Inter-examiner reliability of a proposed decision-making treatment based classification system for low back pain patients.

Evolving evidence has shown increased clinical outcomes, when low back pain (LBP) patients are classified and receive matched physical treatment. The present study aimed to examine the inter-examiner reliability of a proposed new decision-making classification system for non-specific LBP patients, using a mixed simultaneous and independent examiner design. With minimal familiarization, two pairs of experienced physiotherapists trained in Orthopedic Manual Therapy (OMT) at two different out-patient clinics in primary care, examined and classified 64 consenting consecutive patients. Further, inter-examiner reliability on five examination items was examined. The agreement between examiners was expressed by percentage of agreement (%) and by the un-weighted (κ) or weighted (κ(w)) kappa coefficient. The overall % agreement, categorizing patients into one of four classifications was 80% and κ = 0.72. For each classification, pain modulation, stabilization exercise, mobilization and training, agreement was 90%, 83%, 58% and 89% (κ = 0.77, 0.67, 0.11 and 0.75), respectively. Agreement on five individual examination items was; irritability 82% (κ(w) = 0.41), specific movement pattern 68% (κ = 0.38), specific segmental signs 67% (κ = 0.28), uni- or bilateral signs 62% (κ = 0.42), and neurological signs and symptoms 92% (κ = 0.84). This study demonstrated that this new classification system had substantial inter-examiner reliability when used by clinically experienced OMT-trained physiotherapists. Agreement within classification was substantial, except for mobilization which was poor. Inter-examiner reliability for the individual examination items varied from fair to almost perfect. Further studies are needed to investigate utility and validity of this new classification system.

Factors predicting clinical outcome 12 and 36 months after an exercise intervention for recurrent low-back pain.

PURPOSE: The aim of this cohort study was to identify early predictive factors for a poor outcome of disability and pain 12- and 36-months after an intervention in patients with recurrent low-back pain, currently at work. METHOD: Seventy-one patients with recurrent low-back pain, all at work, seeking care in a primary health care setting were included. Predictive indicators including demographic data and health-related variables were derived from questionnaires pre- and post intervention over eight weeks. The dependent outcome variables were perceived disability and present pain at 12- and 36-months. RESULTS: Multivariate regression analyses show that early data on poor self-efficacy for physical activity, greater disability, and higher level of pain-ratings emerged as independent predictors of a poor outcome of disability at 12 and 36 months. Higher ratings of pain and poor self-efficacy appeared again as independent predictors of a poor outcome of pain at the 12-month follow-up. Pain frequency ratings predicted a poor outcome of pain at 36 months. CONCLUSIONS: Our results suggest that ratings of poor self-efficacy for physical activity, greater disability, and pain-ratings, are the most consistent independent predictors of long-term poor outcome of disability and pain. This indicates the importance of screening for such factors to optimize the management of low-back pain. However, larger studies in similar patient populations are needed to confirm these results.

Graded exercise for recurrent low-back pain: a randomized, controlled trial with 6-, 12-, and 36-month follow-ups.

STUDY DESIGN: The study was a randomized controlled trial. Treatment was for 8 weeks, with follow-up posttreatment and at 6-, 12-, and 36- months. OBJECTIVE: The purpose was to evaluate the effect of a graded exercise intervention emphasizing stabilizing exercises in patients with nonspecific, recurrent low back pain (LBP). SUMMARY OF BACKGROUND DATA: Exercise therapy is recommended and widely used as treatment for LBP. Although stabilizing exercises are reportedly effective in the management of certain subgroups of LBP, such intervention protocols have not yet been evaluated in relation to a more general exercise regimen in patients with recurrent LBP, all at work. METHODS: Seventy-one patients recruited consecutively (36 men, 35 women) with recurrent nonspecific LBP seeking care at an outpatient physiotherapy clinic were randomized into 2 treatment groups; graded exercise intervention or daily walks. The primary outcome was perceived disability and pain at 12-month follow-up. Secondary outcomes included physical health, fear-avoidance, and self-efficacy beliefs. RESULTS: Of the participants, 83% provided data at the 12-month follow-up and 79% at 36 months. At 12 months, between-group comparison showed a reduction in perceived disability in favor of the exercise group, whereas such an effect for pain emerged only immediately postintervention. Ratings of physical health and self-efficacy beliefs also improved in the exercise group over the long term, though no changes were observed for fear-avoidance beliefs. CONCLUSION: A graded exercise intervention, emphasizing stabilizing exercises, for patients with recurrent LBP still at work seems more effective in improving disability and health parameters than daily walks do. However, no such positive results emerged for improvement regarding pain over a longer term, or for fear-avoidance beliefs.

Recurrent low back pain: relapse from a patients perspective.

OBJECTIVE: To explore and describe how patients with recurrent low back pain perceive and respond to the recurrence of pain. DESIGN: A semi-structured interview study. SUBJECTS: Seventeen patients (10 women and 7 men) with recurrent low back pain. METHODS: Semi-structured interviews were analysed using the phenomenographic method. RESULTS: Patients' perceptions of relapse of low back pain could be divided into 4 different categories: (i) an unsolved mystery, a source of uncertainty and self-accusation; (ii) an obvious part of life that has to be ignored; (iii) a reminder to keep within limits, both physically and psychologically; and (iv) an indication to change behaviour to prevent further relapse. The categories could be grouped hierarchically such that they reflect to what extent the patients showed readiness and self-efficacy in adopting self-management strategies to prevent further relapses. CONCLUSION: The results suggest that patients with relapse in low back pain could respond in different ways to the recurrence of pain and show different degree of readiness to change behavioural and movement patterns in order to prevent further relapses. The different responses might be important aspects to which physicians and allied health professionals should pay attention in the rehabilitation process.