalence rates of LBP, when defined in a number of ways, were constant over time at a group level, but did not necessarily involve the same individuals. Reporting more severe LBP indicated a higher risk of also reporting future LBP but less than 11% were in these categories at each survey.
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http://dx.doi.org/10.1186/s12891-016-1377-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5251228PMC
January 2017

Degenerative Pathways of Lumbar Motion Segments--A Comparison in Two Samples of Patients with Persistent Low Back Pain.

PLoS One 2016 25;11(1):e0146998. Epub 2016 Jan 25.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Magnetic resonance imaging (MRI) is used to identify spinal pathoanatomy in people with persistent low back pain. However, the clinical relevance of spinal degenerative MRI findings remains uncertain. Although multiple MRI findings are almost always present at the same time, research into the association with clinical outcomes (such as pain) has predominantly focused on individual MRI findings. This study aimed to: (i) investigate how multiple MRI lumbar spine findings cluster together within two different samples of patients with low back pain, (ii) classify these clusters into hypothetical pathways of degeneration based on scientific knowledge of disco-vertebral degeneration, and (iii) compare these clusters and degenerative pathways between samples.

Methods: We performed a secondary cross-sectional analysis on two dissimilar MRI samples collected in a hospital department: (1) data from the spinal MRI reports of 4,162 low back pain patients and (2) data from an MRI research protocol of 631 low back pain patients. Latent Class Analysis was used in both samples to cluster MRI findings from lumbar motion segments. Using content analysis, each cluster was then categorised into hypothetical pathways of degeneration.

Results: Six clusters of MRI findings were identified in each of the two samples. The content of the clusters in the two samples displayed some differences but had the same overall pattern of MRI findings. Although the hypothetical degenerative pathways identified in the two samples were not identical, the overall pattern of increasing degeneration within the pathways was the same.

Conclusions: It was expected that different clusters could emerge from different samples, however, when organised into hypothetical pathways of degeneration, the overall pattern of increasing degeneration was similar and biologically plausible. This evidence of reproducibility suggests that Latent Class Analysis may provide a new approach to investigating the relationship between MRI findings and clinically important characteristics such as pain and activity limitation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0146998PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4725847PMC
July 2016

Progression of lumbar disc herniations over an eight-year period in a group of adult Danes from the general population--a longitudinal MRI study using quantitative measures.

BMC Musculoskelet Disord 2016 Jan 15;17:26. Epub 2016 Jan 15.

Medical Department, Spine Centre of Southern Denmark, Lillebaelt Hospital, Oestre Hougvej 55, Middelfart, DK-5500, Denmark.

Background: A lumbar disc herniation (LDH) is a localised displacement of disc material, which may initiate changes in the disc and adjacent structures such as the nerve root and the spinal canal. Knowledge about how morphological changes in the disc relate to changes in other spinal structures might give the clinician a better understanding of the natural history and consequences of lumbar disc herniations. However, few longitudinal studies have investigated this process using reliable measures from magnetic resonance imaging (MRI). The objectives of this study were to examine changes in and associations between the size of lumbar disc herniations, dural sac area and disc height over an eight-year period using MRI at three time-points.

Methods: Individuals from a population-based cohort, the 'Backs on Funen Cohort', had MRIs taken at age 41 years and again at 45 and 49 years. Only disc levels with MRI-confirmed disc herniations at 41 or 45 years were included. Cross-sectional areas (mm(2)) of the LDH, dural sac and disc height were calculated from measurements performed on sagittal T2-weighted images using a previously validated method. Changes over time for the three MRI findings were defined as "unchanged", "increased ", "decreased", or "fluctuating". Only changes beyond 95% limits of agreement of the same measurements were regarded as valid. Associations between the three types of measures were examined cross-sectionally and longitudinally.

Results: One hundred and forty disc levels, from 106 people (48 women and 58 men), were included. Over eight years, 65% of the herniations remained unchanged, 17.5% decreased, 12.5% increased, and 5% had a fluctuating pattern. Increased herniation size was associated with decreased dural sac area (β-0.25[-0.52;0.01]) and increased disc height (β 0.35[0.14;0.56]). Moreover, larger herniation size predicted a statistically significant reduction in both dural sac area (β-0.35[-0.58;-0.13]) and disc height (β-0.50[-0.81;-0.20]).

Conclusions: On average, most LDHs do not change over a four- to eight-year period. However, larger herniation size predicts a reduction in both dural sac area and disc height. Further research should be done to determine the correlations between the progression of LDH and resolution of patient symptoms.
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http://dx.doi.org/10.1186/s12891-016-0865-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714478PMC
January 2016

In a secondary care setting, differences between neck pain subgroups classified using the Quebec task force classification system were typically small - a longitudinal study.

BMC Musculoskelet Disord 2015 Jun 16;16:150. Epub 2015 Jun 16.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: The component of the Quebec Task Force Classification System that subgroups patients based on the extent of their radiating pain and neurological signs has been demonstrated to have prognostic implications for patients with low back pain but has not been tested on patients with neck pain (NP). The main aim of this study was to examine the association between these subgroups, their baseline characteristics and outcome in chronic NP patients referred to an outpatient hospital department.

Methods: This was an observational study of longitudinal data extracted from systematically collected, routine clinical data. Patients were classified into Local NP only, NP + arm pain above the elbow, NP + arm pain below the elbow, and NP with signs of nerve root involvement (NP + NRI). Outcome was pain intensity and activity limitation. Associations were tested in longitudinal linear mixed models.

Results: A total of 1,852 people were classified into subgroups (64 % females, mean age 49 years). Follow ups after 3, 6 and 12 months were available for 45 %, 32 % and 40 % of those invited to participate at each time point. A small improvement in pain was observed over time in all subgroups. There was a significant interaction between subgroups and time, but effect sizes were small. The local NP subgroup improved slightly less after 3 months as compared with all other groups, but continued to have the lowest level of pain. After 6 and 12 months, those with NP + pain above the elbow had improved the least and patients with NP + NRI had experienced the largest improvements in pain intensity. Similar results were obtained for activity limitation.

Conclusions: This study found baseline and outcome differences between neck pain subgroups classified using the Quebec Task Force Classification System. However, differences in outcome were typically small in size and mostly differentiated the local NP subgroup from the other subgroups. A caveat to these results is that they were obtained in a cohort of chronic neck pain patients who only displayed small improvements over time and the results may not apply to other cohorts, such as people at earlier stages of their clinical course and in other clinical settings.
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http://dx.doi.org/10.1186/s12891-015-0609-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466808PMC
June 2015