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| Title: | Contemporary management of low back pain |
| Authors: | Costa, Leonardo |
| Keywords: | low back pain, randomised controlled trials, clinimetrics |
| Issue Date: | 27-Mar-2009 |
| Publisher: | University of Sydney.
Faculty of Medicine, |
| Abstract: | Abstract
Low back pain is a significant public health problem in many countries of the world
being one of the major causes of work absence and disability. Although the outlook
for evidence-based management of low back pain has greatly improved over the past
decades, many questions remain. Questions related to treatment options, underlying
mechanisms of treatment effects and optimal assessment of low back pain have yet to
be fully addressed by researchers. The broad aim of this thesis therefore was to
contribute to a better understanding of the contemporary management of low back
pain by performing studies in these key research areas.
Most clinical practice guidelines recommend exercise as an effective treatment
option for chronic low back pain. However the evidence for this recommendation
comes from trials that are not placebo-controlled and so this may potentially provide
biased estimates of the effects of exercise. Therefore a randomised controlled trial
testing the effect of motor control exercise versus placebo in patients with chronic
low back pain was conducted. Chapters 2 and 3 describe the trial protocol and the
report of the trial respectively. A total of 154 patients with chronic low back pain
were randomised to receive a motor control exercise program, or placebo (i.e.
detuned short-wave therapy and detuned ultrasound therapy). Primary outcomes
were pain, function, and the patient’s global impression of recovery measured at 2
months. The exercise intervention improved function and patient’s global impression
of recovery, but not pain, at 2 months. The mean effect of exercise on function was
1.1 points (95%CI, 0.3 to 1.8), the mean effect on global impression of recovery was
1.5 points (95%CI, 0.4 to 2.5) and the mean effect on pain was 0.9 points (95%CI, -
0.01 to 1.8), all measured on 11 point scales. Secondary outcomes also favoured
motor control exercise. This is the first study ever to demonstrate that motor control
exercise is better than placebo for patients with chronic low back pain. Most of the
treatment effects were maintained at 6 and 12 months follow-up. These results
suggest that this intervention should be considered for patients with chronic low back
pain in order to improve disability, function, and global impression of recovery, and
to improve pain intensity in the long term, but not in the short term.
Rehabilitative ultrasound imaging (RUSI) has been increasingly used by
physiotherapists in order to identify impairments in motor control as well as to
monitor progress of patients with low back pain. As with any other clinical measure
it is important to know how reproducible the RUSI measures are, and although there
are some reproducibility studies in the literature, no systematic review on this topic
has been conducted. Therefore a systematic review was performed with the objective
of assessing the reproducibility studies of RUSI for abdominal wall muscles (Chapter
4). Eligible studies were indentified via searches in CINAHL, EMBASE and
MEDLINE with citation tracking via the Web of Science Index. A total of 21 studies
were included. Due to heterogeneity of the studies’ designs, pooling the data for a
meta-analysis was not possible. RUSI measures of thickness of abdominal wall
muscles were found to be reliable. Few studies analysed the reliability for the
measurement of thickness changes (reflecting the muscle activity) finding good to
poor results. Evidence for the reproducibility of the difference in thickness changes
over time (necessary to evaluate improvements in muscle activity with treatment)
was not available. A limitation of the existing literature is that studies typically had
suboptimal designs and analysis. The current evidence for the reproducibility of
RUSI for measuring abdominal muscle activity is mainly based upon studies with
suboptimal designs that included mostly healthy subjects, making generalisability to
clinical settings uncertain.
Some questions about the reproducibility of RUSI measures of abdominal wall
muscles are still unanswered; this is mainly due to design issues, such as inadequate
statistics, inadequate sampling and lack of control of sources of bias (e.g. blinding
and absence of controlling for ordering effects). In addition the clinically important
questions about the reproducibility of thickness changes (reflecting the muscle
activity) and differences in thickness changes over time (reflecting the improvement
or deterioration of muscle activity) have not been adequately investigated. Therefore
a reproducibility study that aimed to answer these questions was performed (Chapter
5). Thirty-five patients seeking care for chronic low back pain participated in this
study. RUSI measures were taken at baseline and eight weeks post-baseline.
Replicate measures of thickness, thickness changes and differences in thickness
changes over time were analysed. The reproducibility of static images (thickness)
was excellent (ICC2,1 = 0.97, 95%CI = 0.96-0.97, Standard Error of the
Measurement (SEM) = 0.04cm, Smallest Detectable Change (SDC) = 0.11cm), the
reproducibility of thickness changes was moderate (ICC2,1 = 0.72, 95%CI 0.65-0.76
SEM = 15%, SDC 41%), while the reproducibility of differences in thickness
changes over time was poor. Improvements in the test protocol should be undertaken in order to enhance the reproducibility of RUSI measures, especially for differences in thickness chang over time.
Self-report outcome measures (questionnaires) are widely used by health care
providers for measuring patient’s health status or treatment outcomes. Most of the
questionnaires related to low back pain were developed in English and therefore their
usefulness in non-English speaking countries is considerably limited. Cross-cultural
adaptation and clinimetric testing are possibly the most efficient methods for solving this problem. Although there are many publications on the topic, a simple guide on how to perform a cross-cultural adaptation and clinimetric testing was not available.
Therefore a “clinician-friendly” narrative review for Brazilian physical therapists
(Chapter 6) was written. This review aimed firstly to explain the concepts and the
relevance of cross-cultural adaptation and clinimetrics testing, secondly to
summarise the current guidelines on the topic, thirdly to provide advice on how to
choose a relevant questionnaire and finally how to evaluate the quality of an adapted
questionnaire. Some examples of cross-cultural adaptations and clinimetrics testing
of relevant low back pain questionnaires in the Brazilian-Portuguese language were
also provided.
Although the number of international versions of low back questionnaires is
growing, to date it is unclear which questionnaires have been cross-culturally
adapted and into which specific language. To answer these questions a systematic
review was conducted in order to describe the available cross-cultural adaptations of
low back pain self-report outcome measures and the clinimetric testing that has
occurred for each adaptation (Chapter 7). Searches were performed in MEDLINE,
EMBASE, CINALH and LILACS; these searches were supplemented with
information from experts in the field of low back pain from 27 different countries to
ensure that the results were comprehensive. Sixty-one adaptations were identified.
While there are a large number of low back pain questionnaires available, very few
have been adapted into other languages, particularly commonly spoken languages
such as Mandarin, Hindi and Portuguese. The quality and comprehensiveness of
clinimetric testing varied considerably, with the evaluation of reliability and
construct validity most common. Further cross-cultural adaptation and clinimetric
studies are clearly needed and special consideration must be given to study designs
for clinimetric testing.
The final aim of this thesis was to cross-culturally adapt self-report instruments
relevant to the management of low back pain in Brazil. This was achieved by two
independent studies. The first study (Chapter 8) aimed to cross-culturally adapt the Functional Rating Index (FRI) into Brazilian-Portuguese and to test the clinimetric properties of the FRI and also of an existing Brazilian-Portuguese version of the
Roland Morris Disability Questionnaire (RMDQ) which was not fully evaluated in
the original study. Both instruments were tested for internal consistency, reliability,
construct validity, ceiling and floor effects and internal responsiveness in 140
chronic low back patients presenting for physiotherapy treatment in Brazil. Both
instruments were considered reliable and valid for the measurement of disability in
Brazilian-Portuguese speakers with low back pain, no ceiling or floor effects were
detected, but the internal responsiveness of both instruments was considered small.
The second study (Chapter 9) aimed to cross-culturally adapt the Patient-Specific
Functional Scale (PSFS) and to perform a head-to-head comparison of the
clinimetric properties of the PSFS, RMDQ and FRI. All instruments were tested for
internal consistency, reliability, construct validity, ceiling and floor effects, internal
and external responsiveness in 99 acute low back patients presenting for
physiotherapy treatment in Brazil. In order to fully test the construct validity and
external responsiveness, it was necessary to cross-culturally adapt the Pain
Numerical Rating Scale and the Global Perceived Effect Scale. The results of this
study demonstrate that the Brazilian-Portuguese versions of the RMDQ, FRI and
PSFS have similar clinimetric properties to each other and to the original English
versions; however the PSFS was the most responsive instrument. The results from
the studies in Chapters 8 and 9 will benefit the understanding of low back pain by
enabling international comparisons between studies conducted in Brazil and English speaking countries. In addition it will encourage researchers to include Brazilian-
Portuguese speakers in their future clinical trials.
Overall, the studies included in this thesis have provided an important contribution to
the contemporary management of low back pain. Firstly the use of motor control
exercise could be considered for patients with chronic low back pain as it produces
improvements in global impression of recovery, function, disability and pain.
Secondly RUSI measures of abdominal wall muscles in patients with low back pain
were considered reproducible for the measurement of muscle activity, but not as an
outcome measure to detect improvement/deterioration of muscle activity over the
course of treatment. Thirdly just a few high-quality cross-cultural adaptations and
clinimetrics testing for self-report outcome measures relevant to the management of
low back pain are available, and clearly more studies in this area are needed. Finally
the Brazilian-Portuguese versions of the Functional Rating Index, the Roland Morris
Disability Questionnaire and the Patient-Specific Functional Scale have acceptable
clinimetric properties and could be used in clinical practice as well as in research
studies in Brazil. |
| Description: | PhD |
| URI: | http://hdl.handle.net/2123/5294 |
| Appears in Collections: | Sydney Digital Theses
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