Low Back Pain: A critical look at management, mechanisms and knowledge translation

Low back pain (LBP) is one of the most burdensome conditions facing health systems today. This thesis takes a critical look at some key areas in LBP; namely management, mechanisms and knowledge translation. Chapters Two, Three and Four focus on the management of LBP, or more specifically, on the risk and prevention of LBP. Chapter Two investigated the views of patients on what triggered their episode of LBP, identifying that patients mostly nominate biomechanical factors as the cause of their LBP and that this agrees with the views of clinicians. This study informed the educational intervention of the trial presented in Chapter Three. Chapter Three presents the protocol for a large randomised controlled trial to investigate the effectiveness and cost-effectiveness of group-based exercise and education classes in preventing recurrence of LBP. This trial is currently ongoing and due for completion in 2020. Before beginning a large and complex trial it is recommend that its feasibility is first investigated with a pilot study. Therefore, Chapter Four presents a randomised controlled pilot trial assessing the feasibility and acceptability of procedures for the trial presented in Chapter Three. Chapters Five and Six investigated aspects relevant to our understanding of the mechanisms involved in the treatment and prevention of LBP. Chapter Five investigated the mechanisms of a workplace intervention for LBP and showed that fear-avoidance beliefs, perceived muscle strength, use of assistive devices at work and physical exertion at work do not seem to mediate the effect of a multifaceted intervention in workers in elderly care. As physical activity is often hypothesised as mediating the effects of time and treatment of LBP, Chapter Six investigated a self-report (the Active Australia Survey) and objective (the Actigraph GT3x accelerometer) measure of physical activity, in patients with chronic pain to identify the instruments’ suitability for studying mediation. The study found that both measures were inadequate for measuring physical activity in this patient group as longitudinal Actigraph data was only obtainable for 52% of participants and the validity and responsiveness of the Active Australia Survey was poor. xix Chapters Seven and Eight investigated two common dissemination methods for knowledge translation in LBP: online evidence databases and clinical practice guidelines. Chapter Seven found that the ability of users of the Physiotherapy Evidence Database to access evidence-based resources was sub-optimal in many cases with 20% of all searches containing errors. This has ramifications for clinicians’ abilities to find evidence based resources to guide their clinical decision making. Chapter Eight found that completeness of reporting for guidelines on advice for managing acute LBP was extremely poor and that the recommendations in guidelines were often discordant with the evidence from clinical trials. This means that the clinical value of advice interventions for patients with acute LBP is probably not being realised. Overall, this thesis advances understanding of the management, mechanisms and knowledge translation of LBP by investigating patient-perceived risks of LBP, setting up a large-scale trial for the prevention of LBP, and investigating the mechanisms involved in the treatment and prevention of LBP. The thesis also found that the tools used to measure physical activity, searches of online evidence databases and the recommendation on advice for acute LBP in clinical practice guidelines are sub-optimal. The primary implications of this thesis are that, although some interventions show benefit for the treatment and prevention of LBP, our understanding of the mechanisms by which these interventions act is deficient. Also, our ability to provide clinicians with relevant research evidence to guide their clinical decision making is lacking and therefore the care provided by clinicians in clinical practice is likely to be less than ideal