A Cognitive Functional Therapy+ Pathway Versus an Interdisciplinary Pain Management Pathway for Patients With Severe Chronic Low Back Pain (CONFeTTI Trial): Protocol for a Pragmatic Randomized Controlled Trial.

OBJECTIVE: Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care). METHODS: This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D. IMPACT: The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.

Physiotherapists' perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies.

Clinical practice guidelines recommend a biopsychosocial approach for the management of musculoskeletal pain conditions, but physiotherapists have reported feeling inadequately trained and lacking in confidence to deal with psychosocial issues. Although a growing number of studies are exploring physiotherapists' perceptions of biopsychosocial training, the results have not been synthesized. Therefore, the aim of this systematic review and metasynthesis of qualitative studies was to explore physiotherapists' perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions. A search of the electronic databases: MEDLINE, EMBASE, CINAHL, ERIC, PsycInfo, SportDiscus, and Sociological abstracts identified eligible studies. We included full-text qualitative and mixed-methodology studies published in English, which investigated physiotherapists' perceptions of learning and implementing biopsychosocial interventions. Twelve studies involving 113 participants met the inclusion criteria, and a thematic synthesis was conducted. The quality of the included studies was appraised using the Clinical Appraisal Screening Program. Four main themes emerged from the data: changed understanding and practice, professional benefits, clinical challenges, and learning requirements. The results of this study indicate that although the physiotherapists reported a shift towards more biopsychosocial and person-centered approaches, the training interventions did not sufficiently help them feel confident in delivering all the aspects. Planning future implementation interventions and training physiotherapists through a biopsychosocial approach should focus on adequate training and individualized mentoring related to psychosocial factors, and discussion of role boundaries, patient expectations, and organizational factors such as time constraints and referral pathways.

Satisfaction after total knee replacement for osteoarthritis is usually high, but what are we measuring? A systematic review.

Objective: Patient satisfaction is considered an important outcome measure after total knee replacement, but the construct is complex. There is large variation both in how satisfaction is measured and estimates of the proportion of people who are satisfied after surgery. The aim of this systematic review was to i) evaluate the proportion of people reported to be satisfied after total knee replacement for osteoarthritis; and ii) assess the content validity of the utilised satisfaction measures. Methods: We searched four literature databases with search phrases 'Total Knee Arthroplasty' OR 'Total Knee Replacement' AND 'Patient satisfaction' for studies that measured satisfaction at least 6 month post-unilateral primary total knee replacement for knee osteoarthritis. Identified studies were assessed for risk of bias, and studies at high risk of bias were excluded (PROSPERO: CRD42017058936). Meta-analysis was not appropriate due to the heterogeneity in satisfaction instruments, thus satisfaction scores were described. The content validity of satisfaction questionnaires was assessed using the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Results: The present review found heterogeneity in the satisfaction questions used, as well as the satisfaction estimates from the various studies. Only two satisfaction instruments were relevant for a Total Knee Replacement population and both failed assessment for content validity due to lack of patient involvement during development and testing in accordance with the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Conclusion: Future research should focus on qualitative methods to elicit patients' perspectives of satisfaction to build theoretical understanding.

Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain.

OBJECTIVES: Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. The aim of this metasynthesis of qualitative studies was to provide clinicians with a richer understanding of their patients' CLBP experience to highlight the importance of moving away from biomedical paradigms in the clinical management of CLBP. METHODS: Qualitative studies exploring the CLBP experience from the perspective of the individual were included. Twenty-five articles representing 18 studies involving 713 participants were subjected to the 3-stage analytic process of extraction/coding, grouping, and abstraction. RESULTS: Three main themes emerged: the social construction of CLBP; the psychosocial impact of the nature of CLBP; and coping with CLBP. DISCUSSION: The authors conceptualize the experience of CLBP as biographical suspension in which 3 aspects of suspension are described: suspended "wellness," suspended "self," and suspended "future". The implications of improved clinician understanding of the CLBP experience and directions for future research are discussed.