Workshops

Workshop Titles and Summaries

The use of shared decision making tools in research and clinical care for patients with low back disorders
(Steve Atlas, Colin Nelson and Jon Lurie)
Shared decision making seeks to help patients understand their options and increase participation in decision-making, rather than delegating decisions to their providers. A growing body of research suggests improved outcomes among well informed patients who participate in deciding how they are going to manage their health conditions. Workshop goals include, 1) summarize existing research examining the role of shared decision making on outcomes of patients with low back pain and to provide an interactive forum to discuss research opportunities; 2) describe current efforts to implement shared decision making in clinical practice using case examples from workshop participants; and 3) discuss development of decision quality measurement tools for low back disorders and engage in a feedback session of a draft instrument. This workshop will be of interest to conference attendees who have implemented shared decision making in clinical care, have performed research studies, or are interested in learning more about such activities. Pre-workshop activities will include email contact of workshop participants to collect their shared decision making experiences and then distribute them in advance. During the workshop, attendees will learn about research and clinical opportunities in shared decision making and will participate in evaluating a draft decision quality instrument.

Recovery from LBP: what is it and how should we measure it?
(Julia Hush, Kathryn Refshauge, Raymond Ostelo, et al)
There is currently no universally accepted definition of recovery from LBP. Current approaches to define recovery are based on assumptions that the domains of pain and disability are the most meaningful to patients for their recovery and that low scores on pain and disability instruments are valid indicators of patient recovery. There is emerging evidence that challenges these assumptions. The aim of this workshop is to develop consensus-based definitions of recovery for patients with LBP that are meaningful to patients and researchers. Prior to the conference, participants will be provided with relevant background material and will be required to respond to stimulus questions about how we define and measure recovery from LBP. At the conference, workshop organizers will facilitate small group activities and structured discussion to target key topics. As a result of the workshop, we aim to produce a consensus-based plan of action for the development of a uniform and valid measurement of recovery, and its translation into clinical practice.

Non-specific effects of primary care interventions: harnessing the benefits to improve outcomes
(Majid Artus, Danielle van Der Windt, Aage Indahl et al)
Only modest and often insignificant differences are found between interventions in trials on the effectiveness of clinical interventions for non-specific low back pain. The overall improvement in symptoms suggests a response that is largely not specific to a particular intervention, related to factors such as patients’ beliefs or conception, trial’s setting, or practitioner’s interaction. We will explore methods to harness the non-specific effects of primary care interventions for back pain to improve patients’ outcomes. Active participation is invited from all those who have special interest in this area.
There will be a pre-workshop activity involving a web-based Delphi-style survey on identifying non-specific effects of clinical interventions for back pain in primary care and their potential role in current research on back pain. In the workshop, themes from the pre-workshop survey will be discussed, then small groups will explore methods to harness these non-specific effects. A final consensus plan will then be agreed on, for research priorities in this area, that will be published.

Addressing fear-avoidance beliefs in a fear-avoidance world - translating research to clinical practice.
(Jim Rainville, Aage Indahl et al)
Fear-avoidance beliefs (FABs) encompass a person’s perception of the importance of low back pain and susceptibility of their back to further injury. The genesis of FABs is likely complex, with contributions from personal, family, societal and medical sources. FABs are important predictors of disability, and can be successfully targeted by medical interventions. Regardless, FABs are infrequently addressed during medical encounter. This workshop seeks participants interested in the clinical application of addressing FABs to the care of low back pain. It will require review of reading materials relevant to this topic prior to the workshop. This workshop will include 5 short lectures reviewing the experiences of clinicians, educators and researchers that have studies FABs and translated the findings into daily clinical practice and teaching. Group discussion will then explore the challenges of educating health care providers about addressing FABs during low back pain encounters. A manuscript reviewing workshop content will be produced.

A new approach for measuring the personal and societal burden of back pain
(Rachelle Buchbinder, Richard H Osborne, Clermont E. Dionne and Emma Irvin)
Chronic pain is relatively common and is expressed as limitation in the ability to perform activities of daily living and reduced psychological wellbeing. It results in substantial lost workplace and personal productivity as well as reduced participation in society. Very few studies have attempted to simultaneously investigate how back pain impacts on individuals, their families, the health care system, and society. The overall aim of this workshop will be to develop a comprehensive system to estimate the impacts and overall burden of back pain on individuals, their families and the community as a whole that can be generalised cross-culturally. Participants will be asked to characterize how back pain affects the life of people with the condition, and the community, and sort statements into conceptually similar groups. Multidimensional scaling and cluster analysis will be used to process participants’ input and generate 2 dimensional maps of key dimensions of back pain impact. The workshop members will derive a consensus on mapping the quantitative results. A manuscript describing the process and results of the workshop will be written after the conference and circulated to workshop participants for comments. This workshop will provide a timely opportunity for researchers interested in measuring the impacts and overall burden of back pain to further our understanding of the issues and set priorities for future research.

A new approach for measuring the personal and societal burden of back pain
(Chris Main, Bill Shaw and Nadine Foster)
This workshop is intended to clarify key psychosocial and workplace prognostic factors identified in primary care, discuss how to identify them, and develop a consensus on biopsychosocial risk factor-based interventions. It is intended for both clinicians and researchers, and will link screening with clinical decision-making, in the context of improved patient-provider communications. Participants will evaluate a briefing paper in advance, will have ample time to discuss the issues related to screening for these factors, and will also participate in a post-workshop critique of the summary document.

Measuring activity and participation in primary care: extending the IMPACCT recommendations?
(Rob Smeets, Jeanine Verbunt, Kathy Refshauge et al)
The focus of most LBP outcomes research has been on measuring symptoms, and limitations in activities that are important for the individual suffering from low back pain. Self rated pain and disability levels have at best moderate correlation with activity levels measured in daily life. Furthermore, qualitative research highlights that the patient’s perception of what is an important outcome can differ from the researcher’s and perhaps societal point of view. The objective of this workshop is to define patient relevant outcome measures for the domains of activity and participation, ways to measure these outcomes, compare disease-specific and generic measures, and self-report vs. more objective tools. Before the workshop, participants will submit responses to questions that will be addressed in the workshop group activities. There will be short presentations on measurement in LBP research, what is important to patients, and evidence on the association between self-reported measures of activity and other measures of real life activity levels. Each organizer will facilitate one of four small groups which will include structured activities and open discussion, leading to consensus-based recommendations for extending the IMPACCT guidelines for the reporting of research in primary care low back pain. The results will be published in the scientific literature.

Is there sufficient evidence to support a new subgroup within the non-specific low back pain category and would it be accepted?
(Ronald Donelson, Raymond Ostelo, and Kevin Spratt)
In current classification systems for 'nonspecific' LBP, the intent of initial assessment is to identify pain centralization (Cn) and directional preference. Over the past 25 years, a substantial body of published literature has validated both the inter-examiner reliability and validity of this assessment. Yet, most international LBP clinical guidelines have so far failed to acknowledge this form of examination, these two clinical findings, and the subgroup they identify. The goals of this workshop are to evaluate the evidence regarding the validation of the Cn/DP subgroup of non-specific LBP, and to direct and formulate future research activity. Before the workshop, attendees will develop a bibliography of relevant studies pertaining to the current and proposed LBP classification system, that will be consolidated by the workshop leaders, into a draft document that will be reviewed by attendees prior to the Forum. During the workshop, there will be presentations on current science and proposed research, discussion in order to establish a consensus, and the results will be merged into a position paper for publication that addresses the workshop’s objectives.

Towards international criteria for "symptomatic radiculopathy due to herniated disc" & "neurogenic claudication due to lumbar spinal stenosis"
(Stephane Genevay, Steve Atlas, and Jeff Katz)
LBP research is hampered by a lack of standardization in terminology, perhaps a consequence of the ambiguous causal relationships between pathoanatomic processes and symptoms. This workshop will develop a set of internationally recognized criteria to classify patients with low back pain related symptoms for research trials and clinical practice, focusing on radiculopathy and neurogenic claudication. Prior to the workshop, participants will provide feedback on potential domains that may define these syndromes, and submit their list of key descriptors for each of the two syndromes. At the workshop, participants will discuss key descriptors and domains, towards development of a provisional definition of each symptom complex. Post-Forum email correspondence will finalize the provisional definitions and the development of a validation study.

How to evaluate low back pain diagnostic tests
(Chris Maher, Mark Hancock, and Bart Koes)
Improved diagnostic research has the potential to improve outcomes for patients with low back pain. The workshop is designed to increase interest in diagnostic research, and provide a venue to foster research collaborations. The target audience is low back pain researchers interested in diagnostic research. Before the workshop, each participant will be allocated a diagnostic test or tests (eg the red flags for fracture, centralization for discogenic low back pain) that they will consider. The workshop will commence with a presentation outlining the types of diagnostic research that are possible (eg traditional cross-sectional study, randomized controlled trial, systematic review of diagnostic studies) using examples from back pain and related fields. This will be a brief overview of readings that will be distributed in advance. Participants will divide into 2 groups and develop a research plan to evaluate the diagnostic test they were allocated prior to the workshop, present their proposal to all participants, and then discuss strengths and weaknesses of the proposed designs.

How to evaluate treatment effects in subgroups of low back pain—methodological and practical issues
(Bart Koes, Chris Maher, Mark Hancock et al)
The workshop aims to increase interest and knowledge of studying treatment effects in subgroups of patients with low back pain, and will provide a venue for the initiation of research collaborations in this field. The target audience are low back pain researchers interested in research evaluating treatment effects in subgroups. The workshop will commence with a 20 minute presentation outlining the types of research that are possible for investigating treatment effects in subgroups. This will be a brief overview that will recap the main points of the pre-workshop readings. Participants will then divide into 2 groups and develop a research plan to evaluate the efficacy of a specific therapy for a subgroup of patients. One group will focus on a situation in which already some preliminary findings are available about the effect of the intervention for a particular subgroup (validation study) The other group will focus on the situation in which there are only preliminary ideas about treatment effects in subgroups but not yet any data (derivation study). Each group will present their plan to the all workshop participants, followed by discussion.

Capacity based measures of activities: predictive for what?
(Michiel Reneman, Remko Soer, Harriet Wittink et al)
Many performance based measures are currently available, with psychometric properties that vary greatly. These measures are ‘related but different’ from other non-performance based measures of activities. Looking at performance-based measures, questions include what is being measured, which outcomes are predicted , and how performance and capacity relate. This workshop will address these issues, including what factors of the activity domain are predictive for which factors in the participation domain, and what can be predicted based on capacity-based measures. The goal is to develop the basis for a Delphi study to validate capacity-based measures, and ultimately to publish a scientific article on this topic. Pre-workshop reading will include prior work on consensus definitions for functional capacity evaluations, a review of scientific literature on capacity-based outcome measures, and a theoretical framework for these measurements. The workshop will include short presentations and discussion of a draft framework statement, followed by a focus-group design for discussion.

Pregnancy as a risk for long-term lumbopelvic pain
(Birgitta Öberg, Annelie Gutke, Jenny Sjödahl et al)
Back pain is considered a normal consequence of pregnancy, and expected to disappear shortly after delivery, yet at least 20% of women have persistent non-specific lumbopelvic pain 2-3 years after delivery, with significant impact on work disability and costs to society. The goals of this workshop are to discuss the definition and classification of pregnancy-related lumbopelvic pain in a bio- psycho- social model, its clinical course, persistence, and attitudes of stakeholders towards this entity. Based on completion of pre-workshop readings, participants will discuss important factors are that needs to be discussed for use in future studies including subgrouping, predictors for long term course and outcome. Based on workshop discussion, a consensus will be developed on definitions, important predictors of outcome and outcome variables, and approaches for future research.

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• email: contedu@hsph.harvard.edu • web: http://www.hsph.harvard.edu/ccpe