Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial

Frequency and clinical meaning of long-term degenerative changes after lumbar discectomy visualized on imaging tests

The aim of this retrospective controlled study was to evaluate radiographic degeneration in the lumbar spine of patients who had undergone lumbar discectomy minimum 21 years earlier and its clinical meaning. Indeed, no previous investigation on degenerative changes occurring after lumbar discectomy with a comparable long follow-up has been published. The study participants consisted of 50 patients who had undergone discectomy for lumbar disc herniation. The mean length of follow-up was 25.3 +/- 3.0 years. Patients were assessed by Short Form-36 Health Survey (SF-36), Oswestry Disability Index, and a study-specific questionnaire. Radiographic views of the lumbar spine were obtained from all patients and compared to those of 50 asymptomatic controls. A five-step published classification was used to assess the increasing severity of radiographic changes. CT or MRI scans were also available for 27 patients who had undergone discectomy. Moderate to severe radiographic changes were present in 45 patients (90%) and 34 controls (68%), respectively (P = 0.013). The most prevalent MRI/CT changes were loss of disc height (89%), facet joint arthritis (89%), and endplate changes (57%). Thirty-two of 33 subjects (97%) reporting pain during the last 12 months had significant degeneration on their radiographs, and the frequency of changes was higher with respect to subjects without pain (P = 0.040). In conclusion, standard lumbar discectomy frequently leads to long-term degenerative changes on imaging tests. The presence of moderate to severe degeneration is associated with self-reported pain.

Cascade effects of laboratory testing are found to be rare in low disease probability situations: prospective cohort study

OBJECTIVES

(1) To investigate the frequency of cascades of further diagnostic investigations and referrals after abnormal laboratory results in situations of low disease probability; (2) to investigate pretest and posttest determinants; and (3) to describe the cascades that occur.

STUDY DESIGN AND SETTING

Prospective cohort study in primary care in The Netherlands. Numbers of investigations/referrals were recorded during 6 months of follow-up for 256 patients with normal and abnormal laboratory results. The influences of the reason for ordering tests, interpretation of results, and pretest/posttest disease probability were examined.

RESULTS

After receiving the laboratory results, the physicians ordered further investigations for 22 (17.3%) patients with abnormal results and for two (1.6%) patients with normal results (P<0.001). They referred 12 (9.4%) patients with abnormal results and eight (6.2%) patients with normal results (P=0.33). Six patients had two investigations and/or referrals, and one patient had three referrals. There were significantly more investigations/referrals for results interpreted as abnormal (P=0.004) and for cases with a high posttest disease probability (P=0.001).

CONCLUSION

This study suggests that cascade processes after laboratory testing in situations of low disease probability are limited in magnitude and frequency. Improving interpretations may help improve the appropriateness of further investigations and referrals.

Imaging strategies for low-back pain: systematic review and meta-analysis

BACKGROUND

Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.

METHODS

We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.

FINDINGS

We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0.19, 95% CI -0.01 to 0.39 for pain and 0.11, -0.29 to 0.50 for function, negative values favour routine imaging) or long-term (6-12 months, -0.04, -0.15 to 0.07 for pain and 0.01, -0.17 to 0.19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.

INTERPRETATION

Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

Overtreating chronic back pain: time to back off?

Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.

Factors impacting on doctors' management of acute low back pain: a systematic review

The aim of this review was to determine the factors that impact on doctors' management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales. The search generated a total of 28 papers [quantitative (n=27), qualitative (n=1) methodologies]. Themes were identified from the accepted papers: education (n=18), knowledge of clinical guidelines and impact on management (n=7), and doctors' demographics (n=4). There was consistent evidence that doctors did not adhere to clinical guidelines when performing a spinal assessment. There was inconsistent evidence that education increased adherence with acute LBP guideline recommendations in terms of referral rates to physiotherapy, for investigations, to secondary care and for maintaining patients at work. Strategies to address the factors impacting on doctors' management of acute LBP are required; these would lead to improvement in patient outcomes and reduce healthcare costs.

Content and outcome of usual primary care for back pain: a systematic review

BACKGROUND

Most patients seeking help for back pain are managed in primary care.

AIM

To describe the content and outcome of 'usual care' for low back pain in primary care trials.

DESIGN OF STUDY

A systematic review of randomised controlled trials published since 1998.

SETTING

Primary care.

METHOD

Randomised controlled trials of back pain in adults were scrutinised to obtain data on treatment and outcome measures in groups receiving usual primary care. A narrative review of the resulting heterogeneous data was undertaken.

RESULTS

Thirty-three papers were identified for analysis. Overall the exact nature of the treatment received in the 'usual' primary care group was poorly recorded. Medication was frequently used, and there were suggestions that levels of opioid prescription were higher than might be expected from clinical guidelines. Requesting of plain-film X-rays occurred more often than recommended. There was very little information to suggest that doctors were promoting physical activity for patients with back pain. Disability scores (Roland-Morris Disability Questionnaire) and pain scores improved over time for patients with acute or subacute back pain, but not for those with chronic pain.

CONCLUSION

Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and X-ray investigation. The content of the 'usual care' arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the 'usual care' arm.

Clinical management of occupational low back pain in Australia: what is the real picture?

INTRODUCTION

The aim of this study was to compare the clinical management of patients with occupational low back pain (LBP) presenting to secondary care practitioners in Australia with national and international practice guidelines.

METHODS

A consecutive cohort of 401 patients with LBP following a work injury was assembled at the time of referral to secondary rehabilitation. A comprehensive assessment was performed to collect demographic, clinical and occupational data, which were analysed using descriptive statistics. Clinical and occupational management data were compared with evidence-based guidelines for the management of LBP.

RESULTS

This study revealed that in this cohort presenting to secondary care, referral for guideline-based active treatment was delayed until, on average, 10 months post-injury; radiographic investigations had been ordered for almost every patient, including those presenting in the first three months of their injury; the prevalence of co-morbidities was high and there were signs that psychological distress was under-diagnosed.

CONCLUSIONS

This study reveals a lack of compliance with clinical guidelines for occupational back pain management in Australia.

A best-evidence review of diagnostic procedures for neck and low-back pain

This chapter aims to present an overview of the best available evidence on diagnostic procedures for neck and low-back pain. Relatively little is known about the accuracy of such procedures. Although most spinal conditions are benign and self-limiting, the real challenge to the clinician is to distinguish serious spinal pathology or nerve-root pain from non-specific neck and low-back pain. The use of valid procedures can assist the clinician in this aim. A search was conducted in PubMed to identify relevant systematic reviews and primary studies on diagnostic procedures for the neck and low back. A systematic review was included if at least two independent reviewers were used; a systematic procedure was followed for identifying the literature; and a methodological assessment was conducted. In the absence of systematic reviews, primary studies are reported. Systematic reviews were identified which evaluated evidence for diagnostic procedures in the following categories: history, physical examination, and special studies, including diagnostic imaging, diagnostic blocks, and facet and sacroiliac joint injections. In general, there is much more evidence on diagnostic procedures for the low back than there is for the neck. With regard to the history, a number of factors can be identified which can assist the clinician in identifying sciatica due to disc herniation or serious pathology. With regard to the physical examination, the straight-leg raise is the only sign consistently reported to be sensitive for sciatica due to disc herniation, but is limited by its low specificity. The diagnostic accuracy of other neurological signs and tests is unclear. Orthopaedic tests of the neck, such as Spurling's or the upper-limb tension test, are useful to rule a radiculopathy in or rule out, respectively. In patients 50 years of age or older, plain spinal radiography together with standard laboratory tests are highly accurate in identifying underlying systemic disease; however, plain spinal radiography is not a valuable tool for non-specific neck or low-back pain. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections, as well as sacroiliac joint injections for diagnostic purposes. In conclusion, during the history, the clinician can accurately identify sciatica due to disc herniation, as well as serious pathology. There is sufficient evidence regarding the accuracy of specific tests for identifying sciatica or radiculopathy (such as the straight-leg raise) or certain orthopaedic tests of the neck. Plain spinal radiography in combination with standard laboratory tests is useful for identifying pathology, but is not advisable for non-specific neck or low-back pain.

Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain

BACKGROUND AND PURPOSE

We conducted a prospective randomized study of patients with acute low back pain and/or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome. The practice of ordering spinal imaging, perhaps unintentionally, includes a large number of patients for whom the imaging test is performed for purposes of reassurance or because of patient expectations. If this rationale is valid, one would expect to see a measurable effect from diagnostic information, per se.

MATERIALS AND METHODS

A total of 246 patients with acute (<3 weeks) low back pain (LBP) and/or radiculopathy (150 LBP and 96 radiculopathy patients) were recruited. Patients were randomized using a stratified block design with equal allocation to either the unblinded group (MR imaging results provided within 48 hours) or the blinded group (both patient and physician blinded to MR imaging results.) After the initial MR imaging, patients followed 6 weeks of conservative management. Roland function, visual pain analog, absenteeism, Short Form (SF)-36 Health Status Survey, self-efficacy scores, and Fear Avoidance Questionnaire were completed at presentation; 2, 4, 6, and 8 weeks; and 6, 12, and 24 months. Improvement of Roland score by 50% or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome.

RESULTS

Clinical outcome at 6 weeks was similar for unblinded and blinded patients. Self-efficacy, fear avoidance beliefs, and the SF-36 subscales were similar over time for blinded and unblinded patients, except for the general health subscale on the SF-36. General health of the blinded group improved more than for the unblinded group (P = .008).

CONCLUSIONS

Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being.

Acceptance and perceived barriers of implementing a guideline for managing low back in general practice

Background

Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.

Methods

Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.

Results

Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.

Conclusion

Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.

Trial registration

BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].

Influence of magnetic resonance of the knee on GPs' decisions: a randomised trial

BACKGROUND

Magnetic resonance imaging (MRI) of the knee for meniscus and ligament injuries is an accurate diagnostic test. Early and accurate diagnosis of patients with knee problems may prevent the onset of chronic problems such as osteoarthritis, a common cause of disability in older people consulting their GP.

AIM

To assess the effect of early access to MRI, compared with referral to an orthopaedic specialist, on GPs' diagnoses and treatment plans for patients with knee problems.

DESIGN OF STUDY

A multi-centre, pragmatic, randomised controlled trial.

SETTING

Five hundred and fifty-three patients with knee problems were recruited from 163 general practices across the UK from November 2002 to October 2004.

METHOD

Eligible patients were randomised to MRI or consultation with an orthopaedic specialist. GPs made a concomitant provisional referral to orthopaedics for patients who were allocated to imaging. GPs recorded patients' diagnoses, treatment plans, and their confidence in these decisions at trial entry and follow-up. Data were analysed as intention to treat.

RESULTS

There was no significant difference between MRI and orthopaedic groups for changes in diagnosis (P = 0.79) or treatment plans (P = 0.059). Significant changes in diagnostic and therapeutic confidence were observed for both groups with a greater increase in diagnostic confidence (P<0.001) and therapeutic confidence (P = 0.002) in the MRI group. There was a significant increase in within-group changes in diagnostic and therapeutic confidence.

CONCLUSION

Access to MRI did not significantly alter GPs' diagnoses or treatment plans compared with direct referral to an orthopaedic specialist, but access to MRI significantly increased their confidence in these decisions.

A review identifies and classifies reasons for ordering diagnostic tests

OBJECTIVE

To consider the reasons and context for test ordering by doctors when faced with an undiagnosed complaint in primary or secondary care.

STUDY DESIGN AND SETTING

We reviewed any study of any design that discussed factors that may affect a doctor's decision to order a test. Articles were located through searches of electronic databases, authors' files on diagnostic methodology, and reference lists of relevant studies. We extracted data on: study design, type of analysis, setting, topic area, and any factors reported to influence test ordering.

RESULTS

We included 37 studies. We carried out a thematic analysis to synthesize data. Five key groupings arose from this process: diagnostic factors, therapeutic and prognostic factors, patient-related factors, doctor-related factors, and policy and organization-related factors. To illustrate how the various factors identified may influence test ordering we considered the symptom low back pain and the diagnosis multiple sclerosis as examples.

CONCLUSIONS

A wide variety of factors influence a doctor's decision to order a test. These are integral to understanding diagnosis in clinical practice. Traditional diagnostic accuracy studies should be supplemented with research into the broader context in which doctors perform their work.

Management of musculoskeletal pain

Chronic musculoskeletal pain is a major public health problem affecting about one third of the adult population. Pain is often present without any specific findings in the musculoskeletal system and a strictly biomedical approach could be inadequate. A biopsychosocial model could give a better understanding of symptoms and new targets for management. Identification of risk factors for chronicity is important for prevention and early intervention. The cornerstones in management of chronic non-specific, and often widespread, musculoskeletal pain are non-pharmacological. Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments in e.g. chronic low back pain and fibromyalgia. Analgesics are useful when there is a specific nociceptive component, but are often of limited usefulness in non-specific or chronic widespread pain (including fibromyalgia). Antidepressants and anticonvulsants could be of value in some patients but there is a need for more knowledge in order to give general recommendations.

The use of patient-centered outcome measures in radiology: a systematic review

RATIONALE AND OBJECTIVES

To undertake a systematic review of literature on patient centred outcomes and explore the use of patient defined outcomes in radiology research.

MATERIALS AND METHODS

i)

DATA SOURCES

Published empirical studies in peer reviewed journals. ii)

STUDY SELECTION

Systematic search of English language radiology literature between 1990-2003, using four electronic databases, and reference lists of papers. Work relating to diagnostic or interventional imaging was included. Screening was excluded, together with articles based solely on the audit of patients' medical records. Patients needed to have inputted directly into the study, for example responding to questionnaires or participating in interviews. iii)

DATA EXTRACTION

Abstracts were retrieved and relevant full text articles obtained. Each paper was reviewed independently by two reviewers (research team members) using a data extraction form, developed by the authors. Categorisation of papers was undertaken at team meetings.

RESULTS

A total of 26 publications met the inclusion criteria for the review. Papers were placed within three categories: i) the primary aim of the study was investigate patient centred outcomes (n = 10); ii) the primary aim of the study was to describe the radiological procedure itself but patient contact was made post-procedure (n = 5) and iii) the primary aim of the study was to investigate patients' experiences during procedures (n = 11). Validated outcome measures were used in 10 studies. None of the outcome measures used were developed specifically for radiology. No papers were found where researchers had used patient defined outcomes.

CONCLUSION

The research highlighted difficulties relating to the review and reporting of outcomes research. The results indicated little patient engagement in outcome research in radiology.

Reasons for ordering spinal x-ray investigations: how they influence general practitioners' management

OBJECTIVE

To explore whether general practitioners who request spinal x-ray investigations are less likely to refer, prescribe medication, or order additional tests when they intend only to reassure patients rather than to exclude or confirm disease.

DESIGN

Cross-sectional survey. Physicians recorded reasons for requesting x-ray examinations and differential diagnoses on the request form. When they received a radiologist's report on a spinal x-ray test, GPs also received a questionnaire on their subsequent management.

SETTING

Maastricht region of the Netherlands.

PARTICIPANTS

All 90 GPs in the Maastricht region who referred patients for spinal x-ray examinations during 19 consecutive weeks.

MAIN OUTCOME MEASURES

Reason for requesting spinal x-ray investigations, results, and subsequent management.

RESULTS

We received completed questionnaires on 386 patient contacts. Physicians were significantly less likely to refer, prescribe medication, or order additional tests when they intended only to reassure patients rather than to exclude or confirm disease (odds ratio 0.3, 95% confidence interval 0.1 to 0.6). This effect was independent of the results of the x-ray examinations.

CONCLUSION

Physicians seem to be aware that they have requested spinal x-ray examinations only to reassure patients, and they account for this in their management. These findings support debate on the negative consequences of requesting tests for other than purely medical reasons. Concerns about unjustified actions based on the results of x-ray examinations that were requested primarily to reassure patients should probably have only a minor role in the debate about unnecessary testing.

Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?

STUDY DESIGN

Prospective study.

OBJECTIVE

To examine the association between structural abnormalities recorded on magnetic resonance imaging (MRI) and outcome after evidence-based conservative treatment in patients with chronic nonspecific low back pain (LBP).

SUMMARY OF BACKGROUND DATA

In most guidelines for the management of LBP, MRI is not recommended unless the diagnostic triage suggests serious spinal pathology or nerve root involvement for which surgical treatment is foreseen. This is because many structural changes seen on MRI appear to be as common in asymptomatic individuals as in people with LBP and are, therefore, considered of little value in either explaining the cause of pain or deciding the subsequent course of management. However, to our knowledge, no studies have assessed whether the presence of such MRI abnormalities influences the outcome of the conservative treatment that patients with chronic nonspecific LBP typically receive.

METHODS

T2-weighted, 4-mm spin-echo MRI sequences of the lumbar spine were obtained from 53 patients with chronic nonspecific LBP before a 3-month program of exercise therapy. Disc degeneration, disc bulging, high intensity zones, and endplate/bone marrow changes were assessed for each lumbar segment. Back pain (average and worst) and disability (Roland Morris score) were assessed before and after therapy, and 12 months later, and the improvements were examined in relation to the presence or absence of baseline MRI "abnormalities."

RESULTS

Eighty-nine percent of patients had severe disc degeneration (grade 4 or 5), 74% had disc bulging, 60% had high intensity zones, and 62% had endplate/bone marrow changes in at least 1 lumbar segment. Only 11% patients had none of these changes at any level. The MRI abnormalities showed only minimal association with baseline symptoms. In multivariate regression analyses, in which age, gender, and baseline symptoms were controlled for, only 1 significant association between the MRI variables and outcome was observed: the presence of a high intensity zone in any vertebral segment was associated with lower average pain at the 12-month follow-up (standardized beta -0.376, P = 0.006, 16.5% variance accounted for).

CONCLUSION

In the patient group examined, the presence of common "structural abnormalities" on MRI had no significant negative influence on the outcome after therapy.

Prediction of sickness absence in patients with chronic low back pain: a systematic review

OBJECTIVES

To provide evidence of predictors for sickness absence in patients with non-specific chronic low back pain (CLBP), distinguishing predictors aimed at the decision to report sick (absence threshold) and decision to return to work (return to work threshold).

METHODS

Medical and psychological databases were searched, as well as citations from relevant reviews. In- and exclusion criteria were applied. Two reviewers assessed the methodological quality of the papers independently.

RESULTS

Many different predictors were studied, and few factors were studied more than once. Consistent evidence was found for own expectations of recovery only as predictor for the decision to return to work. Patients with higher expectations had less sickness absence at the moment of follow-up measurement. As expected, different predictors were found aiming at the absence threshold or the return to work threshold. Furthermore, predictors varied also with the measurement instruments used, timing of follow-up measurements, and definition of outcomes. Until now, too few studies are available to overcome several potential sources of heterogeneity.

CONCLUSIONS

No core set of predictors exists for sickness absence in general. The characteristics of the study including the decision to report sick or to return to work determined the influence of several predictors on sickness absence in patients with CLBP. Further research and use of a core set of measurements and uniform definitions are needed to predict sickness absence and return to work in patients with CLBP.

[Back pain: do we follow the recommendations in the guidelines?]

OBJECTIVE

To describe how patients with back pain are usually handled at a health centre.

DESIGN

Retrospective, descriptive study.

SETTING

Urban health centre.

PARTICIPANTS

All patients seen for back pain in the centre's general medical consultations during 2003.

MAIN MEASUREMENTS

Patients' personal details, clinical characteristics of back pain (alarm signals), semiological data, request for further tests, treatments prescribed, referral to specialists.

RESULTS

Five hundred and thirty eight clinical histories were included. 53.2% of patients were women, and 33.6% were over 55. 35% of patients were not questioned on pain characteristics; and in over half the cases (54.6%), there were no questions on the presence of alarm signals, either. Only in 0.6% of cases was any analogical visual scale used to assess pain. Only 46.8% of the x-rays taken were thought to be well indicated, in terms of pre-established criteria. Total rest was not normally advised (1.9%); the drugs most commonly prescribed were NSAIDs (39.6%).

CONCLUSIONS

Clinical evaluation of patients with back pain is still inadequate in our centre, and x-rays are requested without adherence to formal or explicit criteria. We prescribe more NSAIDs than paracetamol for therapy.

Explaining variation in GP referral rates for x-rays for back pain

BACKGROUND

Despite the availability of clinical guidelines for the management of low back pain (LBP), there continues to be wide variation in general practitioners' (GPs') referral rates for lumbar spine x-ray (LSX). This study aims to explain variation in GPs' referral rates for LSX from their accounts of the management of patients with low back pain.

METHODS

Qualitative, semi-structured interviews with 29 GPs with high and low referral rates for LSX in North East England. Thematic analysis used constant comparative techniques.

RESULTS

Common and divergent themes were identified among high- and low-users of LSX. Themes that were similar in both groups included an awareness of current guidelines for the use of LSX for patients with LBP and the pressure from patients and institutional factors to order a LSX. Differentiating themes for the high-user group included: a belief that LSX provides reassurance to patients that can outweigh risks, pessimism about the management options for LBP, and a belief that denying LSX would adversely affect doctor-patient relationships. Two specific differentiating themes are considered in more depth: GPs' awareness of their use of lumbar spine radiology relative to others, and the perceived risks associated with LSX radiation.

CONCLUSION

Several key factors differentiate the accounts of GPs who have high and low rates of referral for LSX, even though they are aware of clinical guideline recommendations. Intervention studies that aim to increase adherence to guideline recommendations on the use of LSX by changing the ordering behaviour of practitioners in primary care should focus on these factors.

Low back pain investigations and prognosis: a review

Low back pain is reviewed in terms of when investigations are useful and its clinical course. Despite the extensive evaluation of the accuracy of investigations such as radiography, magnetic resonance imaging, and myelography, there is a surprising dearth of research to inform their use in primary care. There is no clear evidence on which to base judgments for selection of appropriate tests to confirm or exclude low back pain pathology. It appears that investigations are rarely necessary for low back pain. Specific investigations should be ordered to identify a particular pathology but should not be ordered routinely for general screening. In the absence of pathology, low back pain and its associated disability improve rapidly in the first weeks after onset, but, in contradiction to all guidelines, both commonly persist and the best evidence suggests that recurrences are common.

The appropriate use of radiography in clinical practice: a report of two cases of biomechanical versus malignant spine pain

BACKGROUND

To describe the evaluation, treatment, management and referral of two patients with back pain with an eventual malignant etiology, who were first thought to have a non-organic biomechanical disorder.

CLINICAL FEATURES

The study was a retrospective review of the clinical course of two patients seen by a chiropractor in a multi-disciplinary outpatient facility, who presented with what was thought to be non-organic biomechanical spine pain. Clinical examination by both medical and chiropractic physicians did not indicate the need for radiography in the early course of management of either patient. Upon subsequent re-evaluation, it was decided that certain clinical factors required investigation with advanced imaging. In one instance, the patient responded to conservative care of low back pain for nine weeks, after which she developed severe pain in the pelvis. In the second case, the patient presented with signs and symptoms consistent with uncomplicated musculoskeletal pain that failed to respond to a course of conservative care. He was referred for medical therapy which also failed to relieve his pain. In both patients, malignancy was eventually discovered with magnetic resonance imaging and both patients are now deceased, resulting in an inability to obtain informed consent for the publication of this manuscript.

CONCLUSION

In these two cases, the prudent use of diagnostic plain film radiography did not significantly alter the appropriate long-term management of patients with neuromusculoskeletal signs and symptoms. The judicious use of magnetic resonance imaging was an effective procedure when investigating recalcitrant neuromusculoskeletal pain in these two patients.

Health related quality of life outcome instruments

Health is the most significant part of quality of life. Generally, quality of life outcome instruments used in healthcare confine their attention to health related areas, assessing health related quality of life. The present study aims to describe some commonly used health profile instruments such as the generic measures SF-36, Nottingham Health Profile and Sickness Impact Profile; and the preference-based measures EuroQol and SF-6D. The latter preference-based instruments are increasingly used in outcome studies and obtained data might be used for calculating quality-adjusted life-years.

The use and diagnostic yield of radiology in subjects with longstanding musculoskeletal pain--an eight year follow up

BACKGROUND

Longstanding musculoskeletal pain is common in the general population and associated with frequent use of health care. Plain radiography is a common diagnostic approach in these patients despite knowledge that the use in the investigation of musculoskeletal pain is associated with low diagnostic yield, substantial costs and high radiation exposure. The aim of this study was to assess the use of diagnostic imaging and the proportion of pathological findings with regard to duration and distribution of pain in a cohort from the general population.

METHODS

An eight-year longitudinal study based on questionnaires at three occasions and medical records on radiological examinations done in medical care. Thirty subjects were selected from an established population based cohort of 2425 subjects that in 1995 answered a postal survey on pain experience. At baseline there were ten subjects from each of three pain groups; No chronic pain, Chronic regional pain, and Chronic widespread pain (CWP). Those who presented with CWP at two or all three occasions were considered to have a longstanding or re-occurring CWP. In total the thirty subjects underwent 102 radiological examinations during the eight year follow up.

RESULTS

There was a non-significant (p = 0.10) finding indicating that subjects with chronic pain at baseline (regional or widespread) were examined three times more often than those with no chronic pain. When the indication for the examination was pain, there was a low proportion of positive findings in subjects with longstanding CWP, compared to all others (5.3% vs 28.9%; p = 0.045). On the other hand, in examinations on other indications than pain the proportion of positive findings was high in the CWP group (62.5% vs 14.8%; p = 0.001).

CONCLUSION

Radiological examinations had a low diagnostic yield in evaluation of pain in subjects with longstanding/reoccurring CWP. These subjects had on the other hand more often positive findings when examined on other indications than pain. This may indicate that subjects with longstanding/reoccurring CWP are more prone to other diseases. It is a challenge for caregivers, often primary care physicians, to use radiological examinations to the best for their patients.

Les manipulations vertébrales : enquête concernant la pratique des médecins formés dans le cadre du diplôme inter-universitaire de Strasbourg

INTRODUCTION

The use of spinal manipulation (SM) is widespread, particularly in English-speaking countries, where many studies are published showing its popularity. However, no study exists of the demography and activity of the French medical profession. Our objective was to investigate the use of SM by French doctors in their daily practice.

MATERIALS AND METHODS

We questioned 234 doctors, general practitioners and specialists who obtained the Inter-Academy of Manual Medicine and Osteopathy Diploma from Strasbourg University between 1985 and 2002.

RESULTS

We obtained a response from 140 physicians: 110 (79%) practiced SM in their daily practice. They considered the technique efficient and used it as a first intention. Approximately one quarter of cases resulted in adverse effects on the back. Most of the doctors (77%) continued their education during their career.

CONCLUSION

This first assessment of the practice of physicians trained in a university in manual medicine allows for confirming the respect of good medical practice with regular actualization of knowledge and reasonable outpatient care.

What diagnostic tests are useful for low back pain?

Low back pain (LBP) is a common problem that poses some interesting and difficult diagnostic problems. It is typically benign and self-limited, but it is occasionally the presenting symptom of serious systemic disease. The general diagnostic approach to low back pain is to check for 'red flags' in the history and physical that suggest the presence of malignancy, infection or spondyloarthridites, and for neurological compromise that could indicate that surgery is required (cauda equina syndrome) or may be beneficial (such as herniated discs or spinal stenosis that have not improved with conservative care). In the absence of these features, imaging is of limited value. Recent research has begun to evaluate subgroups with 'non-specific' low back pain that seem to benefit from specific interventions such as median branch or sacroiliac joint injections, manipulation, or specific exercises, but these require further investigation and validation.

[Feasibilities and bounds of diagnostic radiology in case of back pain]

Chronic monotone back pain is no pressing indication for radiographic procedures, but chronic progressive or symptomatic back pain should be investigated by radiographic means. Beneath conventional radiology and computed tomography (CT) magnetic resonance imaging (MRI) has become a more method of standard in these cases. The radiographic investigation of back pain is shown in cases of discal and vertebral degeneration and spondylitis. Typical signs and differential diagnosis are demonstrated. After demonstration of radiological means. After introduction and valuation of radiological means, as conventional radiography, CT, MRI, myelography and scintigraphy, it is entered into degenerative changes and degenerative diseases of vertebra endplates and vertebra bodies as a reason of pain. Reasons of spinal stenosis are discussed. In case of inflammatory changes, bacterial inflammation of vertebrae and intervertebral joints are represented. Changes of spondylodiscitis/spondylitis are opposed to inflammatory changes of Morbus Bechterew and Morbus Scheuermann.

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.

When should the doctor order a spine X-ray? Identifying vertebral fractures for osteoporosis care: results from the European Prospective Osteoporosis Study (EPOS)

Vertebral fractures are common but usually remain unrecognized in primary care. Data from 2908 women and 2653 men in the EPOS study were used to derive algorithms to indicate the need for a spine X-ray to identify a fracture using easily elicited determinants. At a sensitivity of 50% for identifying cases, the specificity was increased from 50% to 78% in women and from 50% to 72% in men compared with a random allocation of X-rays. Use of X-rays can be optimized by selecting patients at high risk using a short screening procedure.

INTRODUCTION

Previous osteoporotic fracture is an independent risk factor for further fractures and an indication for treatment. Vertebral fractures are the most common osteoporotic fractures before age 75, accounting for 48% of all fractures in men and 39% in women over 50. They usually remain unrecognized, so many patients requiring treatment are denied it, doubling their risk of a further fracture. Our objective was to develop an efficient algorithm indicating the need for an X-ray.

MATERIALS AND METHODS

Data from 2908 women and 2653 men >or=50 years of age in the European Prospective Osteoporosis Study (EPOS) were analyzed. Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. Prevalent fractures were qualitatively diagnosed by an experienced radiologist. Fracture risk was modeled as a function of age, statural height loss since age 25, gender, and fracture history including limb fractures in the last 3 years using negative binomial regression. Receiver operating characteristic (ROC) curves were used to summarize a model's predictive ability, and a prediction algorithm was devised to identify those most likely to have a fracture.

RESULTS

In a multivariate model for women, the risk of prevalent vertebral fracture significantly increased with age (RR, 1.67 [95% CI, 1.46, 1.93] per decade), statural height loss (1.06, [1.03, 1.10] per centimeter decrease), self-reported history of spine fracture (7.52 [5.52, 10.23]), and history of other major fracture (1.83 [1.46, 2.28]). Higher body weight reduced risk (0.86 [0.79, 0.95] per 10-kg increase). In men, the respective RR estimates were as follows: age (1.32 [1.18, 1.49]); height loss (1.06 [1.04, 1.09]); self-reported spine fracture (5.05 [3.69, 6.90]); other major fracture (1.42 [1.12, 1.81]); and weight (0.86 [0.79, 0.94]). Using algorithms based on these easily elicited determinants, specificity was increased from 50% to 78% in women and from 50% to 72% in men at a sensitivity of 50% compared with a random allocation of X-rays. At a sensitivity of 75%, the specificity was 50% in women and 40% in men. Inclusion of hip BMD (femoral neck or trochanter), measured in 1360 women and 1046 men, significantly improved the area under the ROC curves by 4% in women (p < 0.002) but not in men (p > 0.350). Spine BMD, measured in 982 women and 847 men, produced a significant 5% AUC improvement in women (p = 0.007) but not in men (p = 0.554).

CONCLUSION

A woman 65 years of age with one vertebral fracture has a one in four chance of another fracture over 5 years, which can be reduced to one in eight by treatment. Positive treatment decisions are often contingent on identifying a vertebral fracture. Selective use of lateral vertebral X-rays can be optimized using a 2-minute screening procedure administered by a nurse.

Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies

STUDY DESIGN

A systematic review of qualitative and quantitative studies.

OBJECTIVES

To summarize evidence from studies among patients with low back pain on their expectations and satisfaction with treatment as part of practice guideline development.

SUMMARY OF BACKGROUND DATA

Patients are often dissatisfied with treatment for acute or chronic back pain.

METHODS

We searched the literature for studies on patient expectations and satisfaction with treatment for low back pain. Treatment aspects related to expectations or satisfaction were identified in qualitative studies. Percentages of dissatisfied patients were calculated from quantitative studies.

RESULTS

Twelve qualitative and eight quantitative studies were found. Qualitative studies revealed the following aspects that patient expectation from treatment for back pain or with which they are dissatisfied. Patients want a clear diagnosis of the cause of their pain, information and instructions, pain relief, and a physical examination. Next, expectations are that there are more diagnostic tests, other therapy or referrals to specialists, and sickness certification. They expect confirmation from the healthcare provider that their pain is real. Like other patients, they want a confidence-based association that includes understanding, listening, respect, and being included in decision-making. The results from qualitative studies are confirmed by quantitative studies.

CONCLUSIONS

Patients have explicit expectations on diagnosis, instructions, and interpersonal management. New strategies need to be developed in order to meet patients' expectations better. Practice guidelines should pay more attention to the best way of discussing the causes and diagnosis with the patient and should involve them in the decision-making process.

Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial

PURPOSE

To establish whether early use of magnetic resonance (MR) imaging or computed tomography (CT) influences treatment and outcome of patients with low back pain (LBP) and whether it is cost-effective.

MATERIALS AND METHODS

In a multicenter randomized study, two imaging policies for LBP were compared in 782 participants with symptomatic lumbar spine disorders who were referred to orthopedists or neurosurgeons. Participants were randomly allocated to early (393 participants; mean age, 43.9 years; range, 16-82 years) or delayed selective (389 participants; mean age, 42.8 years; range, 14-82 years) imaging groups. Delayed selective imaging referred to imaging restricted to patients in whom a clear clinical need subsequently developed. Main outcome measures were Aberdeen Low Back Pain (ALBP) score, Short Form 36 (SF-36) score (for multidimensional health status), EuroQol (EQ-5D) score (for quality-adjusted life-year [QALY] estimates), and healthcare resource use at 8 and 24 months after randomization. Data were evaluated with analysis of covariance, ordinal logistic regression analysis, and chi(2) and Mann-Whitney tests.

RESULTS

Both groups showed improvement in ALBP score, but this was greater in the early group (adjusted mean difference between groups, -3.05 points [95% CI: -5.16, -0.95; P =.005] and -3.62 points [95% CI: -5.92, -1.32; P =.002] at 8 and 24 months, respectively). Scores for SF-36 (bodily pain domain) and EQ-5D were also significantly better at 24 months. Clinical treatment was similar in both groups. Differences in total costs reflected cost of imaging. Imaging provided an adjusted mean additional QALY of 0.041 during 24 months at a mean incremental cost per QALY of $2,124.

CONCLUSION

Early use of imaging does not appear to affect treatment overall. Decisions about the use of imaging depend on judgments concerning whether the small observed improvement in outcome justifies additional cost.

Post-traumatic stress associated with low self-rated well-being in primary care attenders

In this study, we assessed the prevalence of self-rated post-traumatic stress in relation to reported trauma in an unselected primary care population. A total of 1,113 out of 1,378 consecutive attenders (response rate 81%) to 10 health centres completed the self-report instruments Impact of Event Scale (IES), and Post Traumatic Symptom Scale (PTSS-10). A horizontal visual analogue scale (VAS; 0-100 mm) resembling the EuroQoL (quality of life) health barometer was used for evaluating well-being. Trauma was reported by 325 attenders (29.2%) when applying DSM-IV trauma criteria. Prevalence of possible post-traumatic stress disorder (PTSD) was 6.5% (n=72) using cut-off scores of >35 for IES and >5 for PTSS-10. The two most common traumas in the PTSD group were accidents (2.0%, n=22), followed by cancer (1.3%, n=15). When excluding diseases and unspecified death as trauma, the rate of possible PTSD was 3.5% (n=39). Mean VAS-QoL score was 39.6 mm in the PTSD group (n=72), and 64.7 mm in the non-PTSD group with a reported trauma (n=253). In a multiple logistic regression analysis low self-rated well-being showed the strongest association with possible PTSD, followed by sexual assault, female gender, immigrant status and less than 2 years since trauma.

Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain

STUDY DESIGN

Fifty-two practices in the East Midlands, United Kingdom, were included.

OBJECTIVES

To test the hypothesis that referral for lumbar spine radiography is cost-effective in primary care patients with low back pain of at least 6 weeks' duration compared with usual care in which referral is not routine.

SUMMARY OF BACKGROUND DATA

Lumbar spine radiography is commonly used in the management of low back pain, although the yield of findings that alter clinical management is low. Evidence is needed on the cost-effectiveness of lumbar spine radiographs in patients with low back pain.

METHODS

A prospective economic analysis alongside a randomized controlled trial was used. Outcomes included the Roland disability score, pain, health status scale, EuroQol, satisfaction, direct health care costs (primary, secondary, and community care; prescribed and over-the-counter medicines; special equipment), and indirect costs (informal care, extra expenses, welfare benefits, loss of earnings and productivity). RESULTS A total of 210 participants were randomly assigned to lumbar spine radiography, and 211, to usual care. At 9 months' postrandomization, no difference between the groups was found in any health outcomes other than satisfaction. The intervention group had a higher overall satisfaction score (21 19, < 0.01). The intervention group had higher direct costs (150 pounds sterling vs 109 pounds sterling, < 0.01). Cost-effectiveness analysis shows that patient satisfaction can be increased using lumbar radiography but at an additional cost (point estimate 20 pounds sterling per point on satisfaction scale). The simulated distribution based on trial data shows that only when a 1-point increase in satisfaction is valued at more than 50 pounds sterling can it be claimed that radiography is cost-effective in these terms (incremental net monetary benefit mean = 116 pounds sterling, 95% CI pound 7, 225 pounds sterling).

CONCLUSIONS

Radiography is likely to be cost-effective only when satisfaction is valued relatively highly. Strategies to enhance satisfaction for patients with low back pain without using lumbar radiography should be pursued.