What is the Natural History of Low Back Pain? It Depends
By: Chad E Cook PT, PhD, FAPTA
Definition: The natural history of a disease refers to the progression of a disease in an individual over time, from its onset (pathological or exposure to causal agents) to its resolution. It is generally considered “natural” when no interventions are used that could affect the resolution process [1,2]. Natural history should encompass both the subclinical phase (when the disease is asymptomatic) and the clinical phase (when symptoms are apparent), thus how the “episode” of the disease is defined is of considerable importance. Other terms used to represent natural history include disease progression, course over time, epidemiological trajectory, or disease lifecycle.
Favorable Outcomes: Historically, most musculoskeletal conditions, specifically, low back pain (LBP) are thought to have a favorable natural history. For example, in an older, very well cited paper, it was stated that LBP episodes are self-limiting, suggesting that 90% of patients recover in 6 weeks without loss of function [3]. As such, natural history is commonly factored in to the management process for individuals with LBP in clinical practice guidelines and dedicated treatment strategies. Most clinical practice guidelines have nominal suggestions for acute LBP (pain less than six weeks) when compared to chronic LBP, as it is thought to resolve on its own [4,5]. Stepped care strategies for managing LBP often align with the concept of natural history, and emphasize non-invasive, self-management approaches as the first step, allowing the natural recovery process to take its course [6].
Unfortunately, our understanding the natural history of conditions such as LBP is less clear than what we might think. This is because the process of measuring natural history has varied markedly across studies and is highly dependent on a number of factors [7].
Advantages and Disadvantages of Research Metrics used to Evaluate a Researcher’s Impact or Influence
By: Chad E Cook PT, PhD, FAPTA
Background:
Each year, in Duke University’s Division of Physical Therapy, I teach a class on research methodology. One of the topics we discuss in class involves ways to measure research impact among physical therapists’ (and other professions’) researchers. The discussion is complimentary to those that occur during the Appointment, Promotion and Tenure (AP&T) committee in the Department of Orthopaedics, of which I am a committee member. By definition, research impact metrics are quantitative tools used to assess the influence and productivity of researchers, to give some understanding who are leaders in their fields. Without fail, in the class (each year), there is some debate on the best methods. This blog will discuss four of the most common methods and will evaluate their advantages and disadvantages. The order presented does not imply superiority and these methods are not transferable with evaluating the impact of a single journal publication.
“It’s Not You, It’s Us…”: Heterogeneity of Treatment Effects as a Challenge to Effectiveness Trials.
By: Damian L Keter, PT, DPT, PhD
Background:
Comparative effectiveness studies are the cornerstone of medicine and health sciences research. They have a goal of finding ‘the best’ treatment for each associated condition. In comparative effectiveness studies, statistical models are able to provide ‘average’ treatment effects, which are often used to establish standardized mean difference between the interventions; however, it is clear across interventional studies that the ‘average’ effect is not to be consistently expected. Whereas interventional design focuses on central tendency (mean or median of the population), one may more importantly consider the dispersion of data around that point.
Heterogeneity of treatment effects (HTE) refers to the variation in how different individuals respond to the same treatment or intervention. HTE are often represented by standard deviations which are impacted by outliers, demonstrating individuals who respond ‘differently’ to the intervention than the ‘average’ results. There are a number of ways in which HTE can be analyzed or managed in secondary analyses including subgroup analysis of covariates and specific statistical methods to identify heterogeneity [1]. HTE is critically important in interpretation of results in interventional studies; however, they are often poorly reported [1]. Two factors must be considered when understanding HTE in interventional effectiveness trials: 1) what factors contribute to HTE, 2) the limitations and challenges in attempting to control HTE.
Is Myofascial Pain Syndrome a Legitimate Primary Diagnosis?
By: Chad E Cook, Damian Keter, Ken Learman
Background:
Myofascial Pain Syndrome (MPS) is hypothesized to be both a primary and/or a secondary chronic pain disorder that can refer symptoms to other parts of the body. MPS is relatively common, affecting millions of people worldwide, particularly those who have experienced muscle overuse, trauma, or stress [1]. MPS can significantly impact daily activities and quality of life, as the persistent pain and discomfort can be both physically and emotionally draining [2]. Despite its notable impact on health and wellness, MPS is a controversial diagnosis that mainly stems from the lack of consensus on its diagnostic criteria and the underlying mechanisms. The objective of this blog is to identify whether MPS meets current criteria as a unique diagnosis, using the four criteria from the World Health Organization (WHO).
Risk of Bias Measures can be Biased
By: Chad E Cook, Damian Keter, Ken Learman
Navigating the Literature: Navigating the ever-growing, healthcare literature can be challenging [1]. The sheer amount of new research, articles, and guidelines published regularly can be overwhelming. The number of biomedical publications has been steadily increasing over the years. As of 2022, there were approximately 3.3 million scientific and technical articles published worldwide [2]. The volume of information and the time constraints of a busy clinician can lead to information overload. This is particularly important since it can be difficult to determine which information is relevant and credible amidst the vast amount of available content.
In publishing, risk of bias measures are tools and methods used to assess the likelihood that the results of a study are influenced by systematic errors or biases. With the very high number of systematic reviews, which are designed to summarize overall results into a common understanding, the use of risk of bias measures is crucial for evaluating the quality, reliability, and trustworthiness [3-5] of research findings. This, and a focus on transparency in research, has led to the proliferation of risk of bias measures and their adoption into publication practice. However, there are limitations to risk of bias measures that may denude their utility in reconciling the literature. The purpose of this blog is to: 1) outline the limitations of risk of bias measures and 2) discuss the best ways of interpreting the literature when risk of bias measures provides interpretation conflict.
Why Isn’t Everyone Using Stepped Care for Musculoskeletal Injuries?
By: Chad E. Cook PT, PhD, FAPTA
Resource efficiency models
Musculoskeletal (MSK) outcomes have shown some concerning trends over the last decade. Conditions like low back pain, neck pain, and joint pain have become more prevalent, contributing to the overall burden of a MSK disorder [1]. According to a report analyzing medical claims data from 2010 to 2020, MSK healthcare costs have doubled, despite the number of individuals reporting MSK disorders remaining relatively constant. This increase in costs is driven by a rise in per-member costs and the growing number of health plan members [2] and has prompted a number of novel management models that emphasize cost-effectiveness rather than a current fee-for-service dominant strategy (which rewards higher utilization and does not penalize the provider when outcomes are not optimized). These novel “resource efficiency models” focus on the optimal use of resources—such as time, personnel, equipment, and finances—to achieve comparable or superior patient outcomes to a traditional approach.
Three Ways That Recruitment in Randomized Controlled Trials May Not Reflect Real Life
By: Chad Cook, Amy McDevitt, Derek Clewley, Bryan O’Halloran
As we wind up a year of recruitment on the SS-MECH trial [1], we are compelled to reflect on our recruitment strategies and study participants. Our study has included four recruitment sites and we’ve enrolled over 110 participants, which is nearly 85% of our targeted sample. We are using well-rehearsed and successful strategies at our work sites, providing access to a wide range of individuals with chronic neck disorders. As an example, the recruitment process at Duke University uses the electronic medical record to identify individuals who have recently been seen for neck related conditions, who are not seeking a physical therapist’s care at the given time. This process and the processes at all recruitment sites have been very effective, leading to high conversion rates (enrollment) and strong study retention. The study investigators provide care for both arms, which increases the fidelity of the interventions, as each of us has a vested interest in doing this right. Further, thanks to generous external funding (https://foundation4pt.org/), we have financial support for our six-month follow-ups, which has also been instrumental in a very high completion rate.
Pros and Cons of Paying Peer Reviewers
By: Juliana Ancalmo, Chad E Cook PT, PhD, FAPTA, Ciara Roche
Background:
Critical appraisal is a hallmark of peer reviewed publishing. Critical appraisal provides analytical evaluations of whether the results of the study can be believed, and can be transferred appropriately into other environments, for use in policy, education, or clinical practice [1]. Historically, critical appraisal is performed by peer reviewers who are either content or research experts (or both). Peer reviewers have viewed this act as an obligation for science, especially those who benefit from peer review as authors, and are not currently paid for this service.
Recent limitations brought forth by qualified peer reviewers has ignited discussion around paying for reviewing services. Although this topic had been highly debated previously, a new wave of conversation was reignited when researcher and Chief Scientific officer James Heathers [2] argued for a $450 fee for a peer review in an editorial published on Medium. This, coupled with the challenges many researchers faced post-COVID have spurred people on both sides of this argument to speak out. In this blog we will outline the pros and cons of this debate and discuss the complexity of the issue at hand.
Yes, Peer Review is Broken, but It’s Probably Worse than You Think
By: Chad E. Cook PT, PhD, FAPTA
We have problems: There are countless publications, editorials, and blogs indicating we have a notable problem with the peer review system used in scientific publications [1-4]. Concerns have included its inconsistency, its slow process, and the biases associated with reviewers (especially reviewer two) who have an axe to grind. These limitations and the knowledge that publishing companies are making record profit margins [5] off the free labor of reviewers, while authors are required to pay to publish, are especially difficult to stomach. This problem has been ongoing for some time but in my opinion, it seems to have worsened recently. Having been immersed in publishing for over 25 years as an author, and over 20 years as an editor-in-chief or associate editor for four journals, I’d like to outline my concerns that qualify my statement in the title that it’s “probably worse than you think”.
On Mastery
By: Seth Peterson, PT, DPT, OCS, FAAOMPT
“I don’t know how they can sleep at night.” I was getting chewed out in a hallway in my first year of residency training. My mentor was speaking in general terms, but it was painfully clear that “they” meant me. I had just seen an 11-year-old girl with an ankle sprain. I had given her a painful balance exercise in standing (because the evidence showed it was more effective) and we had talked about pain neurophysiology, which was cutting-edge at the time. Her problem with what she’d just witnessed was that, despite me applying “evidence-based care,” she hadn’t really seen me apply that care to the individual. She hadn’t seen me think.
Looking back, my lack of thinking about the interventions was made worse by the fact that I was doing so much thinking about the simple things. While my mentor was thinking about the words used to greet someone and deciding what mattered to that person on that day, I was focused on how to sequence an ankle examination. I was focused on the basics—and the basics were something they did unfailingly well. Using the conscious competence learning model, you could say I was at a stage of “conscious incompetence” while they were well into the “unconscious competence” stage. Another way to say it is they had “mastered” the basics, while I was just beginning to grasp them.
