Exploration of physicians' recommendations for activities in chronic low back pain

Pain centers professionals' beliefs on non-cancer chronic pain

The beliefs and attitudes of health professionals affect the care ultimately provided to patients. The objective of this study was to analyze health professionals' beliefs toward chronic no cancer pain in nine (82%) pain centers in the city of S.Paulo. The Survey of Chronic Pain Attitudes-Professionals was employed to evaluate pain professionals' beliefs toward emotions, control, disability, solicitude, cure and harm. A total of 75 health professionals (59%), most of whom were doctors (44), followed by physical therapist (11) and dentists (8), were interviewed. The professionals professed a belief in a medical cure for chronic pain, that solicitous displays were desirable behaviors in treating pain, that chronic pain is related to injury and that it is the cause of disability, all of which are erroneous beliefs. Contrary to the expected result, the health professionals with more experience and education did not express more appropriate beliefs. These beliefs may compromise the treatment of patients with chronic pain and should therefore be reviewed.

How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists

Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n=2000) and PTs (n=2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT.PT), and a vignette of a patient with non-specific LBP (NSLBP) with questions asking about recommendations for work, activity and bedrest. Data from 1022 respondents (442 GPs and 580 PTs) who had recently treated patients with LBP were analysed. Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations, 28% reported they would advise this patient to remain off work. Work advice was significantly related to the PABS.PT scores with higher biomedical (F(1,986)=77.5, p<0.0001) and lower behavioural (F(1,981)=31.9, p<0.001) scores associated with advice to remain off work. We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse. Many HCPs held the belief that LBP necessitates some avoidance of activities and work. The attitudes and beliefs of these HCPs were associated with their self-reported clinical behaviour regarding advice about work. Future studies need to investigate whether approaches aimed at modifying these HCP factors can lead to improved patient outcomes.

Health care practitioners’ attitudes and beliefs about low back pain: A systematic search and critical review of available measurement tools

The attitudes and beliefs that health care practitioners (HCPs) hold about back pain have been shown to affect the advice they provide to patients seeking healthcare. In order to develop a questionnaire for a national survey of attitudes, beliefs and practice behaviour of HCPs about back pain, a systematic review of available measurement tools was undertaken. Measurement tools were identified from a systematic search of databases (Medline, Embase, CINAHL, Psychinfo, AMED and British Nursing Index) in the English language for papers published from January 1990 to October 2006. Quality criteria were applied to each of the tools by two independent reviewers. The initial search strategy generated a total of 5269 references. Following assessment of titles and abstracts, 12 papers describing five tools were identified for inclusion in the review. The tools were the Attitudes to Back Pain scale for musculoskeletal practitioners (ABS.mp), a fear avoidance beliefs tool, the Fear Avoidance Beliefs Questionnaire (FABQ) adapted for HCPs, the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT). The HC-PAIRS and PABS.PT have undergone the most thorough testing to date, but gaps in the properties of all the tools remain, particularly test-retest reliability and responsiveness. This review identified only five tools and demonstrated limited reporting of their validity and reliability. Further development and testing of existing tools should be a priority to ensure they are robust and valid measures of attitudes and beliefs of HCPs about back pain.

General practitioner sickness absence certification for low back pain is not directly associated with beliefs about back pain

Recent research has demonstrated a relationship between healthcare practitioner beliefs about low back pain and recommendations about activity, work restrictions and work absence. None of the research to date has looked at the relationship between practitioner beliefs and actual behaviour. This study investigated the internal consistency of the pain attitudes and beliefs scale (PABS) and if general practitioner (GP) beliefs about back pain were more predictive of sickness certification for non-specific low back pain (NSLBP) than a general predisposition to sick certify patients with other non-specific conditions (common mental illness and non-specific upper respiratory disorders). Ninty-four eligible general practitioners were invited to participate in the study and data from 83 (88.3%) were included in the full analysis. Evaluation of the internal consistency of the PABS found the biomedical subscale was good (alpha=0.781) but the psychosocial subscale was poor (alpha=0.396) after item elimination both subscales improved; biomedical alpha=0.790, psychosocial alpha=0.602. GP sickness certification behaviour for 1 year was gathered from the Department of Employment and Social Security database. Multiple regression analysis demonstrated that neither the biomedical nor the psychosocial subscale of the PABS predicted the number of sickness certificates issued even after controlling for the time employed as a GP, number of hours worked per week and the number of NSLBP patients seen. Certification for other conditions was predictive of NSLBP certificates issued. These results demonstrate that sickness absences certification for NSLBP is predicted by sickness certification behaviour in general and not by scores on the PABS.

Attitudes to back pain amongst musculoskeletal practitioners: A comparison of professional groups and practice settings using the ABS-mp

Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group (n=900). Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations.

Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?

BACKGROUND

In many countries, community pharmacists can be consulted without appointment in a large number of convenient locations. They are in an ideal position to give advice to patients at the onset of low back pain and also reinforce advice given by other healthcare professionals. There is little specific information about the quality of care provided in the pharmacy for people with back pain. The main objectives of this survey were to determine the attitudes, knowledge and reported practice of English pharmacists advising people who present with acute or chronic low back pain.

METHODS

A questionnaire was designed for anonymous self-completion by pharmacists attending continuing education sessions. Demographic questions were designed to allow comparison with a national pharmacy workforce survey. Attitudes were measured with the Back Beliefs Questionnaire (BBQ) and questions based on the Working Backs Scotland campaign. Questions about the treatment of back pain in the community pharmacy were written (or adapted) to reflect and characterise the nature of practice. In response to two clinical vignettes, respondents were asked to select proposals that they would recommend in practice.

RESULTS

335 responses from community pharmacists were analysed. Middle aged pharmacists, women, pharmacy managers and locums were over-represented compared to registration and workforce data. The mean (SD) BBQ score for the pharmacists was 31.37 (5.75), which was slightly more positive than in similar surveys of other groups. Those who had suffered from back pain seem to demonstrate more confidence (fewer negative feelings, more advice opportunities and better advice provision) in their perception of advice given in the pharmacy. Awareness of written information that could help to support practice was low. Reponses to the clinical vignettes were generally in line with the evidence base. Pharmacists expressed some caution about recommending activity. Most respondents said they would benefit from more education about back pain.

CONCLUSION

Those sampled generally expressed positive attitudes about back pain and were able to offer evidence based advice. Pharmacists may benefit from training to increase their ability and confidence to offer support for self-care in back pain. Further research would be useful to clarify the representativeness of the sample.

The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence

Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.

General practitioners' fear-avoidance beliefs influence their management of patients with low back pain

The objectives of this cross-sectional study conducted in primary care practice in France were to describe general practitioners' (GPs) fear-avoidance beliefs about low back pain (LBP), investigate the impact of these beliefs on their following guidelines for bed rest, physical activities, and sick leave, and uncover factors associated with GPs' fear-avoidance beliefs. A total of 864 GPs completed a 5-part self-administered questionnaire. Parts 1, 2, and 3 concerned demographic, professional data, and personal history of back pain, respectively. Part 4 dealt with GPs' education about LBP and practice for LBP. Part 5 assessed GPs' fear-avoidance beliefs on the Fear-Avoidance Beliefs Questionnaire (FABQ). GPs' mean age was 48.2+/-7.0 years, 80% were male, 88% had been practicing for more than 10 years, and 52% reported a previous personal episode of acute LBP. Forty-six percent had participated in an educational session on LBP during the last 3 years. Mean scores for the FABQ Phys and Work were 9.6+/-4.8 and 17.5+/-6.7, respectively. Sixteen percent of participants had high rating on the FABQ Phys (FABQ Phys score>14). FABQ Phys score was associated with recommendation of bed rest or rest during sick leave (p<0.0001) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. FABQ Work score was associated with prescribing sick leave during painful periods (p<0.005) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. GPs' fear-avoidance beliefs about LBP negatively influence their following guidelines concerning physical and occupational activities for patients with LBP.

The Attitudes to Back Pain Scale in Musculoskeletal Practitioners (ABS-mp)

OBJECTIVES

Little is known about practitioners' beliefs and attitudes to the treatment of low back pain, and whether these influence their clinical decisions, intervention strategies, and patient-centered outcomes. This study aimed to develop, test, and explore the underlying dimensions of a new questionnaire, the Attitudes to Back Pain Scale (ABS), in a specific group of clinicians, practitioners who specialize in musculoskeletal therapy.

METHODS

Items for the draft questionnaire were derived from interviews with practitioners (chiropractors, osteopaths, and physiotherapists). The draft questionnaire (52 items) sought to assess practitioners' attitudes concerning role and self-image plus their beliefs about treatment goals and prognosis of low back pain. The questionnaire was sent to a random selection of 300 practitioners from each professional group, and 546 (61%) responded. Split-sample analyses were performed using exploratory and confirmatory factor analysis.

RESULTS

Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains: limitations on sessions, psychologic, connection to health care system, confidence and concern, reactivation, and biomedical. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorization and low levels of difficulty in categorizing the items.

CONCLUSIONS

The internal structure of the new questionnaire not only shows excellent psychometric properties and good face validity, but also has the added advantage of being developed with a specific clinical context in mind. Additional evaluation is required to fully describe the psychometric integrity of this instrument.

Reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy

BACKGROUND/OBJECTIVE

Pain is a common secondary complication of spinal cord injury (SCI). However, the literature offers varying estimates of the numbers of persons with SCI who develop pain. The variability in these numbers is caused in part by differences in the classification of pain; there is currently no commonly accepted classification system for pain affecting persons after SCI. This study investigated the interrater reliability of the Bryce/Ragnarsson SCI pain taxonomy (BR-SCI-PT). The hypothesis was that, when used by physicians with minimal training in the BR-SCI-PT, it would have high interrater reliability for the categorization of reported pains.

METHODS

One hundred thirty-five vignettes, each of which described a person with SCI with one or more different etiologic subtypes of pain, were evaluated by 5 groups of up to 10 physicians with SCI subspecialization (39 respondents total). Physician classifications were compared with those made by the investigators.

RESULTS

Of 179 pain descriptions, 83% were categorized correctly to one of the 15 BR-SCI-PT pain types; 93% were categorized correctly with respect to level (above/at/below neurological level of injury), whereas 90% were categorized correctly as being either nociceptive or neuropathic. Subjects expressed a generally high confidence in the correctness of their classifications.

CONCLUSIONS

Substantial interrater agreement was achieved in determining subtypes of pain within the BR-SCI-PT. The agreement was improved for categorizing within less restrictive categories (ie, with respect to the neurological level of injury and whether the pain was nociceptive or neuropathic).

Outcome of subacute low back pain: influence of patients' and rheumatologists' characteristics

OBJECTIVES

To assess the outcome of subacute low back pain, to identify the characteristics of patients and physicians which were related to outcome and to evaluate the influence of rheumatologists' beliefs about back pain on their following the guidelines for physical and occupational activity.

METHODS

DESIGN

a longitudinal descriptive survey.

SETTING

a secondary care practice in France.

PARTICIPANTS

266 rheumatologists; 440 patients with subacute low back pain.

OUTCOME MEASURES

the main outcome measure was persistence of back pain 3 months after baseline evaluation. A self-administered questionnaire for physicians assessed attitudes and beliefs about back pain [Fear-Avoidance Beliefs Questionnaire (FABQ)], and one for patients assessed pain, perceived handicap and disability (Quebec Scale), anxiety and depression (Hospital Anxiety Depression Questionnaire), and beliefs about back pain (FABQ).

RESULTS

Forty per cent of patients had persistent low back pain at 3 months; 5.5% of these had sciatica. A total of 10% of rheumatologists and 68% of patients at baseline had a high FABQ physical score (phys; >14). Determinants of outcomes were work-related back pain [odds ratio (OR) = 3.37; 95% confidence interval (CI) 1.08-5.17], anxiety (OR = 2.41; 95% CI 1.44-4.09), sex (female OR = 2.03; 95% CI 1.30-3.18) and patients' beliefs about back pain at work (OR = 1.02; 95% CI 1.00-1.05). Physicians with high FABQ physical scores were less likely to follow guidelines on prescribing rest and occupational activity for back pain.

CONCLUSION

Back pain commonly persists 3 months later in patients with subacute low back pain. Patients and rheumatologists still have negative beliefs about back pain. Rheumatologists' beliefs influence their following guidelines on physical and occupational activities. National education programmes about low back pain are needed in France.

Physical exercise interventions to improve disability and return to work in low back pain: current insights and opportunities for improvement

INTRODUCTION

There is a body of literature that indicates that physical exercise interventions, with a primary focus on improvement of functioning instead of pain relief, might be effective to stimulate return to work and improve function in workers who are absent from work due to low back pain (LBP). Successful application and implementation of these interventions however, depends on multiple factors that need to be addressed carefully in clinical practice as well as research.

METHODS

Descriptive literature review, to identify an overview of current knowledge with respect to the safety, content- and context-related aspects of physical exercise interventions, issues relating to timing, the influence of treatment confidence and patient expectations, and the process of changing provider and employer behavior.

RESULTS

Physical exercises are not associated with an increased risk for recurrences. The effects of interventions may vary depending on content-related factors (i.e., type of exercises, dosage, frequency, skills of the healthcare providers, etc.) and contextual factors (i.e., treatment setting, compensation system, etc.). Treatment confidence and patients' expectations also significantly influence outcomes of physical exercise interventions. Timing is also important; interventions targeting return to work, applied during the acute phase of work absenteeism, compete with a high rate of spontaneous recovery and may therefore be inefficient.

CONCLUSIONS

Despite numerous studies, more quantitative and qualitative investigations are needed to further clarify the requirements for a successful application and implementation of physical exercise interventions for disabled workers with low back pain.

The physician as disability advisor for patients with musculoskeletal complaints

STUDY DESIGN

Literature review.

OBJECTIVES

To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area.

SUMMARY OF BACKGROUND DATA

While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being.

METHODS

Medical literature search.

RESULTS

Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians.

CONCLUSIONS

Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

How to identify patients with a poor prognosis in daily clinical practice

Predicting poor outcomes in daily practice is challenging. As well as prior episodes of low back pain and pain intensity, various psychosocial risk factors have been identified, although the independent prognostic value of these is rather low. This supports the necessity for a multidimensional view of the transition from acute to chronic pain and/or the development of disability. Psychological distress has been found to increase the risk of such a transition. Patients' beliefs and expectations about their pain seem to influence the recovery process; pain-related fear and fear avoidance can be influential psychological variables, from pain inception to its chronic stage. The influence of occupational factors such as job satisfaction, low workplace support or physical workload has also been emphasized. Treatment provider factors and the relationship between patients and care providers also contribute to the realistic or unrealistic expectations and meaningful or acceptable outcomes.

Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: the UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761]

BACKGROUND

Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines. Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level.

METHODS

The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.

Perceptions of Medical Errors by Internal Medicine Residents

Efforts to identify the underlying structure of 40 survey items dealing with perceptions of medical errors are reported on the basis of responses from 195 medical residents. Factor analysis revealed that the medical errors perceptions were represented by a 10-factor solution. The external validity of these factors was examined relative to perceptions about the cost of medical errors, the cost of errors to health care, and the need for education and interventions to address errors. Results indicated that 13.9% of the variation in the perceived cost of medical errors and 17.1% of the variation in the perceived need for additional physician education was explained by the factor structure.

Health care providers' orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity

The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) differentiates between a biomedical versus a biopsychosocial treatment orientation with regard to common low back pain. This study re-examined the factor structure and psychometric properties of the PABS-PT, along with the relationship between PABS-PT scores and the perceived harmfulness of physical activities and treatment recommendations for common low back pain. Two hundred and ninety-seven paramedical therapists completed the PABS-PT and questionnaires measuring related concepts, rated the perceived harmfulness of 41 daily physical activities depicted in photographs and gave recommendations for return to normal activity for three patients with low back pain. Analysis revealed two factors labelled 'biomedical' and 'biopsychosocial treatment orientation'. Furthermore, scores on both factors of the PABS-PT were related to measures of related concepts (statistically significant Pearson correlation coefficients between 0.30 and 0.65) such as the HC-PAIRS and a therapist version of the TSK. Regression analyses revealed that both factors were consistent predictors of judgements of the harmfulness of physical activities (PHODA) and of recommendations for return to work and normal activity.

Do physical therapists in the United kingdom recognize psychosocial factors in patients with acute low back pain?

STUDY DESIGN

A cross-sectional, descriptive vignette survey of practicing, musculoskeletal physical therapists.

OBJECTIVES

The aim of this study was to determine if musculoskeletal physical therapists, in the United Kingdom, recognize when patients with low back pain (LBP) are at risk of chronicity due to psychosocial factors. A secondary aim was to explore the advice they give to patients about work and activities.

SUMMARY OF BACKGROUND DATA

Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability. Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention.

METHODS

Three vignettes were written based on acute LBP patients attending for physical therapy and incorporated into a self-completed postal questionnaire sent to a simple random sample of musculoskeletal physical therapists in the United Kingdom (n = 900). After one reminder, 20% of nonresponders were sent a further questionnaire (n = 80). Data were analyzed using the Statistical Package for the Social Sciences (SPSS version 11).

RESULTS

The response rate was 57.7% (n = 518) with 453 meeting all inclusion criteria. The sample consisted of physical therapists working in the musculoskeletal field across all practice settings. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes. Advice to restrict work and activity was common.

CONCLUSIONS

Most physical therapists recognize when patients are at high risk of developing chronicity, yet many recommend the patient limit their activity levels and not work. Advice to "not work" is associated with more severe perceived spinal pathology, suggesting persistence of the biomedical model for LBP.

Prevalence and factors associated to low back pain among hospital staff

OBJECTIVES

Because of its frequency and consequences on professional life, low back pain (LBP) represents a real health care problem. Our study is aimed at determining the prevalence of LBP among hospital staff, analyzing the medical and professional consequences as well as investigating into the factors associated to this health problem.

METHODS

We have conducted an inquiry among 350 employees at Fattouma Bourguiba teaching hospital. The employees have answered a pre-established questionnaire including 51 items.

RESULTS

The cumulative life-prevalence was 57.7% of the cases. The annual prevalence was 51.1% of the cases. Chronic LBP prevalence was 12.8% of the cases. Medical care was required in 61.9% of the cases. Radiological explorations were performed in 45% of the cases. Sick leave was observed in 26.1% of the cases and an occupational change was necessary in two cases. Factors associated to LBP were age (P <0.01), female gender (P = 0.024), high BMI (P = 0.01), the fact of being married or divorced (P < 0.01), smoking (P = 0.016), past medical LBP history (P < 0.0001), extra professional activity (P < 0.01), migraine (P < 0.001), years' service (P = 0.007) as well as heavy weight lifting (P = 0.008). Exercise is rather a protecting factor against LBP (P = 0.019).

CONCLUSION

The prevalence of LBP among hospital staff as well as the socio-professional drawbacks is important. Many factors are associated to LBP urging medical teams to take some preventive measures to reduce this affliction.

Increasing Days at Work Using Function-Centered Rehabilitation in Nonacute Nonspecific Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of function-centered compared with pain-centered inpatient rehabilitation in patients whose absence from work is due to chronic nonspecific low back pain (LBP).

DESIGN

Single-blinded randomized controlled trial with follow-up assessments immediately after treatment and at 3 months.

SETTING

Center for work rehabilitation in Switzerland.

PARTICIPANTS

Patients with more than 6 weeks of work absence due to chronic nonspecific LBP (N=174; 137 men, 37 women; mean age +/- standard deviation, 42+/-8 y; mean sick leave before study, 6.5 mo).

INTERVENTIONS

Function-centered treatment (FCT) (4h/d, 6d/wk, for 3 wk) consisted of work simulation, strength, endurance, and cardiovascular training. Pain-centered treatment (PCT) (2.5h/d, 6d/wk, for 3 wk) used a mini back school, individually selected passive and active mobilization, stretching, and low-intensity strength training.

MAIN OUTCOME MEASURES

The number of days at work in 3 months after treatment, self-efficacy, lifting capacity, pain, mobility, strength, and global perceived effect. Effect sizes (ESs) (Cohen d ) were defined as small (ES range, 0.2-0.5), moderate (ES range, 0.5-0.8), and large (ES, >0.8).

RESULTS

Groups were comparable at baseline. Moderate ESs for the FCT group versus PCT group were found for days at work (25.9 d vs 15.8d, ES=.36, P =.029), self-efficacy (5.9 points vs -7.4 points, ES=.55, P =.003), and lifting capacity (2.3 kg vs 0.2 kg, ES=.54, P =.004).

CONCLUSIONS

Function-centered rehabilitation increases the number of work days, self-efficacy, and lifting capacity in patients with nonacute nonspecific LBP.

Do health care providers' attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures

The current study aimed to measure the differential predictive value of implicit and explicit attitude measures on treatment behaviour of health care providers. Thirty-six physiotherapy students completed a measure of explicit treatment attitude (Pain Attitudes And Beliefs Scale For Physiotherapists-PABS-PT) and a measure of implicit treatment attitude (Extrinsic Affective Simon Task-EAST). Furthermore, they gave treatment recommendations for a patient simulating back pain on three video scenes. The implicit and explicit measures of attitudes were only weakly related to each other. However, both were differentially related to treatment recommendations. The implications of the differential predictive value of implicit and explicit attitude measures for treatment behaviour are discussed.

Swedish Council on Technology Assessment in Health Care (SBU). Chapter 11. Physicians' sick-listing practices

Physicians' sick-listing practices have been studied to a very limited extent. There is limited scientific evidence that physicians perceive sick-listing duties to be difficult and problematic, regarding both the medical and the insurance-related aspects. There is limited scientific evidence also that quality is often deficient in the sickness certificates issued by physicians. This may affect case management at the local insurance office. There is insufficient scientific evidence to explain the differences in physicians' sick-listing patterns. The effects on patients are also insufficiently studied.

Acute low back pain: diagnostic and therapeutic practices reported by Brazilian rheumatologists

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

To assess resource utilization in the diagnosis, management, and hospitalization of patients with low back pain (LBP) as prescribed by Brazilian rheumatologists.

SUMMARY OF BACKGROUND DATA

LBP is an important cause of disability, suffering, and social costs. Two to five percent of patients miss workdays because of LBP; it is the second highest cause of physician visits and absenteeism.

METHODS

Rheumatologists taking part in a national rheumatology medical congress answered a questionnaire to assess management of patients with LBP. It consisted of two hypothetical scenarios describing patients with acute LBP (scenario 1) and sciatica (scenario 2). There were 29 questions mainly related to education, protective measures, rest, and medication.

RESULTS

A total of 207 questionnaires were returned. In scenario 1, 70% of the participants ordered some diagnostic test at first visit; lumbar radiograph was the most ordered (92%), while more than 80% prescribed rest and 100% at least one drug. Nonsteroidal anti-inflammatory drugs were prescribed by 69% of the participants. In scenario 2, 93% of the physicians ordered diagnostic tests at first visit, with computed tomography being the most ordered test (69%). Rest was prescribed by 90% (average 18 days) of the participants and physical therapy was counseled by 84%.

CONCLUSIONS

Considering the hypothetical scenarios, participants overused diagnostic and therapeutic procedures. A dissemination of guidelines for optimizing resource use in LBP diagnosis and management is needed.

Do evidence-based guidelines have an impact in primary care? A cross-sectional study of Swedish physicians and physiotherapists

STUDY DESIGN

A cross-sectional study of physicians and physiotherapists in primary care.

OBJECTIVES

To survey how familiar clinicians were with evidence-based guidelines for back pain and their opinion about their clinical usefulness and to compare self-reported practice behavior with the guidelines.

SUMMARY OF BACKGROUND DATA

Guidelines, based on empirical evidence, are meant to ensure that patients get the most effective treatment. These evidence-based guidelines should steer clinical praxis, but clinicians may not read, let alone heed, them.

METHODS

Using a questionnaire, the authors surveyed all physicians and physiotherapists in primary health care in Orebro County, Sweden (N = 235).

RESULTS

Forty-two percent of the physicians and 37% of the physiotherapists were unfamiliar with the content of the guidelines, and 40% of the physicians and 25% of the physiotherapists were unfamiliar with the concept of 'red flags.' Less than half of the clinicians, 47%, were familiar both with the content of the guidelines and the concept of red flags. Their opinion about the guidelines showed that 54% of the physicians and 56% of the physiotherapists agreed that the guidelines were useful in clinical praxis. Concerning the self-reported practice behavior, the majority indicated that they followed the key points in the guidelines.

CONCLUSIONS

A relatively large proportion of clinicians were unfamiliar with the content of evidence-based guidelines and/or with the concept of red flags. The process of implementing research into clinical practice is in need of an overhaul, and the impact of guidelines on clinical practice may be questioned.

Survey of general practitioner, family physician, and chiropractor's beliefs regarding the management of acute whiplash patients

STUDY DESIGN

Questionnaire Survey.

OBJECTIVE

The purpose of this study was to survey the whiplash management beliefs for practicing general practitioners, family physicians, and chiropractors.

SUMMARY OF BACKGROUND DATA

Many treatments are prescribed by general practitioners, family physicians, and chiropractors for acute whiplash, but to date no survey of management beliefs for acute whiplash has been reported.

METHODS

A total of 483 physicians and 123 chiropractors in the urban setting of Edmonton, Alberta, Canada were asked to participate by completing a questionnaire with 24 items designed to assess management beliefs regarding acute whiplash.

RESULTS

A total of 362 physicians (75%) and 88 chiropractors (72%) completed the survey. Only 1% of physicians and none of the chiropractors believed that whiplash patients should be prescribed bed rest until almost all their pain goes away. As well, only 1% of physicians and none of the chiropractors believed that patients with acute whiplash should not return to work until almost all their pain goes away. More than 89% of physicians and 76% of chiropractors believed that encouragement of maintaining normal activities, even if they hurt, is important in the recovery from whiplash. Also, 91% of physicians and 84% of chiropractors agreed that exercise therapy was effective in acute whiplash patients. Physicians are more likely to have negative feelings about treating patients who have whiplash, were more likely to believe there was nothing physically wrong with many patients with chronic whiplash, and agree that nonsteroidal anti-inflammatory drugs and muscle relaxants are effective in acute whiplash. Chiropractors are more likely to agree that traction, transcutaneous electrical nerve stimulation, manipulation, massage, and acupuncture are effective in acute whiplash.

CONCLUSIONS

Physicians and chiropractors generally hold beliefs that are consistent with the current evidence regarding the most helpful approaches to acute whiplash, although chiropractors were more likely to be supportive of passive therapy methods.

The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach

The present study aimed at clarifying the precise role of pain catastrophizing, pain-related fear and personality dimensions in vigilance to pain and pain severity by means of structural equation modelling. A questionnaire survey was conducted in 122 patients with chronic or recurrent low back pain. Results revealed that pain catastrophizing and pain-related fear mediated the relationship between neuroticism and vigilance to pain. Furthermore, vigilance to pain was found to be associated with heightened pain severity. Finally, we found that neuroticism moderated the relationship between pain severity and catastrophic thinking about pain. The results strongly support the idea that vigilance to pain is dependent upon catastrophic thinking and pain-related fear. Neuroticism is best conceived of as a vulnerability factor; it lowers the threshold at which pain is perceived as threatening, and at which catastrophic thoughts about pain emerge.

Health Care Providers' Attitudes and Beliefs Towards Common Low Back Pain: Factor Structure and Psychometric Properties of the HC-PAIRS

OBJECTIVE

The factor structure, reliability and validity of the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) were determined in the current study. Furthermore, the ability of the HC-PAIRS to serve as a predictor for work and activity recommendations of paramedical health care providers was examined.

DESIGN

For the current study, 156 therapists from several paramedical disciplines (mostly physiotherapy, manual therapy, chiropractic, and McKenzie) completed the HC-PAIRS and questionnaires measuring the perceived harmfulness of physical activities. Furthermore, the therapists gave recommendations for work and physical activity for patients described in vignettes. Since a factor structure was already known for the HC-PAIRS a confirmatory factor analysis was carried out. Reliability of the HC-PAIRS was determined by computing Cronbach's alpha. Validity was examined by reviewing associations between scores on the HC-PAIRS and scores on measures of the harmfulness of physical activities and recommendations for work and physical activity. Regression analyses were carried out to determine whether scores on the HC-PAIRS were a predictor of recommendations for work and physical activity while controlling for other variables.

RESULTS

In contrast to previous research, factor analysis revealed only 1 factor and suggested that 2 items should be removed from the HC-PAIRS. This factor had a Cronbach's alpha of 0.84. The HC-PAIRS showed adequate validity. All associations between scores on the HC-PAIRS and scores on measures of the harmfulness of physical activities and recommendations for work and physical activity were in the expected directions and ranged between 0.25 and 0.62 (P < 0.01). Scores on the HC-PAIRS were the only significant predictor of recommendations for work and physical activity when controlling for possible confounders including gender, years of experience in the treatment of back pain, judgments of severity of symptoms, and judgments of severity of pathology.

CONCLUSION

The HC-PAIRS appears to be a reliable and valid measure of health care providers' attitudes and beliefs about the relationship between pain and impairment. The role of health care providers' attitudes in the treatment of low back pain is discussed.

Performance problems of patients with chronic low-back pain and the measurement of patient-centered outcome

STUDY DESIGN

In a prospective interventional study, problems with performance were evaluated in 101 consecutive patients with chronic low-back pain for more than 12 months, before and after participation in an outpatient-based multidisciplinary pain management program in Mansfield, United Kingdom.

OBJECTIVES

To describe problems identified as most important by patients with chronic low-back pain and to evaluate the Canadian Occupational Performance Measure (COPM) as a tool for measuring problem-specific outcomes.

SUMMARY OF BACKGROUND DATA

Patients with chronic low-back pain report difficulties with a variety of activities. The COPM permits the identification and measurement of problems of particular concern to the patient.

MATERIALS AND METHODS

COPM, likert-modified Roland and Morris Disability Questionnaire, Pain Self-Efficacy Questionnaire, and 5-minute walk test were administered at baseline, immediately after, and 9 months after intervention. Differences and statistical interactions were determined by nonparametric tests.

RESULTS

Participants identified 60 different types of problem activity, 45 of which were identified by nine or fewer participants. Decreased walking tolerance was the most frequently identified problem (56% of participants). Improvements were observed in all outcomes following intervention. Approximately one third of participants reported improvements two or more COPM units in overall performance and satisfaction with their performance at 9 months. Higher reported performance and satisfaction were associated with greater self-efficacy. Increased reported walking performance was associated with increased observed 5-minute walk distance (R = 0.35, P = 0.02).

CONCLUSIONS

Patients with chronic low-back pain report problems with diverse activities. The COPM provides a patient-centered outcome measure that displays good external validity and responsiveness to change when addressing the individual's goals.

Health care provider's attitudes and beliefs towards chronic low back pain: the development of a questionnaire

Attitudes and beliefs, or the treatment orientation, of health care providers appear to be important in the management of non-specific chronic low back pain (CLBP). The aims of the current study were two-fold: First of all, the physiotherapists' opinion towards various aspects of the management of CLBP was surveyed. Secondly, in a principal factor analysis, it was investigated whether underlying dimensions could be identified in order to develop the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS_PT). In total, 421 physiotherapists (response rate 62.3%) participated in this study. The results suggested that the majority of physiotherapists hold the opinion that CLBP is not a dangerous condition, that sport should not be discouraged and that patients should not refrain from all physical activity. Moreover physiotherapists seem to hold the opinion that the way patients view their pain influences the progress of symptoms. Finally, physiotherapists seem to hold the opinion that therapy can completely alleviate the functional symptoms and that therapy may have been successful even if pain remains. The principal factor analysis (PAF) yielded an interpretable 2-factor model. Based on highest loading items, factor 1 was labelled 'biomedical orientation', whereas factor 2 was labelled 'behavioural orientation'. The internal consistency (Cronbach's Alpha) of factor 1 was 0.84 and for factor 2, 0.54 explaining 25.2% and 8.2%, respectively, of the total variance. Assessment of the effect of the physiotherapists' characteristics on scores on the different scales was encouraging as results pointed in the directions one would expect. Physiotherapists who attended biopsychosocial education courses had statistically significantly higher scores on the 'behavioural orientation' factor and vice versa. Biomedical specialists scored statistically significantly higher on the 'biomedical orientation' factor. Furthermore, the findings suggested that the PABS_PT discriminates between physiotherapists with a 'behavioural orientation' vs those with a 'biomedical orientation'. To examine the influence of these different treatment orientations with regard to CLBP on patient outcome is a challenge for the near future.

Implicit attitude towards pictures of back-stressing activities in pain-free subjects and patients with low back pain: an affective priming study

In this paper, it is investigated whether an implicit evaluative-negative attitude towards back-stressing activities exists in pain-free subjects and in chronic low back pain patients. Using an affective priming task, it was investigated whether pictures of threatening back-stressing movements (primes) facilitate (respectively, slow down) the categorisation of subsequent evaluative-negative (evaluative-positive) words (targets). In study 1 using 20 pain-free subjects, the affective priming effect indicated evidence for an implicit negative attitude towards pictures of back-stressing activities. In study 2 using 30 low back pain patients, a reverse priming effect was found. In line with previous research, it is argued that this reverse priming effect is owing to the evaluative extremity of the primes: patients recognize the possibility that extreme primes will interfere with the categorisation of the targets and overcompensate for this possible effect. The implications for the prevention of negative attitudes towards back-stressing activities in non-clinical and clinical samples are discussed.

Pain beliefs and perceived physical disability of patients with chronic low back pain

Cognitive-behavioural therapy and maintenance of exercise have emerged as major tools in the treatment of patients with chronic low back pain. Patients' beliefs about their problem may influence their uptake of and responses to particular treatment modalities. In particular, we hypothesised that patients' beliefs about the cause and treatment of pain may mediate changes in physical disability following participation in a multidisciplinary pain management programme. A cohort of 84 patients was invited to respond to booklets of self-report questionnaires prior to, immediately after and 3 months following participation in multidisciplinary pain management programmes. Questionnaires addressed subjects' beliefs about the nature and treatment of pain (Pain Beliefs Questionnaire), and their disability (Likert-modified Roland and Morris Disability Questionnaire, Physical Functioning scale of the Short Form-36 Health Survey, and Oswestry Low Back Pain Disability Questionnaire). Patients with chronic low back pain who more strongly endorsed 'organic' concepts about the nature and treatment of pain reported higher levels of physical disability at baseline, and displayed greater reductions in disability following participation in the pain management programmes. Reductions in reported 'organic' pain beliefs were associated with improvements in reported disability. Endorsement of 'psychological' concepts about the nature and treatment of pain was not associated with disability. These findings support a view that patients' beliefs about the nature and treatment of their pain can change during participation in a multidisciplinary pain management programme based on cognitive-behavioural intervention. Modification of these beliefs may be associated with improvements in patients' perceptions of the level of their disability.

Aggressive exercise as treatment for chronic low back pain

Exercise has long been a standard of treatment for back pain. Over the last 2 decades, the use of intense, non-pain-contingent exercises for treatment of chronic back pain has received increased advocacy. The main goals of these treatments are to improve functioning of painful lumbar soft tissue and to decrease the fears and concerns of patients about using their backs for daily activities. The methodology of an aggressive quota-based exercise approach to back pain is outlined in this article. This approach relies on objective quantification of physical capabilities, treatment directed at altering these parameters, and repeat quantification for determination of treatment efficacy and positive feedback. By eliminating impairments in back function, altering fears and beliefs about pain, and reducing disability, patients with chronic low back pain can achieve meaningful improvements in their quality of life.

What is the rational diagnostic approach to spinal disorders?

A problem that is encountered in patients with low back pain is that a definite diagnosis is rare. The heart of our clinical dilemma is how best to diagnose those rare patients with severe disease as early as possible. The main reasons for diagnostic errors have been summarized in this chapter. Numerous guidelines have been developed to help in the approach to this difficult problem. However, the limitations of such an approach are highlighted. History and clinical examination are the best single test for diagnostic purposes and neither questionnaires nor computers can replace the clinician. However, the values of clinical abilities should not be overestimated. Finally, the clinical application of guidelines needs to be re-evaluated for each individual patient.