Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study

Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics

BACKGROUND

The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations.

OBJECTIVE

To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity.

METHODS

A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models.

RESULTS

The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%.

CONCLUSIONS

The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.

Disc Degeneration in Lumbar Spine of Asymptomatic Young Adults: A Descriptive Cross-Sectional Study

Objective

This descriptive cross-sectional observational study aimed to investigate the prevalence of various types of disc degeneration in the lumbar spine of asymptomatic young adults. The disc degeneration of lumbar spine could be due to age-related physiological changes than to pathological changes in asymptomatic people. Due to the ethnic and racial differences in lifestyle, it is proposed that the prevalence of disc degeneration in the normal population in different region of the world would differ. There are scarce data on the Indian population on the same.

Methods

Fifty individuals between 15 and 30 years of age, with no history of low back pain undergoing MR imaging for spinal pathology other than the lumbar spine, were included in the study. Various abnormalities (herniation HN, annular fissure AF, nuclear degeneration ND) were recorded and their prevalence was calculated by disc counts (DC) and person count (PC). DC is the number of discs with degeneration and PC is the number of patients with disc degeneration.

Results

56% asymptomatic individuals were found to have either HN or AF or ND at one or more levels. The DC of disc degeneration was 20.8% and it was most commonly observed in L4-L5 intervertebral disc (38%) followed by L5-S1 disc (30%). Thirteen individuals had disc degeneration at single level, 12 at two levels and 3 individuals at all the five lumbar intervertebral disc levels.

Conclusion

The current study showed a high prevalence of disc degeneration (either HN, AF or ND) in young asymptomatic individuals. Even if the MRI shows disc degeneration, patients can be asymptomatic and one needs to correlate the symptoms with the MRI. The limitations of the current study are small numbers of patients from a localized geographical area; hence, we recommend a larger multi-centric study as a follow-up.

Can EQ-5D-3L utility values of low back pain patients be validly predicted by the Oswestry Disability Index for use in cost-effectiveness analyses?

Purpose

To assess whether regression modeling can be used to predict EQ-5D-3L utility values from the Oswestry Disability Index (ODI) in low back pain (LBP) patients for use in cost-effectiveness analysis.

Methods

EQ-5D-3L utility values of LBP patients were estimated using their ODI scores as independent variables using regression analyses, while adjusting for case-mix variables. Six different models were estimated: (1) Ordinary Least Squares (OLS) regression, with total ODI score, (2) OLS, with ODI item scores as continuous variables, (3) OLS, with ODI item scores as ordinal variables, (4) Tobit model, with total ODI score, (5) Tobit model, with ODI item scores as continuous variables, and (6) Tobit model, with ODI item scores as ordinal variables. The models’ performance was assessed using explained variance (R²) and root mean squared error (RMSE). The potential impact of using predicted instead of observed EQ-5D-3L utility values on cost-effectiveness outcomes was evaluated in two empirical cost-effectiveness analysis.

Results

Complete individual patient data of 18,692 low back pain patients were analyzed. All models had a more or less similar R² (range 45–52%) and RMSE (range 0.21–0.22). The two best performing models produced similar probabilities of cost-effectiveness for a range of willingness-to-pay (WTP) values compared to those based on the observed EQ-5D-3L values. For example, the difference in probabilities ranged from 2 to 5% at a WTP of 50,000 €/QALY gained.

Conclusion

Results suggest that the ODI can be validly used to predict low back pain patients’ EQ-5D-3L utility values and QALYs for use in cost-effectiveness analyses.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03082-6.

[Non-specific low back pain: interpretation of North American Spine Society (NASS) guidelines for evidence-based medicine]

Low back pain is a common disease. In 2020, the North American Spine Society (NASS) formulated an evidence-based clinical guideline for the diagnosis and treatment of non-specific low back pain. The guidelines mainly addressed five aspects of non-specific low back pain: diagnosis, imaging examination, conservative treatment, interventional treatment, and surgical treatment. Based on an in-depth understanding of the guidelines, this article gives a brief explanation of the diagnosis and treatment of non-specific low back pain, so as to provide references for clinicians.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Prognostic factors for pain chronicity in low back pain: a systematic review

Supplemental Digital Content is Available in the Text.

Several prognostic factors are related to low back pain chronicity, and these should be taken into account when planning more comprehensive models in its prevention.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.

Factors associated with delay to video-EEG in dissociative seizures

PURPOSE

While certain clinical factors suggest a diagnosis of dissociative seizures (DS), otherwise known as functional or psychogenic nonepileptic seizures (PNES), ictal video-electroencephalography monitoring (VEM) is the gold standard for diagnosis. Diagnostic delays were associated with worse quality of life and more seizures, even after treatment. To understand why diagnoses were delayed, we evaluated which factors were associated with delay to VEM.

METHODS

Using data from 341 consecutive patients with VEM-documented dissociative seizures, we used multivariate log-normal regression with recursive feature elimination (RFE) and multiple imputation of some missing data to evaluate which of 76 clinical factors were associated with time from first dissociative seizure to VEM.

RESULTS

The mean delay to VEM was 8.4 years (median 3 years, IQR 1-10 years). In the RFE multivariate model, the factors associated with longer delay to VEM included more past antiseizure medications (0.19 log-years/medication, standard error (SE) 0.05), more medications for other medical conditions (0.06 log-years/medication, SE 0.03), history of physical abuse (0.75 log-years, SE 0.27), and more seizure types (0.36 log-years/type, SE 0.11). Factors associated with shorter delay included active employment or student status (-1.05 log-years, SE 0.21) and higher seizure frequency (0.14 log-years/log[seizure/month], SE 0.06).

CONCLUSIONS

Patients with greater medical and seizure complexity had longer delays. Delays in multiple domains of healthcare can be common for victims of physical abuse. Unemployed and non-student patients may have had more barriers to access VEM. These results support earlier referral of complex cases to a comprehensive epilepsy center.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Fear-avoidance beliefs: A predictor for postpartum lumbopelvic pain

OBJECTIVE

To evaluate potential prognostic factors of self-reported lumbopelvic pain 6 months postpartum for pregnant women with and without lumbopelvic pain.

METHODS

Questionnaires were answered at gestational weeks 34-37 and again at 6 months postpartum. Psychosocial determinants and lumbopelvic pain symptoms were investigated using a visual analogue scale to assess pain intensity, and further using the Disability Rating Index, the Nottingham Health Profile, the Pain Catastrophizing Scale and the Fear-Avoidance Beliefs Questionnaire. Logistic regression analysis was used to analyse the data.

RESULTS

Of the 260 women who answered the questionnaires on both occasions, 186 did not suffer from lumbopelvic pain 6 months after pregnancy. The remaining 74 did. The results of the logistic regression analysis showed that fear-avoidance beliefs was a significant predictor of lumbopelvic pain 6 months postpartum, with an odds ratio of 1.060 (p ≤ .05).

CONCLUSION

Women with high fear-avoidance beliefs at 34-37 weeks of gestation had a higher risk of having lumbopelvic pain at 6 months postpartum. We theorize that early lumbopelvic pain intervention postpartum may be important in avoiding chronicity. Women at risk can be identified through clinically relevant questions which may help the clinician to choose appropriate rehabilitation strategies.

Differential Psychometric Properties of EuroQoL 5-Dimension 5-Level and Short-Form 6-Dimension Utility Measures in Low Back Pain

STUDY DESIGN

Prospective study.

OBJECTIVE

To examine the acceptability and validity of EuroQoL 5-dimension 5-level (EQ-5D-5L) and Short-Form 6-Dimension (SF-6D) health utility measures in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

LBP requires multiple diagnostic tests and treatment that can incur high medical costs. It is thus desirable to have an appropriate measure for cost-utility analysis of various LBP-related interventions.

METHODS

Health-related quality of life (HRQoL) questionnaires including generic 12-item Short Form Health Survey (SF-12), EQ-5D-5L, and low back/back-related questionnaires were administered at a specialty clinic. SF-12 items responses were transformed to SF-6D utility scores using the Hong Kong population scoring algorithm whereas EQ-5D-5L responses were mapped onto EQ-5D-3L response, then converted to EQ-5D-5L utility scores using the Chinese-specific value set. Construct validity was determined by evaluating Spearman correlation between SF-12 and EQ-5D-5L scores. Correlation between back-specific questionnaires and HRQoL scores were assessed.

RESULTS

A total of 100 patients were recruited. No significant (>15%) floor and ceiling effects were observed for EQ-5D-5L and SF-6D scores. Detailed proportion of respondents for each EQ-5D-5L domain indicated that Pain/Discomfort domain was the most prevalent problem. SF-6D utility score and EQ-5D-5L had respective strong (0.600-0.855) and moderate-to-strong (0.455-0.700) correlations with SF-12 domain and summary scores. EQ-5D-5L and SF-6D scores were correlated (0.625), with adequate construct validity as both utility scores conceptually measure the similar construct. Patients with no previous spine surgery nor disc degeneration had significantly higher EQ-5D-5L scores. Both EQ-5D-5L and SF-6D significantly correlated with back-specific questionnaires.

CONCLUSION

Both EQ-5D-5L and SF-6D appeared as applicable and valid measures in assessing HRQoL of LBP patients. Being the first study examining the differential psychometric properties and validation of the use of EQ-5D-5L and SF-6D in Chinese LBP population, this allows future exploration of the impact of utility score selection on assessing effectiveness of clinical intervention for LBP.

LEVEL OF EVIDENCE

2.

Poor general health and lower levels of vitality are associated with persistent, high-intensity low back pain and disability in community-based women: A prospective cohort study

While low back pain significantly impacts on an individual's well-being, our understanding of the role of well-being in the natural history of low back pain is limited. This cohort study aimed to investigate the association between psychological and general well-being and the development and progression of low back pain and disability in community-based women over a 2-year period. 506 women recruited from a research database were invited to participate. Overall psychological and general well-being and its subdomains were assessed at baseline using the Psychological General Well-Being Index (PGWB). The intensity of and degree of disability arising from low back pain were examined using the Chronic Pain Grade Questionnaire at baseline and at 2-year follow-up. Participants were categorized as having no, developing, resolving, or persistent high-intensity pain and disability. 444 participants (87.8%) completed the study. Women with persistent high-intensity pain had lower PGWB scores at baseline than those with no high-intensity pain at follow-up, after adjusting for confounders (M(SE) = 69.9(2.55) vs 80.1(2.63), p < 0.005). Furthermore, women with persistent high disability scores had lower well-being scores than those without persistent high disability scores (M(SE) = 69.1(3.49) vs. 81.2(0.802), p = 0.001). Moreover, lower scores in the well-being subdomains of general health and vitality were associated with persistent high pain intensity and disability (all p < 0.007). In summary, lower levels of general health and vitality were associated with persistent high-intensity low back pain and disability, suggesting that improving these aspects of well-being has the potential to reduce high levels of chronic low back pain and disability in community-based women.

Acute effects of Kinesio taping on pain, disability and back extensor muscle endurance in patients with low back pain caused by magnetic resonance imaging-confirmed lumbar disc degeneration

BACKGROUND

Individuals with disc degeneration experience associated pain and disability. Considering its safety and affordability, Kinesio tape (KT) may be a viable treatment. However, most KT studies have demonstrated its effects in healthy adults and patients with nonspecific low back pain. The efficacy of KT in patients with disc degeneration is yet to be investigated.

OBJECTIVES

To examine the acute effects of KT on patients with lumbar disc degeneration confirmed through magnetic resonance imaging.

METHODS

A total of 31 eligible patients (aged 25-64 years) with low back pain caused by lumbar disc degeneration were divided into mild and moderate-to-severe pain groups. KT was applied to the painful lumbar region in a lumbar brace-like pattern for 1 day. A visual analogue scale for pain and the Oswestry disability index were analysed before and after 1 day of taping. The Biering-Sorensen test for trunk muscle endurance was performed before, immediately after, and 1 day after taping as well as immediately after tape removal.

RESULTS

After taping, both groups showed significant pain reduction (p< 0.001), but the reduction was of minimal clinical importance in the moderate-to-severe pain group. The magnitude of treatment (i.e. effect size) was higher in the moderate-to-severe pain group. Disability significantly decreased in both groups, particularly in the moderate-to-severe pain group, but the improvement was not clinically worthwhile. Trunk muscle endurance significantly improved in both groups with in situ taping, but it decreased after tape removal.

CONCLUSIONS

KT may be adopted as an assistive aid for immediate pain reduction, particularly in lumbar disc degeneration patients with moderate-to-severe pain; however, its effects on disability and trunk muscle endurance are not clinically worthwhile. The long-term effects of KT, with or without active exercise, warrant further assessment.

Factors associated with the prevalence of back pain and work absence in shipyard workers

Background

We conducted a questionnaire survey of shipyard workers to identify difficulties experienced due to orthopedic or musculoskeletal disorders.

Methods

The subjects were 375 workers (male, 361; female, 14) who worked for a single shipbuilding company. Questionnaire items covered the working environment, including work environment, working posture, and the weight of objects that the subject dealt with, as well as physical and lifestyle characteristics, namely smoking habits, drinking habits, sleeping hours, medications, exercise habits, and any weight gain of 20 kg or more since the age of 20. Subjects were also asked to indicate if they regularly experienced any of 17 listed difficulties in their daily lives, and to use an illustration of the human body to mark any body parts that were painful or hard to move.

Results

The mean age was 41.8 years (19–73 years). The lower and/or upper back was the most frequent site of pain (46.5%), followed by the shoulders (11.4%), knees (9.6%), and neck (5.3%). Maintaining a half-sitting posture was the most problematic activity of daily living. Back pain was less frequent in subjects who exercised regularly, and more common in those who worked with heavy loads or in narrow spaces. A multinomial logistic regression analysis showed that absence from work was more common in subjects with back pain who had gained weight since their youth, who smoked, who used fire while welding metal, or who worked in a lying posture. While 35.4% of subjects had experienced absence from work due to musculoskeletal pain, only 5.1% were permitted by their employer to alter their work content or reduce their workload.

Conclusions

These results indicate that a large number of shipyard workers have difficulties in their work and daily life activities due to back pain. To prevent worsening of pain and to reduce work absence, it is important to provide appropriate training to minimize the risk factors for back pain that were identified in this study.

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.

Discriminative ability of reflex receptive fields to distinguish patients with acute and chronic low back pain

Low back pain has a life time prevalence of 70% to 85%. Approximately 10% to 20% of all patients experience recurrent episodes or develop chronic low back pain. Sociodemographic, clinical, and psychological characteristics explain the transition from acute to chronic low back pain only to a limited extent. Altered central pain processing may be a contributing mechanism. The measurement of reflex receptive fields (RRF) is a novel method to assess altered central pain processing. The RRF area denotes the area of the foot sole from which spinal nociceptive reflexes can be elicited. It was shown to be enlarged in patients with acute and chronic low back pain compared with pain-free individuals. The aim of the study was to explore the discriminative ability of the RRF to distinguish patients with acute and chronic low back pain with the hypothesis that enlarged RRF are associated with chronic low back pain. We included 214 patients with either acute or chronic low back pain and compared RRF between groups in both univariable and multivariable analyses adjusted for different sociodemographic and clinical characteristics possibly associated with the transition to chronic pain. We found a mean difference between patients with acute and chronic low back pain of -0.01 (95% confidence interval [CI], -0.06 to 0.04) in the crude, -0.02 (95% CI, -0.08 to 0.04) in the age and sex adjusted, and -0.02 (95% CI, -0.09 to 0.05) in the fully adjusted model. Our results suggest that the enlargement of RRF area may not be associated with the transition from acute to chronic low back pain.

The effect of Kinesio taping application for acute non-specific low back pain: a randomized controlled clinical trial

Objective:

To investigate the effect of Kinesio taping application in acute non-specific low back pain.

Design:

A randomized controlled clinical trial.

Setting:

Physical Medicine and Rehabilitation Clinic.

Participants:

A total of 109 patients with acute low back pain were randomized into either Kinesio taping ( n = 54) or control ( n = 55) groups.

Intervention:

The intervention group was treated with information and reassurance plus Kinesio taping, while the control group received merely information and reassurance. All participants were allowed to use as-needed doses of paracetamol. Kinesio tape was applied to the most painful area of the low back for a total of 12 days.

Main outcome measures:

Worst pain and disability were assessed at baseline, after the 12-day intervention, and at four weeks follow-up. During the first 12 days, participants filled in a pain diary consisting of a numeric rating scale and recorded the number of paracetamol tablets consumed daily. Disability was assessed with the Oswestry Disability Index.

Results:

After 12 days of intervention, pain intensity and the Oswestry Disability Index improved significantly in both groups; the improvements were significantly superior in the Kinesio taping group ( p = 0.003, p = 0.011). The Kinesio taping group reached pain control earlier (sixth day vs. 12th day) and consumed less paracetamol. At the fourth week, although pain intensity was significantly more reduced in the Kinesio taping group ( p = 0.015), there were no differences with regard to disability.

Conclusions:

Kinesio taping provided significant improvements in pain and disability; thus, it can be used as a complementary method in acute non-specific low back pain.

Comparative cross-sectional study for understanding the burden of low back pain among public bus transport drivers

BACKGROUND

Even though low back pain (LBP) is common, some occupations pose a higher risk. Identifying these occupations and specific factors will help to reduce the suffering and burden. This study aims to compare the prevalence of chronic LBP among bus drivers and to find its association with some occupational factors.

MATERIALS AND METHODS

It is a cross-sectional study to compare prevalence of LBP and factors associated with it, in two groups of drivers (n = 178) and nondrivers (n = 184).

RESULTS

The 10 years' percentage prevalence of LBP was found to be 70.8 and 51.6 among drivers and nondrivers respectively, whereas point prevalence in the same was 64.0 and 44.6. Drivers are at a higher risk for LBP with Odds ratio-2.270 (1.471-3.502). Risk factors such as prolonged sitting in one posture, night shifts, job dissatisfaction, tobacco use, and lack of exercise were significantly higher among drivers. Though the prevalence and intensity of LBP was higher among drivers, their number of leaves and hospital admitted days were less among drivers.

CONCLUSION

This is a potential group for intervention as prevalence of LBP, neck pain, and most of the suspected risk factors were higher among the drivers. Drivers got less recovery time and had higher sequelae.

Prognostic factors for disability and sick leave in patients with subacute non-malignant pain: a systematic review of cohort studies

OBJECTIVE

This systematic review aims to identify generic prognostic factors for disability and sick leave in subacute pain patients.

SETTING

General practice and other primary care facilities.

PARTICIPANTS

Adults (>18 years) with a subacute (≤ 3-month) non-malignant pain condition. Eligibility criteria were cohort studies investigating the prediction of disability or long-term sick leave in adults with a subacute pain condition in a primary care setting. 19 studies were included, referring to a total of 6266 patients suffering from pain in the head, neck, back and shoulders.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was long-term disability (>3 months) due to a pain condition. The secondary outcome was sick leave, defined as 'absence from work' or 'return-to-work'.

RESULTS

PubMed, EMBASE, CINAHL and PEDro databases were searched from 16 January 2003 to 16 January 2014. The quality of evidence was presented according to the GRADE WG recommendations. Several factors were found to be associated with disability at follow-up for at least two different pain symptoms. However, owing to insufficient studies, no generic risk factors for sick leave were identified.

CONCLUSIONS

Multiple site pain, high pain severity, older age, baseline disability and longer pain duration were identified as potential prognostic factors for disability across pain sites. There was limited evidence that anxiety and depression were associated with disability in patients with subacute pain, indicating that these factors may not play as large a role as expected in developing disability due to a pain condition. Quality of evidence was moderate, low or very low, implying that confidence in the results is limited. Large prospective prognostic factor studies are needed with sufficient study populations and transparent reporting of all factors examined.

TRIAL REGISTRATION NUMBER

CRD42014008914.

Topics and trends in research on non-clinical interventions aimed at preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs): a systematic, comprehensive literature review

PURPOSE

This study sought to provide an overview of the main topics and trends in contemporary research on successful non-clinical interventions for preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs).

METHODS

A systematic electronic search (English and French) was performed in ten scientific databases using keywords and descriptors. After screening the identified titles and abstracts using specific sets of criteria, categorical and thematic analyses were performed on the retained articles.

RESULTS

Five main topics appear to dominate the research: (1) risk factors and determinants; (2) effectiveness of interventions (programmes, specific components, strategies and policies); (3) viewpoints, experiences and perceptions of specific actors involved in the intervention process; (4) compensation issues; and (5) measurement issues. A currently widespread trend is early screening to identify risks factors for appropriate intervention and multidisciplinary, multimodal approaches. Morover, workplace-related psychosocial and ergonomic factors are considered vital to the success and sustainability of return-to-work (RTW) interventions. Finally, involving workplace actors, and more specifically, affected workers, in the RTW process appears to be a powerful force in improving the chances of moving workers away from disabled status.

CONCLUSIONS

The findings of this literature review provide with information about the main topics and trends in research on rehabilitation interventions, revealing some successful modalities of intervention aimed at preventing prolonged work disability.

IMPLICATIONS FOR REHABILITATION

Successful intervention for preventing prolonged work disability in workers compensated for WRMSDs address workplace issues: physical and psychosocial demands at work, ability of the workers to fill these demands, work organization and support of the worker, and worker' beliefs and attitudes related to work. Successful intervention promotes collaboration, coordination between all actors and stakeholders involved in the process of rehabilitation. Strategies able to mobilize the employees, employers, insurers and health care providers are still needed to be implemented.

Health-related quality of life as a main determinant of access to rheumatologic care

To evaluate a rheumatology outpatient consultation access system for new patients. New patients seen from April 2005 to April 2006 at our rheumatology clinic (n = 4,460) were included and classified according to their appointment type: ordinary appointments (OA) to be seen within 30 days, urgent appointments (UA) and work disability appointments (WDA) to be seen within 3 days. Age, sex, diagnosis, and health-related quality of life (HRQoL) as determined by the Rosser Index were recorded. Logistic regression models were run to identify factors that contribute to each type of appointment. OA was the method of access for 1,938 new patients, while 1,194 and 1,328 patients were seen through WDA and UA appointments, respectively. Younger male patients, and those with microcrystalline arthritis, sciatica, shoulder, back, or neck pain, were more likely to use the faster access systems (UA or WDA), whereas patients with a degenerative disease were mainly seen through OA (<0.001). Subjects with poor (3.96; 95 % CI, 2.8-5.5) or very poor HRQoL (70.8; 95 % CI, 14.9-334) were strongly associated to visiting a rheumatologist through the WDA or UA access systems, respectively, compared to OA. Age, gender, diagnosis, and mainly health-related quality of life are associated with the referral pattern of access to rheumatologic outpatient care. Among new patients subjects with the worst HRQoL were more likely to access with faster methods (UA or WDA) than those with better HRQoL.

Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review

QUESTION

Do negative expectations in patients after the onset of acute low back pain increase the odds of absence from usual work due to progression to chronic low back pain?

DESIGN

Systematic review with meta-analysis of prospective inception cohort studies.

PARTICIPANTS

Adults with acute or subacute non-specific low back pain.

OUTCOME MEASURE

Absence from usual work at a given time point greater than 12 weeks after the onset of pain due to ongoing pain.

RESULTS

Ten studies involving 4683 participants were included in the review. Participants with acute or subacute pain and negative expectations about their recovery had significantly greater odds of being absent from usual work at a given time point more than 12 weeks after the onset of pain: OR 2.17 (95% CI 1.61 to 2.91). The exclusion of five studies with the greatest risk of bias showed that the result was similar when more rigorous quality criteria were applied: OR 2.52 (95% CI 1.47 to 4.31).

CONCLUSION

The odds that adults with acute or subacute non-specific low back pain and negative recovery expectations will remain absent from work due to progression to chronic low back pain are two times greater than for those with more positive expectations. These results were consistent across the included studies despite variations in the risk of bias.

The prognosis of acute and persistent low-back pain: a meta-analysis

BACKGROUND

Although low-back pain is a highly prevalent condition, its clinical course remains uncertain. Our main objective was to systematically review the literature on the clinical course of pain and disability in patients with acute and persistent low-back pain. Our secondary objective was to investigate whether pain and disability have similar courses.

METHODS

We performed a meta-analysis of inception cohort studies. We identified eligible studies by searching MEDLINE, Embase and CINAHL. We included prospective studies that enrolled an episode-inception cohort of patients with acute or persistent low-back pain and that measured pain, disability or recovery. Two independent reviewers extracted data and assessed methodologic quality. We used mixed models to determine pooled estimates of pain and disability over time.

RESULTS

Data from 33 discrete cohorts (11 166 participants) were included in the review. The variance-weighted mean pain score (out of a maximum score of 100) was 52 (95% CI 48-57) at baseline, 23 (95% CI 21-25) at 6 weeks, 12 (95% CI 9-15) at 26 weeks and 6 (95% CI 3-10) at 52 weeks after the onset of pain for cohorts with acute pain. Among cohorts with persistent pain, the variance-weighted mean pain score (out of 100) was 51 (95% CI 44-59) at baseline, 33 (95% CI 29-38) at 6 weeks, 26 (95% CI 20-33) at 26 weeks and 23 (95% CI 16-30) at 52 weeks after the onset of pain. The course of disability outcomes was similar to the time course of pain outcomes in the acute pain cohorts, but the pain outcomes were slightly worse than disability outcomes in the persistent pain cohorts.

INTERPRETATION

Patients who presented with acute or persistent low-back pain improved markedly in the first six weeks. After that time improvement slowed. Low to moderate levels of pain and disability were still present at one year, especially in the cohorts with persistent pain.

Adherence of Irish general practitioners to European guidelines for acute low back pain: A prospective pilot study

There are no national low back pain (LBP) clinical guidelines in Ireland, and neither the level of adherence of General Practitioners (GPs) to the European guidelines, nor the cost of LBP to the patient and the state, have been investigated. A prospective pilot study was conducted on 54 consenting patients (18M, 36F: mean age (SD): 40.5 (14.3) years) with a new episode of acute LBP (<3 months) attending one of nine participating GPs. Baseline demographic, LBP classification [i.e. simple back ache (SBA), nerve root pain (NRP), serious spinal pathology (SSP)] and primary care management data were recorded over a three month period. Adherence and costs were estimated based on: medication prescription, referral for investigations, treatment or consultations, and wage replacement costs (time signed off work). For both SBA and NRP, medication prescriptions were consistent with European guideline recommendations, but not for referral for further treatment (39% of SBA patients were referred on first visit), secondary care (54% of NRP patients were referred on first visit), or discontinuation of work (50% NRP patients on first GP visit). The average total cost (direct and wage replacement) for a single episode of LBP over 12 weeks was 20,531 Euros (20,300-20,762). Direct costs accounted for 43% [8874.36 Euros, (8643.37-9105.37 Euros)] and wage replacement costs 57% (11,657 Euros). In conclusion, management of acute LBP in a cohort of GPs in Ireland was not consistent with European clinical guideline recommendations, and warrants higher levels of postgraduate education among GPs, as well as restructuring of primary care services, which should improve patient outcome and reduce costs.

Acute low back pain and primary care: how to define recovery and chronification?

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

To establish outcome measures for recovery and chronic pain for studies with patients who present with recent-onset acute low back pain (LBP) in primary care.

SUMMARY OF BACKGROUND DATA

Among back pain researchers, no consensus exists about outcome definitions or how to identify primary-care patients as not-recovered from an episode of LBP. Cut points for outcome scales have mostly been arbitrarily chosen. Theoretical models for establishing minimal important change values in studies of patients with LBP have been proposed and need to be applied to real data.

METHODS

A sample of 521 patients who presented with acute LBP (<4 weeks) in primary care clinics were observed for 6 months and scores for pain and disability were compared with ratings on a Global Perceived Effect Scale. Using multiple potential "gold standards" as anchors (reference standards), the receiver operating characteristic method was used to determine optimal cut points for different ways of defining nonrecovery from acute LBP.

RESULTS

Minimal important change values and upper limits for pain and disability scores as well as minimal important percentage changes are presented for five different definitions of recovery. A previously suggested 30% change from baseline scores does not accurately discriminate between recovered patients and nonrecovered patients in patients presenting with acute LBP in primary care.

CONCLUSION

Outcome definitions that combine ratings from perceived recovery scales with pain and disability measures provide the highest accuracy in discriminating recovered patients from nonrecovered patients.

Low back pain predict sickness absence among power plant workers

Background:

Low back pain (LBP) remains the predominant occupational health problem in most industrialized countries and low-income countries. Both work characteristics and individual factors have been identified as risk factors. More knowledge about the predictors of sickness absence from LBP in the industry will be valuable in determining strategies for prevention.

Objectives:

The aim of this longitudinal study was to investigate whether individual, work-related physical risk factors were involved in the occurrence of LBP sickness absence.

Methods:

A follow-up study was conducted among 489 workers, aged 18–65 years, at Kosovo Energetic Corporation in Kosovo. This cross-sectional study used a self-administered questionnaire to collect data on individual and work-related risk factors and the occurrence of LBP sickness absence. Logistic regression models were used to determine associations between risk factors and the occurrence of sickness absence due to LBP.

Results:

Individual factors did not influence sickness absence, whereas work-related physical factors showed strong associations with sickness absence. The main risk factors for sickness absence due to LBP among production workers were extreme trunk flexion (OR = 1.71, 95% CI = 1.05–2.78) as well as very extreme trunk flexion (OR = 6.04, 95% CI = 1.12–32.49) and exposure to whole-body vibration (OR = 1.75, 95% CI = 1.04–2.95).

Conclusion:

Reducing sickness absence from LBP among power plant workers requires focusing on the working conditions of blue-collar workers and risk factors for LBP. Increasing social support in the work environment may have effects in reducing sickness absence from LBP.

Determinants of utilization and expenditures for episodes of ambulatory physical therapy among adults

BACKGROUND

Comprehensive information on determinants and patterns of use and spending for ambulatory physical therapy services is needed to inform health planning and policy decisions. Most research in the literature on this topic is limited to specific payers, age groups, and conditions.

OBJECTIVE

The purpose of this study was to examine factors associated with the resource intensity of physical therapy episodes for adults in the United States as measured by number of visits and expenses per visit.

DESIGN

This study was a secondary analysis of longitudinal survey data from the Medical Expenditure Panel Survey (MEPS) panels 9, 10, and 11.

METHODS

An analytic file was created based on data from the longitudinal data files for 3 MEPS panels and the annual office-based and hospital outpatient event files. A total of 1,377 episodes of physical therapy care were identified. Variation in both the total number of visits per episode and expenses per visit was examined by fitting regression models to evaluate the effects of selected independent variables classified into 4 categories: episode-level variables, demographic characteristics, geographic variables, and health status indicators.

RESULTS

Average total expenses per episode (in 2007 dollars) were $1,184 (median=$651), with an average number of visits per episode of 9.6 (median=6.0) and average expenses per visit of $130 (median=$95). Significant variation by geographic characteristics, sex, and one comorbid condition (high blood pressure) was found in the number of visits model. In the expenditures model, expenses per visit were associated with age/insurance coverage, setting (hospital outpatient versus office based), primary condition category, and mental health status. Limitations Limitations include limited sample sizes of physical therapy users and lack of detailed clinical information.

CONCLUSIONS

Variability in the resource intensity of physical therapy episodes is influenced to some degree by nonclinical variables.

Psychosocial risk factors for chronic low back pain in primary care--a systematic review

BACKGROUND

Low back pain (LBP) is a major public health problem, often encountered in primary care. Guidelines recommend early identification of psychosocial factors that could prevent recovery from acute LBP.

METHODS

To review the evidence on the prognostic value of psychosocial factors on transition from acute to chronic non-specific LBP in the adult general population. Systematic review is the design of the study. A systematic search was undertaken for prospective studies dealing with psychosocial risk factors for poor outcome of LBP in primary care, screening PubMed, PsychInfo and Cochrane Library databases. The methodological quality of studies was assessed independently by two reviewers using standardized criteria before analysing their main results.

RESULTS

Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.

CONCLUSION

Few independent psychosocial risk factors have been demonstrated to exist. Randomized clinical trials aimed at modifying these factors have shown little impact on patient prognosis. Qualitative research might be valuable to explore further the field of LBP and to define new management strategies.

Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care?

Few studies have investigated whether prognostic indicators, which contribute to the transition from acute to chronic low back pain (LBP), are also those which contribute to continuing persistence of chronic LBP. We compared the contribution of physical, psychological and social indicators to predicting disability after one year between consulters with LBP of less than 3 months duration and more than 3 months duration. Data from two large prospective cohort studies of consecutive patients consulting with LBP in general practices were merged, providing complete data for 258 cases with acute/subacute LBP and 668 cases with chronic LBP at 12 months follow-up. There were significant differences between the two LBP groups in baseline characteristics and clinical course of disability, assessed by Roland Morris Disability Questionnaire, during the year of follow-up. Adjusted associations between potential prognostic indicators and disability at 12months were carried out in the two LBP subgroups. The final multivariable regression models showed that being non-employed, having widespread pain, a high level of Chronic Pain Grade, and catastrophising were the strongest prognostic indicators for disability at 12 months in both LBP groups. Fear of pain was significantly associated with disability in chronic LBP. Importantly, beyond baseline disability, the effect size of the other prognostic indicators for poor outcome was rather low. These findings must continue to challenge researchers to identify useful early predictors of outcome in persons with disabling back pain, as screening and targeted treatment approaches are dependent upon prognostic indicators with clinical significance.

How is recovery from low back pain measured? A systematic review of the literature

Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.

Does access to compensation have an impact on recovery outcomes after injury?

OBJECTIVE

To conduct a descriptive study investigating the effect of access to motor vehicle accident (MVA) compensation on recovery outcomes at 24 months after injury.

DESIGN AND SETTING

Longitudinal cohort study conducted in two Level 1 trauma hospitals in Victoria, Australia. Participants were 391 randomly selected injury patients with moderate-to-severe injuries. Compensable and non-compensable patients were compared at 24 months after injury on a number of health outcomes.

MAIN OUTCOME MEASURES

Health outcomes at 24 months, including anxiety and depression severity, quality of life and disability.

RESULTS

Medical records identified two groups of compensation patients: MVA-compensable and non-compensable patients. After controlling for baseline variables, the MVA-compensable patients, at 24 months, had higher levels of post-traumatic stress disorder, anxiety and depression, and were less likely to have returned to their pre-injury number of work hours. However, some patients in the non-compensable group had accessed other forms of compensation (eg, private health care or compensation for victims of crime). When these were removed from the non-compensable group, the differences between MVA-compensable and non-compensable groups all but disappeared.

CONCLUSION

Our findings do not support previous research showing that access to compensation is associated with poor recovery outcomes. The relationship between access to compensation and health outcomes is complex, and more high-level research is required.

How little pain and disability do patients with low back pain have to experience to feel that they have recovered?

Epidemiological and clinical studies of people with low back pain (LBP) commonly measure the incidence of recovery. The pain numerical rating scale (NRS), scores from 0 to 10, and Roland Morris disability questionnaire (RMDQ), scores from 0 to 24, are two instruments often used to define recovery. On both scales higher scores indicate greater severity. There is no consensus, however, on the cutoff scores on these scales that classify people as having recovered. The aim of this study was to determine which cutoff scores most accurately classify those who had recovered from LBP. Subjects from four clinical studies were categorized as 'recovered' or 'unrecovered' according to their self-rating on a global perceived effect scale. Odd ratios were calculated for scores of 0, 1, 2, 3 and 4 on the NRS and RMDQ to predict perceived recovery. Scores of 0 on the NRS and <or=2 on the RMDQ most accurately identify patients who consider themselves completely recovered. The diagnostic odds ratio (OR) for predicting recovery was 43.9 for a score of 0 on the NRS and 17.6 for a score of <or=2 on the RMDQ. There was no apparent effect of LBP duration or length of follow-up period on the optimal cutoff score. OR for the NRS were generally higher than those for RMDQ. Cutoffs of 0 on the NRS and 2 on the RMDQ most accurately classify subjects as recovered from LBP. Subjects consider pain more than disability when determining their recovery status.

Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: secondary analyses of three randomized clinical trials

The objective of this study was to report on secondary analyses of a merged trial dataset aimed at exploring the potential importance of patient factors associated with clinically relevant improvements in non-acute, non-specific low back pain (LBP). From 273 predominantly male army workers (mean age 39 ± 10.5 years, range 20–56 years, 4 women) with LBP who were recruited in three randomized clinical trials, baseline individual patient factors, pain-related factors, work-related psychosocial factors, and psychological factors were evaluated as potential prognostic variables in a short-term (post-treatment) and a long-term logistic regression model (6 months after treatment). We found one dominant prognostic factor for improvement directly after treatment as well as 6 months later: baseline functional disability, expressed in Roland–Morris Disability Questionnaire scores. Baseline fear of movement, expressed in Tampa Scale for Kinesiophobia scores, had also significant prognostic value for long-term improvement. Less strongly associated with the outcome, but also included in our final models, were supervisor social support and duration of complaints (short-term model), and co-worker social support and pain radiation (long-term model). Information about initial levels of functional disability and fear-avoidance behaviour can be of value in the treatment of patient populations with characteristics comparable to the current army study population (e.g., predominantly male, physically active, working, moderate but chronic back problems). Individuals at risk for poor long-term LBP recovery, i.e., individuals with high initial level of disability and prominent fear-avoidance behaviour, can be distinguished that may need additional cognitive-behavioural treatment.

Predicting persistent low back pain in schoolchildren: a prospective cohort study

OBJECTIVE

Low back pain (LBP) is common in children but the prognostic indicators are poorly understood. We report the results of a prospective study to determine the risk factors for chronic LBP in children.

METHODS

A total of 330 children with LBP were identified from a cross-sectional survey in schools in Northwest England. Data were collected by self-completion questionnaire on a number of potential risk factors for LBP persistence, including lifestyle factors, the occurrence of other symptoms, behavioral and emotional characteristics, and symptom severity and duration. Participants were then followed over the following 4 years to determine persistent symptoms.

RESULTS

Complete followup data were available from 178 children, of whom 46 (26%) reported persistent LBP. Forward stepwise Poisson regression identified 5 independent predictors of pain persistence: peer relationship problems, being of smaller stature, the prior report of widespread body pain, long duration of LBP episodes, and radiating leg pain. Of children with none of these factors at baseline, <5% went on to report persistent LBP. In contrast, of those with 4 or 5 factors, nearly 80% experienced persistent symptoms.

CONCLUSION

Although childhood consultations for LBP are infrequent, we have shown that approximately 25% of children 11-14 years of age with LBP still report symptoms 4 years later. These children can be identified early by a combination of clinical markers and etiologic factors. This provides a basis for considering interventions for secondary prevention; the challenge will be to determine whether we can intervene to alter symptom trajectory at an early stage.

Predicting outcome in acute low back pain using different models of patient profiling

STUDY DESIGN

Prospective observational study of prognostic indicators, using data from a randomized, controlled trial of physiotherapy care of acute low back pain (ALBP) with follow-up at 6 weeks, 3 months, and 6 months.

OBJECTIVE

To evaluate which patient profile offers the most useful guide to long-term outcome in ALBP.

SUMMARY OF BACKGROUND DATA

The evidence used to inform prognostic decision-making is derived largely from studies where baseline data are used to predict future status. Clinicians often see patients on multiple occasions so may profile patients in a variety of ways. It is worth considering if better prognostic decisions can be made from alternative profiles.

METHODS

Clinical, psychological, and demographic data were collected from a sample of 54 ALBP patients. Three clinical profiles were developed from information collected at baseline, information collected at 6 weeks, and the change in status between these 2 time points. A series of regression models were used to determine the independent and relative contributions of these profiles to the prediction of chronic pain and disability.

RESULTS

The baseline profile predicted long-term pain only. The 6-week profile predicted both long-term pain and disability. The change profile only predicted long-term disability (P < 0.01). When predicting long-term pain, after the baseline profile had been added to the model, the 6-week profile did not add significantly when forced in at the second step (P > 0.05). A similar result was obtained when the order of entry was reversed. When predicting long-term disability, after the 6-week profile was entered at the first step, the change profile was not significant when forced in at the second step. However, when the change profile was entered at the first step and the 6-week clinical profile was forced in at the second step, a significant contribution of the 6-week profile was found.

CONCLUSION

The profile derived from information collected at 6 weeks provided the best guide to long-term pain and disability. The baseline profile and change in status offered less predictive value.

Incapacidade funcional associada à lombalgia em cuidadores de crianças com paralisia cerebral grave

O objetivo deste estudo foi analisar a contribuição de variáveis físicas, psicossociais e sociodemográficas para a ocorrência de incapacidade funcional associada à dor lombar entre cuidadores de crianças com paralisia cerebral grave. A amostra foi composta de 45 cuidadores com lombalgia crônica. Foram coletados dados sociodemográficos e aplicados instrumentos sobre intensidade da dor, satisfação com a vida e incapacidade funcional. Os dados foram tratados estatisticamente e o nível de significância fixado em p<0,05. As variáveis que apresentaram correlação significativa com incapacidade (p<0,05) foram inseridas no modelo de regressão linear múltipla. A média de intensidade da dor foi 5,67±2,23; os escores médios de satisfação com a vida foram de 18,9±6,64 e de incapacidade, 9±5,35. Apenas a correlação entre intensidade de dor e incapacidade foi significativa (r=0,34; p=0,021). A análise de regressão linear múltipla confirmou a intensidade da dor como o maior preditor de incapacidade e explicou 11% da incapacidade (r=0,36; p<0,05). A intensidade da dor lombar é pois um preditor moderado de incapacidade, mas não foi encontrada interferência das variáveis sociodemográficas e satisfação com a vida no grau de incapacidade funcional dos cuidadores de crianças com paralisia cerebral.

Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?

BACKGROUND

Numerous practice guidelines have been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Guideline implementation has received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care.

OBJECTIVE

Examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy.

RESEARCH DESIGN

Retrospective review of patients with acute low back pain receiving physical therapy in 2004-2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care.

SUBJECTS

A total of 1190 patients age 18-60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region.

MEASURES

Clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care.

RESULTS

Adherence rate was 40.4%. Adherence was greater for patients receiving workers' compensation (P < 0.05). Patients receiving adherent care had fewer visits and lower charges (P < 0.05), and showed more improvement in disability [adjusted mean difference for percentage improvement 25.8%, 95% confidence interval (CI): 21.3-30.4, P < 0.001] and pain (adjusted mean difference for percentage improvement 22.4%, 95% CI: 17.5-27.3, P < 0.001). Patients receiving adherent care were more likely to have a successful physical therapy outcome (64.7% vs. 36.5%, P < 0.001).

CONCLUSIONS

Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost.

A new episode of low back pain: who relies on bed rest?

Bed rest has been shown to be an ineffective treatment for non-specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non-specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration.

Conservative treatment of lumbar disc disease: patient's quality of life compared to an unexposed cohort

BACKGROUND

Lumbar disc disease is a very common condition with a substantial socioeconomic impact. Studies have shown the importance of a multilevel assessment of this disease, as its course is influenced by many factors. Most follow-up studies use the degree of physical impairment to measure the outcome of a certain treatment. This remains unsatisfactory, as physical impairment itself seems to be influenced by the social, psychological and personal condition of a patient. We believe that an overall quality of life assessment is required to evaluate success of treatment. The SF-36 questionnaire seemed appropriate, as it provides consistent data of a patient's overall health status. To ensure measurement of disability due to back pain we combined the SF-36 with the NASS (North American Spine Society) questionnaire, an instrument specific for lumbar spine disorders.

METHOD

One year after the last outpatient consultation in our neurosurgical clinic, a SF-36 questionnaire was sent to 636 patients with conservatively treated lumbar disc disease. We used the Mann Whitney Test to compare patient's data with a standard group. The demographics of the standard group were matched with the study cohort.

FINDINGS

A total of 486 patients (66.5% males and 33.5% females), mean age 49 years (range 21-82 years), returned the questionnaire. The SF-36 data was usable in 76.4% of the patients. Statistical testing reported a significant impact of the disease on all 8 items of the SF-36 questionnaire. The "Role Functioning - Physical (RF)" item was the most, the "Mental Health (MH)" item the less affected. No statistical difference was found between males and females regarding the impact on single items. The NASS scores were also affected suggesting that lumbar back disorder was the influencing factor for the low SF-36 scores.

CONCLUSIONS

Besides impairment in the execution of daily physical tasks, patients with lumbar disc disease also showed a significant impact on the "Mental Health (MH)" item. Early SF-36 assessment could identify subjects with high probability of prolonged recovery and development of chronic pain syndromes. In these patients, an early rheumatologic, rehabilitative and psychiatric treatment might be the key to improve their coping abilities and should become an integral part of the treatment strategy.

The impact of low back pain on work: a study in primary care consulters

BACKGROUND

The cost of low back pain (LBP) to employers is high, with an estimated pound 9090 million lost in the United Kingdom in 1998. Economic analysis of LBP has focused on work absence among the employed. There is little research characterising individuals who report reduced duties or who are not in employment because of LBP.

AIMS

To compare the health related characteristics of primary care LBP consulters reporting usual employment, reduced duties, sick leave and non-employment as a result of LBP.

METHODS

Prospective cohort study recruiting LBP consulters aged 30-59 years of age from five general practices in North Staffordshire.

RESULTS

Nine hundred and thirty-five participants completed the baseline phase, 65% were in employment and 35% were not in employment. Of the employed participants over 1 in 10 (11%) were undertaking reduced duties and almost one-fifth were reporting sick leave (22%). Furthermore, 37% of non-employed consulters reported that LBP was the reason for non-employment. Significant differences at baseline in socioeconomic status, self-rated health, anxiety, depression and disability were found between those undertaking their usual job, those on reduced duties and those on sickness absence due to LBP, with those participants further removed from the work force reporting worse health across all measures. Significant differences were also found in self-rated health between those not working due to LBP and those not working for other reasons, with participants not working due to LBP reporting worse self-rated health. At follow-up, work status was found to be relatively stable.

CONCLUSION

These findings indicate that the economic impact of LBP may be higher than previously estimated when data on reduced duties is combined with work absence. The additional impact of unemployment due to LBP should also be included in future assessments of the impact of LBP on the workforce.