Do different sit-stand workstations influence lumbar kinematics, lumbar muscle activity and musculoskeletal pain in office workers? A secondary analysis of a randomized controlled trial.

Purpose. This study investigated the effect of different sit-stand workstations on lumbar spine kinematics, lumbar muscle activity and musculoskeletal pain. Methods. Thirty-two office workers were randomized to one of three sit-stand workstations (Group 1, ratio of minutes spent sitting to standing each hour at work 40:20, n = 8; Group 2, 30:30, n = 6; Group 3, 20:40, n = 7) and a control group (usual sitting, n = 11). Intervention groups (Groups 1, 2 and 3) were collapsed into one group for analysis (n = 21). Data on lumbar kinematics and muscle activity were only collected for 25 participants due to equipment availability. Results. Participants in the intervention group had lower overall lumbar spine flexion angles during the workday compared to the control group (mean difference 10.6°; 95% confidence interval [-18.1, -3.2]; p = 0.008; Cohen's d = 1.5). There were no between-group differences for the remaining kinematic measures (i.e., mean flexion angle in standing and sitting, mean side flexion angle in standing and sitting, and percentage of time in upright sitting), muscle activity or presence of musculoskeletal pain. Conclusions. Sit-stand workstations reduced overall lumbar spine flexion angles over the course of a workday but had no effect on other kinematic measures, lumbar spine muscle activity or musculoskeletal pain.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12615001018505..

Are leisure-time and work-related activities associated with low back pain during pregnancy?

BACKGROUND: Although working activities are associated with several pregnancy outcomes, there is scarce information regarding the association between working activities and low back pain (LBP) during pregnancy. This study aimed to investigate whether leisure-time and work-related physical activities during pregnancy are associated with LBP. METHODS: Data from the 2015 Pelotas Birth Cohort study were used. Demographic, socioeconomic, gestational, leisure-time (prior to and during pregnancy) and work-related (days of work, hours of work, standing and heavy lifting) physical activity data were collected at birth. LPB was assessed in the 12-month follow-up period. RESULTS: Leisure-time physical activity either prior to and during pregnancy was not associated with LBP. Working during pregnancy, days of work and standing position at work were not associated with self-reported LBP during pregnancy. However, working more than 8 h per day and always lifting heavy objects at work increased the odds ratio for LBP (OR 1.30 95%CI: 1.04; 1.63; and OR: 1.39 95%CI 1.08; 1.81, respectively). In addition, women who had lifted heavy objects often/always, reported an increase in pain intensity. CONCLUSION: Working during pregnancy and days worked per week were not related to experiencing LBP. However, women who worked more than 8 h per day, as well as women who lifted heavy objects at work on a regular basis, were more likely to experience pregnancy-related LBP.

Wearables-based walking program in addition to usual physiotherapy care for the management of patients with low back pain at medium or high risk of chronicity: A pilot randomized controlled trial.

BACKGROUND: Although chronic low back pain (LBP) is a leading cause of disability and accounts for large costs, none of the available conventional treatments are clearly more favourable in treating people at increased risk of chronicity. OBJECTIVES: To examine the feasibility and initial efficacy of a wearables-based walking intervention in addition to usual physiotherapy care in people with LBP at risk of chronicity. METHODS: Twenty-six adult participants, diagnosed with non-specific LBP with medium or high risk of chronicity, were recruited from physiotherapy private practices. Participants were randomized into usual physiotherapy care (control, n = 14) and usual physiotherapy care plus a wearables-based walking intervention (experimental, n = 12). The intervention duration was 8 weeks. Feasibility outcomes included recruitment rate, adherence to the intervention, dropout rate, and serious adverse events reporting rate. Other outcomes included disability and pain (primary); and physical activity level, daily walking steps, depression, pain catastrophizing and fear of movement (secondary). The outcomes were assessed at baseline, post-intervention and 26 weeks post-randomization follow-up. RESULTS: Adherence of experimental participants with the prescribed walking program was moderate. Four participants dropped out during the intervention, and no serious adverse events were reported. Participants in the experimental group showed significant improvement in pain at 26 weeks (ß = -0.38; 95% confidence interval (CI) -0.66, -0.10; P = .013), compared with the control group. No between-group differences were found for disability at any time point and pain immediately post-intervention. Experimental participants demonstrated post-intervention improvement in light-intensity (ß = 156.71; 95% CI 86.79, 226.64; P < .001), moderate-intensity physical activity (ß = 0.46; 95% CI 0.12, 0.80; P = .012), and daily walking steps (ß = 7099.13; 95% CI 4522.93, 9675.32; P < .001). Experimental participants demonstrated post-intervention increase in pain catastrophizing (ß = 0.52, 95% CI 0.18, 0.86; P = .006). No between-group differences were found for pain catastrophizing at 26 weeks and other secondary outcomes. CONCLUSION: Usual physiotherapy care plus a wearables-based walking intervention program was safe and moderately feasible, and provided significant reduction in pain at 26 weeks as well as increasing the total volume of light- and moderate-intensity physical activity, and daily walking steps immediately post-intervention.

Family History Influences the Effectiveness of Home Exercise in Older People With Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To investigate whether a family history of low back pain (LBP) influences patient outcomes and treatment effects following home exercises in older people with chronic LBP. DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Local community. PARTICIPANTS: People older than 55 years with chronic LBP (N=60). INTERVENTIONS: Participants in the intervention group completed video game exercises for 60 minutes 3 times per week for 8 weeks. Participants in the control group were instructed to maintain their usual levels of activity and care seeking behaviors. MAIN OUTCOMES MEASURES: Participants indicated whether any of their immediate family members had a history of "any" LBP or "activity-limiting" LBP at baseline. We collected self-reported measures of pain, function, pain self-efficacy, care seeking, physical activity, disability, fear of movement and/or reinjury, and falls efficacy at baseline, 8 weeks, 3 months, and 6 months. We performed regression analyses to determine whether a family history of LBP predicted patient outcomes and moderated the effects of home exercise. RESULTS: Participants with a family history of any LBP were less likely to be highly active than those without a family history (odds ratio, 0.08; 95% CI, 0.01-0.42; P=.003). Home-based video game exercises led to improvements in function in those without a family history of activity-limiting LBP (ß=1.78; 95% CI, 0.56-3.00; P=.006) but not in those with a family history (ß=-0.17; 95% CI, -2.56 to 2.21; P=.880) (interaction P=.049). A family history of LBP did not influence the remaining patient outcomes or treatment effects. CONCLUSIONS: A family history of LBP appears to negatively influence physical activity levels in older people with chronic LBP. Further, home-based video game exercises appear to be beneficial for older people with chronic LBP that do not have a family history of LBP.

Author Correction: The association between physical activity and low back pain: a systematic review and meta-analysis of observational studies.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Parental Multisite Chronic Pain and the Risk of Adult Offspring Developing Additional Chronic Pain Sites: Family-Linkage Data From the Norwegian HUNT Study.

We investigated if parental multisite chronic pain increases the risk of adult offspring developing additional chronic pain sites, and if offspring body mass index (BMI) and leisure time physical activity modify this association. We used longitudinal data on 7,654 offspring linked with their parents who participated in the population-based HUNT Study (Norway) in 1995 to 1997 and 2006 to 2008. Logistic regression was used to estimate odds ratios (ORs) with 95% confidence interval (CI). One-third of offspring (n = 2,573) developed additional chronic pain sites. Having both parents with 1-2 chronic pain sites increased the risk of developing additional pain sites compared to having parents free of chronic pain (OR = 1.33; 95% CI 1.05-1.68), with larger effects observed when both parents had ≥3 chronic pain sites (OR = 1.46; 95% CI 1.17-1.82). These associations were largely driven by maternal pain, that is, there was no association between paternal chronic pain and risk of additional pain sites in offspring. The parent-offspring transfer of additional pain sites (when both parents had ≥3 pain sites) strengthened when offspring were obese (OR = 2.56; 95% CI 1.75-3.75) or physically inactive (OR = 1.73; 95% CI 1.33-2.27). In conclusion, parental multisite chronic pain increases the risk of offspring developing additional chronic pain sites, particularly those with obesity or inactivity. PERSPECTIVE: This longitudinal analysis investigated the parent-offspring transmission of multisite chronic pain, and whether lifestyle behaviors in offspring modify this association. The findings suggest that having parents with multisite chronic pain increases the risk of offspring developing additional chronic pain sites, particularly if offspring are obese or inactive.

Physical Activity and Health-Related Quality of Life in People With Back Pain: A Population-Based Pooled Study of 27,273 Adults.

BACKGROUND: To investigate the association between moderate- to vigorous-intensity physical activity (MVPA) and health-related quality of life (HRQoL) in people with back pain. METHODS: The sample comprised adults aged 16 years and older who participated in the Welsh Health Survey (2011-2015). The HRQoL was evaluated using the 36-item short form. Participants were categorized into 4 groups based on minutes per week of MVPA: inactive (no MVPA), insufficiently active (<150 min/wk), sufficiently active (≥150 and <300 min/wk), and very active (≥300 min/wk). The authors investigated the association between MVPA and HRQoL using generalized linear models and multiple linear regression. RESULTS: Of the 74,578 adults in the survey cohorts, 27,273 participants diagnosed with back pain were included in the analyses. Consistent direct curvilinear associations between MVPA and HRQoL were demonstrated for all 36-item short form domains (P < .001), in both the minimally and fully adjusted models, with the highest scores observed for sufficiently active and very active participants. Compared with the inactive group, those who were insufficiently active; sufficiently active; and very active had an average difference of 6.31 (95% confidence interval, 5.70-6.92), 7.72 (95% confidence interval, 7.04-8.41), and 8.00 (95% confidence interval, 7.12-8.89) points in the overall HRQoL, respectively. CONCLUSION: The authors found a consistent direct curvilinear association between MVPA and HRQoL.

Physical Activity Before or During Pregnancy and Low Back Pain: Data From the 2015 Pelotas (Brazil) Birth Cohort Study.

BACKGROUND: To investigate whether engagement in leisure-time physical activity before or during pregnancy is associated with low back pain (LBP) outcomes during pregnancy and postpartum prevalence of LBP in women who reported LBP during pregnancy. METHODS: Data from the 2015 Pelotas Birth Cohort Study, were used. Demographic, socioeconomic, and gestational characteristics, as well as physical activity prior to and during pregnancy were recorded at perinatal assessment. LBP outcomes during pregnancy (pain intensity, activity limitation, and care seeking) and postpartum (prevalence of LBP) were collected at the 1-year follow-up. RESULTS: Pain intensity, care seeking, and prevalence of LBP postpartum period were not associated with physical activity either before or during pregnancy. However, women engaged in physical activity during pregnancy and at least for 2 trimesters had lower odds ratio of activity limitation associated with LBP during pregnancy (odds ratio: 0.60; 95% confidence interval, 0.41 to 0.88; odds ratio: 0.20; 95% confidence interval, 0.04 to 0.86, respectively). CONCLUSION: Meeting the recommended levels of physical activity during pregnancy is associated with less activity limitation related to LBP during pregnancy. However, physical activity levels, either before or during pregnancy, were not associated with pain intensity, care seeking, and postpartum LBP.

Physical activity and chronic back conditions: A population-based pooled study of 60,134 adults.

BACKGROUND: Little is known about the association between different types of physical activity (PA) and chronic back conditions (CBCs) at the population level. We investigated the association between levels of total and type-specific PA participation and CBCs. METHODS: The sample comprised 60,134 adults aged ≥16 years who participated in the Health Survey for England and Scottish Health Survey from 1994 to 2008. Multiple logistic regression models, adjusted for potential confounders, were used to examine the association between total and type-specific PA volume (walking, domestic activity, sport/exercise, cycling, football/rugby, running/jogging, manual work, and housework) and the prevalence of CBCs. RESULTS: We found an inverse association between total PA volume and prevalence of CBCs. Compared with inactive participants, the fully adjusted odds ratio (OR) for very active participants (≥15 metabolic equivalent h/week) was 0.77 (95% confidence interval (CI): 0.69-0.85). Participants reporting ≥300 min/week of moderate-intensity activity and ≥75 min/week of vigorous-intensity activity had 24% (95%CI: 6%-39%) and 21% (95%CI: 11%-30%) lower odds of CBCs, respectively. Higher odds of CBCs were observed for participation in high-level manual domestic activity (OR = 1.22; 95%CI: 1.00-1.48). Sport/exercise was associated with CBCs in a less consistent manner (e.g., OR = 1.18 (95%CI: 1.06-1.32) for low levels and OR = 0.82 (95%CI: 0.72-0.93) for high levels of sport/exercise). CONCLUSION: PA volume is inversely associated with the prevalence of CBCs.

The association between physical activity and low back pain: a systematic review and meta-analysis of observational studies.

The aim of this review was to investigate the association between total and domain-specific physical activity (PA) and non-specific low back pain (LBP) in adults. Seven databases were searched for cohort and cross-sectional studies. Pooled estimates of the association of medium and high levels PA and LBP, using the generic inverse-variance method with fixed- and random-effects models were calculated. Twenty-four studies (15 cohort and nine cross-sectional; 95,796 participants) were included. The pooled fully adjusted risk ratios (RR) from cohort studies comparing medium with lowest activity levels were 0.90 (95%CI 0.85 to 0.96) for total PA, and 0.90 (95%CI 0.85 to 0.96) for leisure-time PA (LTPA). The pooled RR comparing highest with lowest activity levels were 1.00 (95%CI 0.92 to 1.08) for total PA, and 1.01 (95%CI 0.93 to 1.10) for LTPA. The pooled fully adjusted odds ratios (OR) from cross-sectional studies comparing medium with lowest activity levels were 0.93 (95%CI 0.65 to 1.32) for total PA, and 0.77 (95%CI 0.62 to 0.96) for LTPA. The pooled OR comparing highest with lowest activity levels were 1.05 (95%CI 0.89 to 1.23) for total PA, and 0.85 (95%CI 0.79 to 0.93) for LTPA. PA seems to be associated with lower prevalence of LBP.

Health Competency Standards in Physical Therapist Practice.

Although the physical therapist profession is the leading established, largely nonpharmacological health profession in the world and is committed to health promotion and noncommunicable disease (NCD) prevention, these have yet to be designated as core physical therapist competencies. Based on findings of 3 Physical Therapy Summits on Global Health, addressing NCDs (heart disease, cancer, hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an urgent professional priority. The Third Summit established the status of health competencies in physical therapist practice across the 5 World Confederation for Physical Therapy (WCPT) regions with a view to establish health competency standards, this article's focus. Three general principles related to health-focused practice emerged, along with 3 recommendations for its inclusion. Participants acknowledged that specific competencies are needed to ensure that health promotion and NCD prevention are practiced consistently by physical therapists within and across WCPT regions (ie, effective counseling for smoking cessation, basic nutrition, weight control, and reduced sitting and increased activity/exercise in patients and clients, irrespective of their presenting complaints/diagnoses). Minimum accreditable health competency standards within the profession, including use of the WCPT-supported Health Improvement Card, were recommended for inclusion into practice, entry-to-practice education, and research. Such standards are highly consistent with the mission of the WCPT and the World Health Organization. The physical therapist profession needs to assume a leadership role vis-à-vis eliminating the gap between what we know unequivocally about the causes of and contributors to NCDs and the long-term benefits of effective, sustained, nonpharmacological lifestyle behavior change, which no drug nor many surgical procedures have been reported to match.

The effectiveness of incidental physical activity interventions compared to other interventions in the management of people with low back pain: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVES: To investigate the effectiveness of incidental (non-structured) physical activity interventions for the management of people with low back pain (LBP). DESIGN: Systematic review and meta-analyses of randomised controlled trials. SETTING: Eligible published trials from the earliest date available to November 2017. PARTICIPANTS: People with non-specific LBP aged 18 years or over. OUTCOME MEASURES: Pain, disability and physical activity-related outcomes. RESULTS: Three trials were included (including a total of 422 participants). The quality of trials, assessed by PEDro scale, was high (7 out of 10). For pain, the pooled results did not show any significant effects between the incidental physical activity intervention and other interventions at any time point. For disability, incidental physical activity was not statistically more effective than other interventions at short-term; however, the pooled results favoured incidental physical activity at intermediate-term (weighted mean difference (WMD) = -6.05, 95%CI: -10.39 to -1.71) and long-term (WMD = -6.40 95%CI: -11.68 to -1.12) follow-ups among participants with chronic LBP. The overall quality of evidence was rated "moderate-quality" based on the GRADE system. CONCLUSIONS: The incidental physical activity intervention provided improvement in disability in intermediate- and long-term for people with chronic LBP, although this improvement was small and may not be clinically significant.

Video-Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlledtable Trial (GAMEBACK).

Background: Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP). Objective: The objective was to investigate the effects of home-based video game exercises on pain self-efficacy and care-seeking in older people with chronic LBP. Design: The study was a randomized controlled trial. Setting: The setting was a community and waiting list. Participants: Sixty participants, aged > 55 years with chronic LBP, were randomized (1:1) to Wii Fit U exercises or to continue their usual activities for 8 weeks. Intervention: The intervention was home-based Wii Fit U flexibility, strengthening, and aerobic exercises for 60 minutes, 3 times per week, with fortnightly calls from a physical therapist. Measurements: Measurements included pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes). Results: The mean age of participants was 67.8 (standard deviation = 6.0) years. Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self-efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes. Limitations: Participants and therapists were not blinded. Conclusions: Wii Fit U exercises improved pain self-efficacy at 6 months, and pain and function immediately postintervention in older people with chronic LBP, but the clinical importance of these changes is questionable. Wii Fit U exercises had no effect on care-seeking, physical activity, disability, fear of movement/reinjury, or falls efficacy.

Familial factors predicting recovery and maintenance of physical activity in people with low back pain: Insights from a population-based twin study.

BACKGROUND: It is unknown how familial factors influence the recovery from low back pain (LBP) and the maintenance activity behaviours. We aimed to investigate whether individual and within-family physical activity (PA) and sedentary behaviour influenced recovery from LBP, and maintenance of PA and sedentary behaviour in people with and without LBP. METHODS: Longitudinal logistic regression analyses were performed on adult twins from the Washington State Twin Registry. First, individual and within-family (based on co-twin data) sufficient PA (at least 75 min of vigorous-intensity PA, or 150 min of moderate-intensity PA per week) and high leisure sitting time (≥3 hr/day) were our exposure variables (baseline). LBP within the past 3 months at follow-up defined non-recovery (outcome). Second, within-family sufficient PA and high leisure sitting time were our exposure variables(baseline) and our outcomes were individual PA and sitting time at follow-up. All analyses were adjusted for follow-up length (range: 1-7 years) and confounding variables. RESULTS: Individual and within-family PA and sitting time were not associated with recovery. Within-family PA and sitting time predicted individual maintenance of PA (OR = 1.47, 95% CI: 1.17-1.84, n = 1,388 twins) and sitting time (OR = 1.41, 95% CI: 1.10-1.82, n = 1,534). Within-family PA and sitting time had the strongest effects on those without (OR = 1.79, 95% CI: 1.33-2.41, n = 788) and with LBP (OR = 1.90, 95% CI: 1.32-2.76, n = 698), respectively. CONCLUSION: Having active family members increased the likelihood of continuing to be active (particularly for those without LBP), while having sedentary family members increased the likelihood of maintaining sedentary behaviours (particularly for those with LBP). SIGNIFICANCE: This study was the first to investigate how familial activity behaviours influence recovery from LBP and ongoing activity behaviours. People with LBP living within a sedentary family likely require specific interventions to reduce their sedentary behaviours.

Australian musculoskeletal physiotherapist's perceptions, attitudes and opinions towards pre-manipulative screening of the cervical spine prior to manual therapy: Report from the focus groups.

BACKGROUND: The Australian Physiotherapy Association 2006 VBI Guidelines are used by many of the member organisations of IFOMPT. These Guidelines are due for revision incorporating recent research findings, international guides, and member's recommendations. PURPOSE: To identify and consider Australian musculoskeletal physiotherapists' recommendations to inform revision of the 2006 VBI Guidelines. METHODS: Focus groups were conducted in the five larger Australian state capitals by an independent qualitative researcher and a subject expert. Qualitative data were collected from 41 musculoskeletal physiotherapists who were purposefully recruited for their broad range of experience and qualifications. The five stage Framework Analysis approach was used to analyse and interpret data. RESULTS: Participants recommended that the revised Guidelines have a new title reflecting a broader risk assessment and management approach, encompassing both musculoskeletal and relevant cardio-vascular risks and informed by contemporary research evidence and clinical experience. Participants requested a positively worded stepwise guide to clinical reasoning for all cervical spine manual treatment scenarios including the process of gaining and recording consent. Participants advised on individual components of the Guidelines needing to be revised or removed. The revised Guidelines, once approved, need to be disseminated in written and electronic formats to all clinicians. Training and education are required to ensure appropriate uptake within and beyond the profession. CONCLUSIONS AND IMPLICATIONS: To ensure their clinical acceptance and utility, the Revised Guidelines need to reflect the current use and recommendations of musculoskeletal physiotherapists. Sound knowledge translation processes are then needed to ensure that the Guidelines are incorporated into practice.

Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials.

OBJECTIVE: To evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP). DESIGN: Systematic review. Two reviewers independently completed searches, eligibility assessment and assessment of risk of bias. DATA SOURCES: Pre-defined search terms/combinations were utilised to search electronic databases. In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts. ELIGIBILITY CRITERIA FOR INCLUDED STUDIES: Randomised controlled trials (RCTs) evaluating clinical or cost-effectiveness of NMP. Measurements reported on one or more outcome(s) of: pain, function, disability, health, social impact, patient-safety, costs-analysis, quality adjusted life years (QALYs), patient satisfaction, clinician perception of clinical and functional outcomes. RESULTS: Three RCTs from two countries were included (n = 932 participants) across primary and tertiary care settings. One RCT was assessed as low risk of bias, one as high risk of bias and one as unclear risk of bias. All RCTs evaluated clinical effectiveness with one also evaluating cost-effectiveness. Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. Participants demonstrated significant improvement in outcomes when receiving NMP compared to treatment as usual (TAU) in all RCTs. An associated cost analysis showed NMP to be more expensive than TAU (regression coefficient p = 0.0000), however experimental groups generated increased QALYs compared to TAU. CONCLUSION: Limited evidence with overall unclear risk of bias exists evaluating clinical and cost-effectiveness of NMP across all professions and clinical settings. GRADE assessment revealed moderate quality evidence. Evidence suggests that NMP is safe and can provide beneficial clinical outcomes. Benefits to the health economy remain unclear, with the cost-effectiveness of NMP assessed by a single pilot RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost effectiveness are required to evaluate NMP across clinical specialities, professions and settings. REGISTRATION: PROSPERO (CRD42015017212).

Is Vitamin D Supplementation Effective for Low Back Pain? A Systematic Review and Meta-Analysis.

BACKGROUND: Low back pain (LBP) is the leading cause of years lived with disability worldwide. Current intervention strategies are failing to reduce the enormous global burden of LBP and are prompting researchers to investigate alternative management strategies, such as vitamin D supplementation. Vitamin D supplementation appears to down regulate pro-inflammatory cytokines which lead to pain and up regulate anti-inflammatory cytokines that reduce inflammation. These mechanisms might explain the increasing interest in the use of vitamin D supplementation for LBP. OBJECTIVES: To determine whether vitamin D supplementation improves pain more than a control intervention for individuals with LBP. STUDY DESIGN: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. METHODS: We performed searches in numerous electronic databases combining key words relating to "vitamin D" and "LBP" until March 2017. Studies were included if they investigated vitamin D supplementation in participants with LBP, provided there was a comparison intervention. There was no restriction on the type of LBP, the intervention parameters investigated, or the type of clinical trial (e.g., randomized, non-randomized). Two reviewers independently performed the selection of studies, extracted data, rated the methodological quality of the included studies, and evaluated the overall quality of the evidence using the Grading of Recommendations Assessment, Delevopment, and Evaulation (GRADE) approach. RESULTS: After screening 3,534 articles, 8 clinical trials were included in this systematic review. There is very low quality evidence (based on the GRADE approach) that vitamin D supplementation is not more effective than any intervention (including placebo, no intervention, and other conservative/pharmacological interventions) (continuous pain measures [0-100]: mean difference [MD] = -2.65, 95% confidence interval [CI]: -10.42 to 5.12, P = 0.504, n = 5; self-reported reduction in pain: pooled odds ratio [OR] = 1.07, 95% CI: 0.35 to 3.26, P = 0.906, n = 5) or placebo/no intervention for individuals with LBP (continuous pain measures: MD = 1.29, 95% CI: -3.81 to 6.39, P = 0.620, n = 4; self-reported reduction in pain: pooled OR = 1.53, 95% CI: 0.38 to 6.20, P = 0.550, n = 4), where 'n' is the number of studies included in the meta-analysis. These results did not change when we stratified the meta-analyses by the type of vitamin supplementation (vitamin D3 vs. alfacalcidol) or the type of LBP (non-specific vs. LBP resulting from osteoporosis or vertebral fractures). LIMITATIONS: The overall quality of evidence was "very low" due to the poor methodological quality and small sample sizes of the included studies. CONCLUSIONS: Vitamin D supplementation is not more effective than placebo, no intervention, or other conservative/pharmacological interventions for LBP (based on very low quality evidence). These results are consistent, regardless of the type of LBP or vitamin D supplementation. Until well-designed and adequately powered clinical trials suggest otherwise, the prescription of vitamin D for LBP cannot be recommended. PROSPERO Registration No: CRD42016046874. www.crd.york.ac.uk/PROSPERO/display_record.asp?ID = CRD42016046874. KEY WORDS: Vitamin D, low back pain, chronic low back pain, alfacalcidol, osteoporosis, vertebral fractures, serum 25-hydroxyvitamin D, systematic review.

Mapping the Association between Vitamin D and Low Back Pain: A Systematic Review and Meta-Analysis of Observational Studies.

BACKGROUND: Low back pain (LBP) is the highest contributor to disability worldwide, with current intervention strategies only providing small to moderate analgesic effects. The use of vitamin D supplementation for LBP has gained interest due to its proposed anti-inflammatory and neuromodulatory properties. However, it is still unclear whether vitamin D levels differ between those with and without LBP or if vitamin D levels are associated with pain intensity. OBJECTIVES: We aim to investigate the association between vitamin D levels and LBP and to determine if vitamin D levels correlate with pain intensity in individuals with LBP. STUDY DESIGN: This study was conducted in accordance with the guidelines for performing a Meta-analysis and Systematic Review Of Observational Studies in Epidemiology (MOOSE). METHODS: We performed electronic database searches combined keywords relating to vitamin D and LBP in MEDLINE, CINAHL, EMBASE, AMED, WEB OF SCIENCE, and SCOPUS from the earliest record to March 2017. Studies were included if they reported any quantitative measure of vitamin D, such as serum 25-hydroxyvitamin D [25(OH)D], with adequate data in patients with and without LBP or adequate data on pain intensity in patients with LBP. No restriction on the type or duration of LBP, nor the age and gender of patients was applied. Two reviewers independently performed the selection of studies, extracted data, and assessed the methodological quality of the included studies using a modified 15-item Downs and Black checklist. RESULTS: After the removal of duplicates and the screening of titles and abstracts, 105 full texts were evaluated. There were 29 articles included in this systemic review (22 entered into a meta-analysis), including 19 cross-sectional studies, 9 case-control studies, and one single-arm surgical trial where the pre-operative data were used in our analyses. The pooled results from 19 studies showed that individuals with LBP were more likely to have vitamin D deficiency (pooled OR = 1.60, 95% CI: 1.20 - 2.12, P = 0.001, n = 19), severe deficiency (pooled OR = 2.08, 95% CI: 1.19 - 3.64, P = 0.010, n = 7), and lower serum concentrations of 25(OH)D (weighted MD = 3.86, 95% CI: 0.20 - 7.52, P = 0.039, n = 12) compared to those without LBP (where "n" is the number of studies). The association between vitamin D deficiency (pooled OR = 1.83, 95% CI: 1.26 - 2.66, P = 0.002, n = 9) or serum 25(OH)D (weighted MD = 7.64, 95% CI: 4.02 - 11.26, P < 0.001, n = 4) and LBP was stronger for women but failed to be statistically significant for men (pooled OR = 1.06, 95% CI: 0.62 - 1.81, P = 0.213, n = 3). In addition, there were strong associations between vitamin D deficiency and LBP in patients < 60 years old (particularly women). We found minimal evidence to support an association between vitamin D levels and pain intensity in patients with LBP. LIMITATIONS: We were unable to investigate whether vitamin D deficiency increases the risk of developing LBP as there were no longitudinal studies included in this review. CONCLUSION: Vitamin D deficiency is associated with LBP, with stronger associations observed in younger women and those with severe levels of deficiency. The association between vitamin D levels and pain intensity is inconsistent. These results may guide the implementation of future studies on vitamin D supplementation for LBP. PROSPERO Registration No: CRD42016046874. KEY WORDS: Vitamin D, low back pain, deficiency, pain intensity, serum 25-hydroxyvitamin D, supplementation, cross-sectional study, case-control study.

Are people with chronic low back pain meeting the physical activity guidelines? A co-twin control study.

BACKGROUND: Despite a large amount of research investigating physical activity (PA) levels in people with chronic low back pain (LBP), no study has investigated whether people with chronic LBP are meeting the World Health Organization (WHO) PA guidelines. Furthermore, with genetics and the early shared environment substantially influencing the presence of LBP and PA engagement, these factors could confound the association between LBP and PA and need to be controlled for. PURPOSE: This study aimed to investigate the association between chronic LBP and meeting the PA guidelines, while controlling for the effects of genetics and early shared environment. DESIGN: This is a cross-sectional co-twin control study. PATIENT SAMPLE: A cross-sectional analysis was performed on 1,588 twins from the Murcia Twin Registry in Spain with available data on LBP and PA from the 2013 data collection wave. OUTCOME MEASURES: The exposure and outcome variables in our study were self-reported. Twins reporting a history of chronic LBP were asked follow-up questions to inform on the presence of recent LBP (within the past 4 weeks), previous LBP (no pain within the past 4 weeks), and persistent LBP (no pain-free month in the last 6 months). These were our exposure variables. Our outcome variable was meeting the WHO PA guidelines, which involved at least 75 minutes of vigorous-intensity PA, or at least 150 minutes of moderate-intensity PA per week. METHODS: To investigate the association between chronic LBP and meeting the PA guidelines, we first performed a multivariate logistic regression on the total sample of twins. Co-variables entered the model if the univariate association between the co-variable, and both the exposure and the outcome reached a significance of p<.2. Second, to adjust for the influence of genetics and early shared environment, we performed a conditional multivariate logistic regression on complete twin pairs discordant for LBP. The Murcia Twin Registry is supported by Fundación Séneca, Regional Agency for Science and Technology, Murcia, Spain (08633/PHCS/08 and 15302/PHCS/10) and the Ministry of Science and Innovation, Spain (PSI11560-2009). Funding for this project has also been received from Fundación MAPFRE (2012). The authors declare that there are no conflicts of interest. RESULTS: There was a significant inverse association between recent LBP and meeting the PA guidelines (odds ratio [OR]=0.71, p=.034). When controlling for genetics and early shared environment, this association disappeared. There was no association between previous (OR=0.95, p=.779) or persistent LBP (OR=0.78, p=.192) and meeting the PA guidelines. CONCLUSION: Twins with recent LBP are less likely to meet the PA guidelines than those with no history of chronic LBP, highlighting the importance of incorporating PA promotion in the treatment of these individuals. Genetics and early shared environment appear to be confounding the association between LBP and PA, although this needs to be further tested in larger twin samples.

Does Familial Aggregation of Chronic Low Back Pain Affect Recovery?: A Population-Based Twin Study.

STUDY DESIGN: Longitudinal twin-cohort study. OBJECTIVE: To investigate the effect familial aggregation of chronic low back pain (LBP) has on the recovery from chronic LBP. SUMMARY OF BACKGROUND DATA: LBP is a worldwide problem, with pain and disability often becoming chronic. Genetics and familial behaviors could significantly affect the recovery from chronic LBP but have not been extensively investigated. METHODS: A total of 624 Spanish twins from the Murcia Twin Registry reported experiencing chronic LBP within the past 2 years during the 2009/11 data collection wave and were followed up in 2013. Familial aggregation of chronic LBP was determined by the co-twin experiencing chronic LBP within the past 2 years at baseline. Twins reporting LBP "within the past 4 weeks" at follow-up were considered to have not recovered. RESULTS: There were 455 twins with available data on LBP at follow-up and available data on LBP from their co-twin at baseline. Twins with an affected co-twin at baseline were significantly more likely to have not recovered from chronic LBP at follow-up (odds ratio [OR] = 1.6, 95% confidence interval [CI]: 1.0-2.4, P = 0.046). This relationship was stronger for monozygotic twins (OR = 2.5, 95% CI: 1.3-4.8, P = 0.006) (n = 172) but disappeared when considering only dizygotic twins (OR = 1.1, 95% CI: 0.6-2.0, P = 0.668) (n = 283). Sibling-relative recurrence risk (λ s) was 1.2 for the total sample, 1.5 for monozygotic twins, and 1.1 for dizygotic twins. CONCLUSION: Having a sibling with chronic LBP at baseline increased the likelihood of LBP at follow-up by 20%, with this likelihood increasing to 50% if the sibling was an identical twin. These results are novel and highlight the important influence genetics have on people's recovery from chronic LBP. Information regarding the presence of chronic LBP within a family is easy to obtain and has the potential to inform clinicians on which patients are less likely to recover when treatment implementation is not considered. LEVEL OF EVIDENCE: 3.