Red flags to screen for vertebral fracture in patients presenting with low-back pain

Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment

BACKGROUND

Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms.

AIM

This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting.

METHOD

This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome.

RESULTS

Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP.

CONCLUSION

GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

Red flags to screen for vertebral fracture in people presenting with low back pain

BACKGROUND

Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.

OBJECTIVES

To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.

SELECTION CRITERIA

We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.

MAIN RESULTS

This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).

AUTHORS' CONCLUSIONS

The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

Physical therapy students' application of an imaging decision rule for acute knee pain

BACKGROUND

Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students.

OBJECTIVE

The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy.

METHODS

An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool.

RESULTS

Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

Screening for Referral of Serious Pathology by Physical Examination Tests in Patients with Back or Chest Pain: A Systematic Review

OBJECTIVE

To investigate the most common physical examination tests (PET) for the screening for referral of patients with back or chest pain caused by serious pathology.

METHODS

A systematic review was conducted. Searches were performed on seven electronic databases between June 2020 and December 2021. Only studies evaluating patients with back and/or chest pain with clear reporting of PETs and prompt patient referrals were included.

RESULTS

316 full texts were included, and these studies had a total of 474/492 patients affected by a serious disease. Only 26 studies of them described suspicion of serious disease due to at least one positive PET. Cardiac/pulmonary auscultation and heartbeats/blood pressure measurements were the most frequently reported tests. None of the reported studies included physiotherapists and chiropractors who reported the use of various tests, such as: cardiac and pulmonary auscultation, lung percussion, costovertebral angle tenderness, and lymph node palpation, highlighting a lack of attention in measuring vital parameters. On the contrary, doctors and nurses reported the assessment of the range of motion of the thoracolumbar spine and hip less frequently.

CONCLUSIONS

Appropriate reporting of PETs is sparse, and their utilization is heterogeneous among different healthcare professionals. Further primary studies are needed to describe PETs results in patients suffering from back and/or chest pain.

[Noninvasive Treatments for Acute and Chronic Back Pain]

Noninvasive Treatments for Acute and Chronic Back Pain Abstract. The therapy of back pain - especially the medication with opioids - can be challenging for the treating physician. Specific back pain can often be diagnosed by imaging and successfully treated by surgery or medication. In contrast, nonspecific back pain can be worsened by inappropriate imaging, questionable surgical indications and uncontrolled drug use. For the therapy of nonspecific back pain, maintaining daily activity and exercise therapy is central. Opioids are effective drugs for short-term use. However, long-term use often leads to opioid-induced hyperalgesia and hormonal dysfunction with decreased quality of life and libido. Furthermore, opioids can lead to abuse and addiction. After an ineffective treatment with non-opioids, opioids may be given for a limited time period (if possible shorter than four weeks) according to international guidelines.

The Symmetry of Lower Back Pain as a Potential Screening Factor for Serious Pathology: A Survey Study

Background: Pain maps provide reliable information on pain location in various conditions. This study explored the feasibility of pain maps as a screening tools for serious underlying conditions. The pain symmetry was evaluated as the possible distinguishing feature. Methods: A Web-based survey on the correlation of pain-related disability and pain pattern was developed. Respondents with lower back pain were asked to mark the exact location of their pain over the pain chart. The symmetry index was calculated and used to divide subjects into two groups that were then compared in terms of the prevalence of red flags for serious pathologies, as well as the pain-related disability measured with COMI and ODI instruments. Results: Of the 4213 respondents who completed the survey, 1018 were included in the study. The pain related disability was greater in respondents with asymmetrical pain patterns, as shown with all instruments. The distribution of red flags was also dependent on pain symmetry. The history of weight loss (6.70 vs. 1.76 p < 0.001) and fever (4.91 vs. 2.14 p < 0.001) were more prevalent with symmetrical pain patterns, and the history of trauma was more frequent with asymmetrical pain (21.41 vs. 10.71 p < 0.001). Conclusions: It was shown that the symmetry of pain is correlated to the prevalence of red flags and pain-related disability.

Knowledge and management of low back pain as running-related injuries among Italian physical therapists: findings from a national survey

OBJECTIVES

To investigate the beliefs, knowledge, attitudes, behavior, and the clinical management procedures of the Italian physical therapists specialized in orthopedic manipulative physical therapy (OMPT) toward running and its correlation with low back pain (LBP).Design: A cross-sectional online survey was conducted in 2019, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.Setting: Italy.Participants: One thousand two hundred and eighteen Italian OMPTs.

METHODS

Survey Monkey software was used to administer the survey. The questionnaire was self-reported and included 26 questions. Descriptive statistics were used and related to the effective respondents for each question.

RESULTS

One thousand two hundred and eighteen questionnaires (60.9%) were included in the analysis. A considerable cohort of OMPTs working in private practice clinical settings (n = 845; 69.4%; 95% CI 66.7-71.9) has indicated running not to be a relevant risk factor for the onset of LBP (n = 806; 66.2%; 95% CI 63.4-68.8). Moreover, most of the participants (n = 679; 55.7%; 95% CI 52.9-58.5) adopted a combination of manual therapy techniques and therapeutic exercise for the management of runners with LBP.

CONCLUSIONS

Widespread knowledge of clinical and theoretical management of LBP in runners-patients has emerged among Italian OMPTs. The OMPTs' academic background agrees with the recent literature and therefore highlights the paucity of studies related to LBP as running-related injuries.

Radiophobic Fear-Mongering, Misappropriation of Medical References and Dismissing Relevant Data Forms the False Stance for Advocating Against the Use of Routine and Repeat Radiography in Chiropractic and Manual Therapy

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as "there is no evidence" for biomechanical spine assessment by X-ray, "there are no guidelines" supporting routine imaging, and also promulgate the reiterating narrative that "X-rays are dangerous." These arguments come in the form of recycled allopathic "red flag only" medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient's progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

Prevalence and incidence of low back pain among runners: a systematic review

Background

Running is one of the most popular sports worldwide. Despite low back pain (LBP) represents the most common musculoskeletal disorder in population and in sports, there is currently sparse evidence about prevalence, incidence and risk factors for LBP among runners. The aims of this systematic review were to investigate among runners: prevalence and incidence of LBP and specific risk factors for the onset of LBP.

Methods

A systematic review has been conducted according to the guidelines of the PRISMA statement. The research was conducted in the following databases from their inception to 31st of July 2019: PubMed; CINAHL; Google Scholar; Ovid; PsycINFO; PSYNDEX; Embase; SPORTDiscus; Scientific Electronic Library Online; Cochrane Library and Web of Science. The checklists of The Joanna Briggs Institute Critical Appraisal tools were used to investigate the risk of bias of the included studies.

Results

Nineteen studies were included and the interrater agreement for full-text selection was good (K = 0.78; 0.61–0.80 IC 95%). Overall, low values of prevalence (0.7–20.2%) and incidence (0.3–22%) of LBP among runners were reported. Most reported risk factors were: running for more than 6 years; body mass index > 24; higher physical height; not performing traditional aerobics activity weekly; restricted range of motion of hip flexion; difference between leg-length; poor hamstrings and back flexibility.

Conclusions: Prevalence and incidence of LBP among runners are low compared to the others running related injuries and to general, or specific population of athletes. View the low level of incidence and prevalence of LBP, running could be interpreted as a protective factor against the onset of LBP.

Systematic review registration

PROSPERO CRD42018102001.

[Nonspecific low back pain and chronification]

Low back pain is the leading cause of incapacitation and medical rehabilitation. The purpose of this German National Health Care Guideline "Nonspecific low back pain" is to optimize the care of patients with low back pain. This guideline was drawn up by 29 professional societies and organizations. In the case of nonspecific low back pain, a detailed medical history and physical examination should be carried out first, but no further diagnostics unless there are indications of the so-called "red flags". For symptomatic treatment, medicine should be given in low doses, and physical activity should be in the foreground. A physician should act as a point of contact throughout the course of the disease, and the patient must be continuously educated and motivated to have a healthy lifestyle, including regular physical activity.

A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data

BACKGROUND

The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder.

METHODS

The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS.

RESULTS

The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed.

CONCLUSIONS

The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.

Importance of screening in physical therapy: vertebral fracture of thoracolumbar junction in a recreational runner

Running is one of the most popular sports worldwide. Studies suggest that 11%-85% of recreational runners have at least one running-related injury (RRI) each year, resulting in a reduction or interruption in training. A high risk for running-related injuries (RRIs) represents an important inconvenience counterbalancing the beneficial effects of running. RRIs primarily affect the joints of the lower limb and lumbar spine. Noteworthy, in some cases, the clinical presentation of signs and symptoms is confusing and may hide serious conditions; thus, clinicians have to pay special attention when potential factors arise, such as the presence of red flags. As reported in this case report, patients can present with low back pain (LBP) as a primary problem, mimicking a red flag such as a fracture of the spine. The aim of this case report was to describe a case of a recreational runner presenting with LBP as the sole symptom of an underlying thoracolumbar fracture.

Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol

BACKGROUND

Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available.

METHODS

This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users.

DISCUSSION

Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.

Evaluation of guideline-endorsed red flags to screen for fracture in patients presenting with low back pain

OBJECTIVES

(1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including the National Guideline Clearinghouse and Canadian Medical Association Infobase.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Evidence-based clinical practice guidelines.

DATA EXTRACTION

Two review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.

RESULTS

78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.

SUMMARY/CONCLUSION

The number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.

Effectiveness of implementing a best practice primary healthcare model for low back pain (BetterBack) compared with current routine care in the Swedish context: an internal pilot study informed protocol for an effectiveness-implementation hybrid type 2 trial

INTRODUCTION

Low back pain (LBP) is a major health problem commonly requiring healthcare. In Sweden, there is a call from healthcare practitioners (HCPs) for the development, implementation and evaluation of a best practice primary healthcare model for LBP.

AIMS

(1) To improve and understand the mechanisms underlying changes in HCP confidence, attitudes and beliefs for providing best practice coherent primary healthcare for patients with LBP; (2) to improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and quality of life in patients with LBP; and (3) to evaluate a multifaceted and sustained implementation strategy and the cost-effectiveness of the BetterBack☺ model of care (MOC) for LBP from the perspective of the Swedish primary healthcare context.

METHODS

This study is an effectiveness-implementation hybrid type 2 trial testing the hypothesised superiority of the BetterBack☺ MOC compared with current routine care. The trial involves simultaneous testing of MOC effects at the HCP, patient and implementation process levels. This involves a prospective cohort study investigating implementation at the HCP level and a patient-blinded, pragmatic, cluster, randomised controlled trial with longitudinal follow-up at 3, 6 and 12 months post baseline for effectiveness at the patient level. A parallel process and economic analysis from a healthcare sector perspective will also be performed. Patients will be allocated to routine care (control group) or the BetterBack☺ MOC (intervention group) according to a stepped cluster dogleg structure with two assessments in routine care. Experimental conditions will be compared and causal mediation analysis investigated. Qualitative HCP and patient experiences of the BetterBack☺ MOC will also be investigated.

DISSEMINATION

The findings will be published in peer-reviewed journals and presented at national and international conferences. Further national dissemination and implementation in Sweden and associated national quality register data collection are potential future developments of the project.

DATE AND VERSION IDENTIFIER

13 December 2017, protocol version 3.

TRIAL REGISTRATION NUMBER

NCT03147300; Pre-results.

The screening process of a patient with low back pain and suspected thoracic myelopathy: a case report

Background

Thoracic disc herniations are rare and difficult to diagnose. Myelopathy is a potential consequence that can lead to irreversible neurological impairment if not treated appropriately. It is incumbent on all clinicians who see patients with low back pain (LBP) to be aware of such pathologies. This case describes a screening process in the detection of a rare serious spinal pathology and discusses the use of red flags and central nervous system signs and symptoms in the decision leading to immediate referral.

Case Description

The subject in this case was a 69-year-old male referred to physical therapy for the treatment of LBP after having seen two medical doctors. He presented with severe spinal pain with gait disturbance, postural balance deficits and bilateral loss of plantar flexor strength. Decreased sensation in the buttocks and a subtle episode of urinary incontinence were also present.

Outcomes

Based on the results of the history and physical examination, the patient was referred back to his medical practitioner, who ordered magnetic resonance imaging. A thoracic disc herniation associated with spondyloarthritis at T10-11 causing myelopathy was detected, and the patient underwent immediate decompressive surgery. One month following initial evaluation, the patient had completely recovered without any neurological compromise.

Discussion

This case highlights the importance of the screening of serious pathologies and the assessment of central nervous impairments in certain cases of LBP. The integration of a cluster of subjective and physical examination findings led to the prompt referral of this patient for urgent medical attention.

Level of Evidence

4.

Acute Lumbar Back Pain

BACKGROUND

Back pain has many causes. In Germany, about 70% of adults have at least one episode of back pain per year.

METHODS

This review is based on a selective literature search and on the German National Disease Management Guideline for Low Back Pain.

RESULTS

The physician taking the history from a patient with back pain should ask about the nature, onset, course, localization, and radiation of the pain and its dependence on physical activity and/or emotional stress. In the differential diagnosis, neurologic deficits and any "red flags" suggesting dangerous conditions such as spinal fracture, bacterial infection, and tumors must be ruled out. If no specific cause of the pain can be identified, no imaging studies are indicated on initial presentation. The treatment of acute, nonspecific low back pain focuses on pain relief and functional improvement. Adequate patient education and counseling are essential. Exercise therapy is no more effective than the continuation of normal daily activities. Restriction of activity, including bed rest, is of no benefit and merely prolongs recovery and the resumption of normal activity. Further diagnostic testing is indicated if there is any suspicion of a fracture, infection, or tumor.

CONCLUSION

After dangerous conditions have been ruled out, low back pain can be pragmatically classified as either nonspecific or specific. More research is needed so that the diagnostic assessment and individualized treatment of acute lower back pain can be further refined.

Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With Low Back Pain

OBJECTIVE

The aim of this study was to describe the process by which a group of subject matter experts in the area of return to work developed a resource tool to provide clinical decision support (CDS) for primary care clinicians.

METHODS

A common musculoskeletal disorder, low back pain (LBP), was selected, pertinent literature reviewed, and specific recommendations for action in the clinical setting developed.

RESULTS

Primary care practitioners (PCPs) are routinely expected to create work activity prescriptions. The knowledge base for a CDS tool that could be embedded in electronic health records has been developed.

CONCLUSION

Improved clinical support should help prevent and manage work limitations associated with LBP not caused by work. The proposed decision support should reduce administrative burden and stimulate PCPs to explore the role of occupation and its demands on patients.

Red flag screening for low back pain: nothing to see here, move along: a narrative review

Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Background

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

Methods

A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

Results

Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

Conclusions

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1549-6) contains supplementary material, which is available to authorized users.

Diagnostic triage for low back pain: a practical approach for primary care

Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP - informed by a focused history and clinical examination - is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral. The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (< 1% of cases), radicular syndrome (∼ 5-10% of cases) or non-specific LBP (NSLBP), which represents 90-95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis. Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category. A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care. Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.

PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol

BACKGROUND

Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes.

METHODS

This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index.

DISCUSSION

The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery.

TRIAL REGISTRATION

ClinicalTrials.gov reference: NCT02454400 (Trial registration date: August 31st 2015) and has been registered on ClinicalTrials.gov, identifier: NCT02454400 .

Evidence base and future research directions in the management of low back pain

Low back pain (LBP) is a prevalent and costly condition. Awareness of valid and reliable patient history taking, physical examination and clinical testing is important for diagnostic accuracy. Stratified care which targets treatment to patient subgroups based on key characteristics is reliant upon accurate diagnostics. Models of stratified care that can potentially improve treatment effects include prognostic risk profiling for persistent LBP, likely response to specific treatment based on clinical prediction models or suspected underlying causal mechanisms. The focus of this editorial is to highlight current research status and future directions for LBP diagnostics and stratified care.

Acute Back Pain: A Survey of Primary Health Care Physicians' Awareness and Knowledge of "Red Flag" Signs

Background:

The failure to detect “red flag” signs in patients presenting with acute low back pain can adversely affect the outcome of management. This can seriously affect the quality of life and productivity of the patient.

Objective:

The present questionnaire-based study was performed to assess the knowledge and awareness of red flag signs among primary health care physicians managing patients with acute back pain in Riyadh, Saudi Arabia.

Materials and Methods:

The study sample size was comprised of 80 subjects. The level of knowledge was assessed by means of a new structured self-administered questionnaire. The design of this questionnaire was based on the Agency for Health Care Research and Policy (AHCRP) guidelines for detection of red flag signs. Physicians were asked about red flag signs that indicate the presence of tumor, infection, spinal fracture, or cauda equina syndrome.

Results:

Sixty-eight (85% of total) physicians were aware of red flag signs. Of the 68 physicians who were aware of the red flag signs, 58 (72%) were aware of neurological deficit, 36 (45% of total) were aware of extremes of age (<10 years and >50 years), and 33 (41% of total) were aware of and routinely inquired about the history of spinal trauma, whereas only 24 (30% of total) were aware of and inquired about constitutional symptoms in their patients with acute back pain.

Conclusion:

Although low back pain is extremely common, knowledge and awareness of red flag signs of primary health care physicians managing patients with acute back pain in Riyadh appear to be inadequate. This indicates a lack of adherence to the international guidelines. Specific educational programs should target these deficiencies and increase awareness.

Imaging during low back pain ED visits: a claims-based descriptive analysis

OBJECTIVE

Low back pain (LBP) is a common reason for emergency department (ED) visits. This study aimed to determine the frequency and type of nonindicated imaging during LBP ED visits and to describe demographic and prior health care use characteristics among the nonindicated population.

METHODS

This study included index ED events for LBP occurring during 2011 through 2012 for Blue Cross Blue Shield of Michigan commercial members ages 18 to 64 years. We identified LBP imaging indications within 12 months before the index event. Frequency estimates of patient demographics, imaging prevalence, type of imaging, and prior health care use characteristics stratified by imaging and indication status are presented with 95% confidence intervals (CIs).

RESULTS

Of the 14838 total events, 51.9% (95% CI, 51.1%-52.7%) did not have indications for imaging. Patients without imaging indications were less likely to have had ED visits, hospital stays, LBP, lower back imaging, primary care physician visits, and back-related specialist visits in the past year compared with patients with indications. Among nonindicated patients, 30.1% (95% CI, 29.1%-31.1%) received imaging; of these, 26.2% received advanced imaging (computed tomography or magnetic resonance imaging). Nonindicated patients who received imaging were slightly older than those who did not receive imaging (27.6% [95% CI, 25.8%-29.4%] were ages 55-64 years vs 20.6% [95% CI, 19.6%-21.7%]) and had a higher prevalence of observation/treatment room use (7.3% [95% CI, 6.2%-8.4%] vs 1.2% [95% CI, 0.9%-1.4%]).

CONCLUSIONS

Our results suggest that a substantial proportion of the patient population presenting to the ED for LBP receives nonindicated imaging, revealing opportunities to reduce costs and radiation exposure.

The etiologies of low back pain in patients with lumbar disk herniation

BACKGROUND

Low back pain (LBP) is a common complaint in population that lowers the quality of life. The main etiology of LBP is recognized in about 20% of patients while it is attributed to lumbar disk herniation (LDH) in 80% of cases and causes some unnecessary lumbar surgeries without realizing the definite cause.

OBJECTIVES

This study was planned to evaluate the etiologies of LBP in patients who had LDH to clarify whether the disc herniation is the main cause of patients` pain or other diseases were responsible for this kind of pain.

MATERIALS AND METHODS

In this cross-sectional study, we analyzed the medical profiles of the patients with proven LDH in a private clinic in Mashhad City, Iran, between 2005 and 2012, for demographic and the etiologies of LBP with clinical and paraclinical studies. We also calculated the incidence of each etiology by SPSS 13.

RESULTS

In our study, among 1250 patients with proven LDH by MRI, 500 patients (40%) had chronic LBP and the most common causes of LBP were heavy constant working (40.2%), osteoporosis (35.6%), and sacroiliac joint pain (34.6%), consecutively. Interestingly, LDH had the ninth rank among the common cause of LBP.

CONCLUSIONS

In this study, we found that in spite of previous beliefs, discopathies were not common etiologies of LBP. Thus, even in patients with proven LDH by imaging studies, the physician should perform a thorough evaluation for other causes of LBP to avoid unnecessary lumbar surgeries.

The Nijmegen decision tool for chronic low back pain. Development of a clinical decision tool for secondary or tertiary spine care specialists

BACKGROUND

In Western Europe, low back pain has the greatest burden of all diseases. When back pain persists, different medical specialists are involved and a lack of consensus exists among these specialists for medical decision-making in Chronic Low Back Pain (CLBP).

OBJECTIVE

To develop a decision tool for secondary or tertiary spine care specialists to decide which patients with CLBP should be seen by a spine surgeon or by other non-surgical medical specialists.

METHODS

A Delphi study was performed to identify indicators predicting the outcome of interventions. In the preparatory stage evidence from international guidelines and literature were summarized. Eligible studies were reviews and longitudinal studies. Inclusion criteria: surgical or non-surgical interventions and persistence of complaints, CLBP-patients aged 18-65 years, reported baseline measures of predictive indicators, and one or more reported outcomes had to assess functional status, quality of life, pain intensity, employment status or a composite score. Subsequently, a three-round Delphi procedure, to reach consensus on candidate indicators, was performed among a multidisciplinary panel of 29 CLBP-professionals (>five years CLBP-experience). The pre-set threshold for general agreement was ≥70%. The final indicator set was used to develop a clinical decision tool.

RESULTS

A draft list with 53 candidate indicators (38 with conclusive evidence and 15 with inconclusive evidence) was included for the Delphi study. Consensus was reached to include 47 indicators. A first version of the decision tool was developed, consisting of a web-based screening questionnaire and a provisional decision algorithm.

CONCLUSIONS

This is the first clinical decision tool based on current scientific evidence and formal multidisciplinary consensus that helps referring the patient for consultation to a spine surgeon or a non-surgical spine care specialist. We expect that this tool considerably helps in clinical decision-making spine care, thereby improving efficient use of scarce sources and the outcomes of spinal interventions.

Analysis of non-traumatic truncal back pain in patients who visited an emergency room

AIM

To investigate epidemiology of acute non-traumatic back pain using modern diagnostic methods in patients who visited an emergency room.

METHODS

The medical charts were retrospectively reviewed for all patients with back pain who were treated in our hospital. In addition, the patients were divided into two groups based on whether they were treated at the hospital or as outpatients.

RESULTS

There were 95 patients with non-traumatic acute back pain. Leading cause of back pain was ureterolithiasis (53 cases), followed by pyelonephritis (10), orthopedic disease including two cases of purulent spondylitis (24), aortic disease (3), pancreatitis (1), renal bleeding (1), adrenal bleeding (1), psoas abscess (1), and torsion of an ovarian tumor (1). All cases of pyelonephritis, aortic disease, purulent spondylitis, renal bleeding, adrenal bleeding, psoas abscess, and torsion of an ovarian tumor were treated in admission. Using a multiple logistic regression analysis, blood pressure, age, and body temperature were the only factors that were independently associated with whether the patient was admitted or treated as an outpatient.

CONCLUSION

This study showed that urological diseases are the most common cause of back pain in patients who visit the emergency room, followed by orthopedic disease. Older age, low blood pressure, and high body temperature were independently associated with the decision to admit the patient who might have lethal disease.

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

OBJECTIVE

To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

DESIGN

Systematic review.

DATA SOURCES

Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

INCLUSION CRITERIA

Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

REVIEW METHODS

Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

RESULTS

We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

CONCLUSIONS

While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

Multi-functionality of computer-aided quantitative vertebral fracture morphometry analyses

Osteoporotic vertebral fractures are an increasingly active area of research. Oftentimes assessments are performed by software-assisted quantitative morphometry. Here, we will discuss multi-functionality of these data for research purposes. A team of trained research assistants processed lateral spine radiographs from the population-based Rotterdam Study with SpineAnalyzer(®) software (Optasia Medical Ltd, Cheadle, UK). Next, the raw coordinate data of the two upper corners of Th5 and the two lower corners of Th12 were extracted to calculate the Cobb's kyphosis angle. In addition, two readers performed independent manual measurements of the Cobb's kyphosis angle between Th5 and Th12 for a sample (n=99). The mean kyphosis angle and its standard deviation were 53° and 10° for the SpineAnalyzer(®) software measurements and 54° and 12° by manual measurements, respectively. The Pearson's correlation coefficient was 0.65 [95% confidence interval (CI): 0.53-0.75; P=2×10(-13)]. There was a substantial intraclass correlation with a coefficient of 0.64 (95% CI: 0.51-0.74). The mean difference between methods was 1° (95% CI: -2°-4°), with 95% limits of agreement of -20°-17° and there were no systematic biases. In conclusion, vertebral fracture morphometry data can be used to derive the Cobb's kyphosis angle. Even more quantitative measures could be derived from the raw data, such as vertebral wedging, intervertebral disc space, spondylolisthesis and the lordosis angle. These measures may be of interest for research into musculoskeletal disorders such as osteoporosis, degenerative disease or Scheuermann's disease. Large-scale studies may benefit from efficient capture of multiple quantitative measures in the spine.