Abstract Background context Great effort has been made toward limiting low back pain (LBP). Recent focus has included factors involved with secondary and tertiary prevention, with less attention ...given to primary prevention. Purpose This review provided a current estimate of the incidence of LBP and risk factors associated with either first-time LBP or transition to LBP from a baseline of a pain-free state. Study design A systematic review and meta-analyses were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient sample Studies included subjects aged 18 years or older, from longitudinal, observational, cohort designs that included baseline risk factors to an outcome of either first-time LBP or transition to LBP from a baseline of a pain-free state. Outcome measures Risk factors and incidence rates were reported using descriptive analysis and the PRISMA guidelines. Methods Electronic search strategies in PubMed, CINAHL/SPORTDiscus, and Cochrane Central Register of Controlled Trials were combined with a hand search to identify articles for inclusion. Studies were classified based on the population studied (community vs. occupational based) and type of LBP outcome (first ever vs. transition from a baseline pain-free state). Results A total of 41 studies were included for review. Meta-analytical incidence rates for first-time LBP and transition to pain from a pain-free state were similar (∼25%), regardless of community or occupational populations. Risk factors for first-time LBP or transition to LBP from a baseline of a pain-free state were psychosocial and physically related. No consistent risk factor emerged as predictive of first-time LBP, although prior LBP was a consistent predictor of future incident LBP. Significant heterogeneity was found across studies in most models, which limits these findings. Conclusions The results of this study suggest that incidence of LBP is similar in community and occupational settings regardless of LBP definition. There were multiple diverse physical and psychosocial risk factors for first-time LBP. A history of LBP was the most consistent risk factor for transition to LBP from a baseline of a pain-free state.
In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, ...termed "psychologically informed practice," is offered as a "middle way" between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the "flags" framework, with psychologically informed practice requiring routine and specific consideration of "yellow flags" and "blue flags" (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification-but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential "black flags"). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment.
There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. ...PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.
Background:
Fear of reinjury and lack of confidence influence return-to-sport outcomes after anterior cruciate ligament (ACL) reconstruction. The physical, psychosocial, and functional recovery of ...patients reporting fear of reinjury or lack of confidence as their primary barrier to resuming sports participation is unknown.
Purpose:
To compare physical impairment, functional, and psychosocial measures between subgroups based on return-to-sport status and fear of reinjury/lack of confidence in the return-to-sport stage and to determine the association of physical impairment and psychosocial measures with function for each subgroup at 6 months and 1 year after surgery.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Physical impairment (quadriceps index QI, quadriceps strength/body weight QSBW, hamstring:quadriceps strength ratio HQ ratio, pain intensity), self-report of function (International Knee Documentation Committee IKDC), and psychosocial (Tampa Scale for Kinesiophobia–shortened form TSK-11) measures were collected at 6 months and 1 year after surgery in 73 patients with ACL reconstruction. At 1 year, subjects were divided into “return-to-sport” (YRTS) or “not return-to-sport” (NRTS) subgroups based on their self-reported return to preinjury sport status. Patients in the NRTS subgroup were subcategorized as NRTS-Fear/Confidence if fear of reinjury/lack of confidence was the primary reason for not returning to sports, and all others were categorized as NRTS-Other.
Results:
A total of 46 subjects were assigned to YRTS, 13 to NRTS-Other, and 14 to NRTS-Fear/Confidence. Compared with the YRTS subgroup, the NRTS-Fear/Confidence subgroup was older and had lower QSBW, lower IKDC score, and higher TSK-11 score at 6 months and 1 year; however, they had similar pain levels. In the NRTS-Fear/Confidence subgroup, the IKDC score was associated with QSBW and pain at 6 months and QSBW, QI, pain, and TSK-11 scores at 1 year.
Conclusion:
Elevated pain-related fear of movement/reinjury, quadriceps weakness, and reduced IKDC score distinguish patients who are unable to return to preinjury sports participation because of fear of reinjury/lack of confidence. Despite low average pain ratings, fear of pain may influence function in this subgroup. Assessment of fear of reinjury, quadriceps strength, and self-reported function at 6 months may help identify patients at risk for not returning to sports at 1 year and should be considered for inclusion in return-to-sport guidelines.
PDF
