Joel E. Bialosky

Importance: The feasibility and acceptability of integrating shared decision making (SDM) for patients receiving physical therapy for low back pain (LBP) is unclear. Objective: This study assessed feasibility and acceptability of integrating SDM for intervention selection facilitated by American Physical Therapy Association clinical practice guidelines for patients with LBP. Design: This was a non-randomized pilot feasibility study. Setting: This study was conducted in outpatient physical therapy clinics. Participants: Physical therapists (n = 10) and patients receiving care for LBP (n = 40) participated. Intervention: Physical therapists were non-randomly allocated to not receive (–SDM, n = 4) or receive (+SDM, n = 6) training to integrate SDM for patients with LBP. Main Outcomes and Measures: Feasibility of study procedures was assessed through recruitment, enrollment, and retention rates. Acceptability was assessed with standard measures for treatment acceptability (Short Assessment of Patient Satisfaction, SAPS), credibility-expectancy (Credibility-Expectancy Questionnaire, CEQ), therapeutic alliance (Work Alliance Inventory Short-Revised, WAI-SR), SDM occurrence (collaborRATE, and 9-item Shared Decision Making Questionnaire, SDM-Q-9) at 4 weeks. Patient-reported outcomes were described for pain intensity and interference (Pain, Enjoyment, General Activity, PEG), pain self-efficacy (4-item Pain Self Efficacy Questionnaire, PSEQ-4), and LBP disability (Oswestry Disability Index, ODI). Results: Of 68 patients that were eligible, 43 (63.2%) communicated with study coordinator, 40 (93.0%) were enrolled, and 24 (60.0%) completed 4-week follow-up. Patient acceptability outcome median scores for SAPS (–SDM = 24.0, +SDM = 24.0), CEQ-credibility (25.0, 26.0), CEQ-expectancy (21.0, 23.0), WAI-SR goal (20.0, 18.0), WAI-SR task (17.0, 18.0), and WAI-SR bond (16.0, 19.0) were observed. Top score rates for collaboRATE (–SDM = 53.8%, +SDM = 72.7%) and SDM-Q-9 (38.5%, 54.5%) were observed. Median within-participant change in PEG (–SDM = −0.7 points, +SDM = −2.0 points), PSEQ-4 (0.0, +2.0), and ODI (−4.0, −12.0) scores were observed with minimal important change rates for PEG (–SDM = 23.1%, +SDM = 54.5%), PSEQ-4 (30.8%, 63.7%), and ODI (38.5%, 63.6%) described. Conclusions: Feasibility findings will inform future efficacy study planning with respect to recruitment, enrollment, and retention procedures. Future studies should consider assessing SDM from both patient and physical therapist perspectives while also evaluating how clinical practice guidelines may be used as resources to facilitate SDM for people with LBP. Relevance: These study findings have implications for SDM as a strategy to incorporate patient preferences into evidence-based clinical decision making for patients with LBP in outpatient physical therapy settings, however, larger scale studies are needed.

Introduction Spinal manipulative therapy (SMT) is a common manual therapy intervention provided by healthcare providers for patients with low back pain (LBP). Responses to SMT are influenced by interactions between the patient and provider. Contextual factors may be specific to the patient, provider, patient-provider relationship or environment in which treatment is provided, with all capable of influencing clinical outcomes. The overall goal of this study is to gain a deeper understanding of contextual factors associated with manual therapy utilisation, perception and outcomes, from both patient and provider perspectives. A better understanding of modifiable contextual factors will inform future studies testing the impact on how SMT is delivered to patients influences clinical outcomes that could potentially advance the clinical science of manual therapy. Methods and analysis A prospective, single-arm study design with follow-up measures assessed up to 26 weeks after initiation of physical therapy for LBP will be used to assess relationships between physical therapy clinical outcomes and contextual factors related to the patient (preference, expectation, pain beliefs, pain associated distress and prior manual therapy experiences), the provider (equipoise, expectation, pain beliefs and clinical experience) and the interaction between the two (therapeutic alliance). Multimodal treatment approach of SMT (required during initial three treatment sessions within a 2week period), exercise and education supported by recent clinical practice guidelines will be encouraged for this study. Ethics and dissemination Ethics approval for the study was obtained from the University of Florida Institutional Review Board. Informed consent is required for physical therapist and patient participant enrolment in this project. The results of this study will be disseminated at professional scientific conferences and submitted for publication in peer-reviewed journals. Reference or approval number: IRB#: IRB202301700 Trial registration number NCT06590116.

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.

(1) Background: In recent years, placebo and nocebo effects have been extensively documented in different medical conditions, including pain. The scientific literature has provided strong evidence of how the psychosocial context accompanying the treatment administration can influence the therapeutic outcome positively (placebo effects) or negatively (nocebo effects). (2) Methods: This state-of-the-art paper aims to provide an updated overview of placebo and nocebo effects on pain. (3) Results: The most common study designs, the psychological mechanisms, and neurobiological/genetic determinants of these phenomena are discussed, focusing on the differences between positive and negative context effects on pain in experimental settings on healthy volunteers and in clinical settings on chronic pain patients. Finally, the last section describes the implications for clinical and research practice to maximize the medical and scientific routine and correctly interpret the results of research studies on placebo and nocebo effects. (4) Conclusions: While studies on healthy participants seem consistent and provide a clear picture of how the brain reacts to the context, there are no unique results of the occurrence and magnitude of placebo and nocebo effects in chronic pain patients, mainly due to the heterogeneity of pain. This opens up the need for future studies on the topic.

Introduction. Individuals with low back pain (LBP) may be classified based on mechanistic descriptors, such as a nociplastic pain presentation (NPP). The purpose of this secondary analysis was to examine the frequency and characteristics of patients with a NPP referred to physical therapy with LBP. Additionally, we characterized patients with LBP meeting the criteria for NPP by demographic, clinical, psychological, and pain sensitivity variables. Finally, we examined short- and long-term clinical outcomes in patients with a NPP compared to those without a NPP. Materials and Methods. Patients referred to physical therapy for LBP completed the Patient Self-report Survey for the Assessment of Fibromyalgia. Participants were categorized as “LBP with NPP” or “LBP without NPP” based on the threshold established in this measure. A rank sum test examined for differences in pain-related psychological factors and pressure-pain threshold between groups. Next, a Friedman test examined if LBP intensity and disability trajectories differed by groups at one and six months after initiation of physical therapy. Results. 22.2% of patients referred to physical therapy for LBP met the criteria for a NPP. Patients with a NPP reported significantly greater disability, pain catastrophizing, depression, anxiety, and somatization compared to individuals without a NPP ( ). Pressure-pain threshold did not differ between groups ( ). Individuals with LBP with a NPP demonstrated nonsignificant, small to medium reductions in pain and disability at one and six months. Individuals experiencing LBP without a NPP demonstrated significant reductions in pain and disability in the short- and long term. Conclusion. Patients with LBP with a NPP displayed greater negative pain-related psychological factors but similar pain sensitivity compared to LBP without NPP.

SYNOPSIS: JOSPT has published scientifically rigorous, clinically-relevant musculoskeletal rehabilitation- and sports-related content for over 40 years. The benefit of so many years of JOSPT is a rich back catalogue of quality musculoskeletal rehabilitation and sports content. To harness the back catalogue, the Journal is launching JOSPT Collections—designed as a bundle of quality, clinically-focused content related to a core musculoskeletal rehabilitation theme. Here we share some of the knowledge translation content that accompanies the first JOSPT Collections topic: Achilles tendinopathy. J Orthop Sports Phys Ther 2022;52(11):703–704. doi:10.2519/jospt.2022.11575