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Harrisson SA, Ogollah R, Dunn KM, Foster NE, Konstantinou K. Prognosis of Patients With Neuropathic Low Back-Related Leg Pain: An Exploratory Study Using Prospective Data From UK Primary Care. THE JOURNAL OF PAIN 2024; 25:533-544. [PMID: 37778405 DOI: 10.1016/j.jpain.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
This prospective cohort study investigates the prognosis of patients with neuropathic low back-related leg pain consulting in UK primary care. Data from 511 patients were collected using standardised baseline clinical examinations (including magnetic resonance imaging scan findings), self-report questionnaires at baseline, 4 months, 12 months, and 3 years. Cases of possible neuropathic pain (NP) and persistent-NP were identified using either of 2 definitions: 1) clinical diagnosis of sciatica, 2) self-report version of leeds assessment for neurological symptoms and signs (s-LANSS). Mixed-effects models compared pain intensity (highest of mean leg or mean back pain [0-10 Numerical Rating Scale]) over 3-years between persistent-NP versus non-persistent-NP based on 1) clinical diagnosis, 2) s-LANSS. Logistic regression examined associations between potential prognostic factors and persistent-NP at 4 months based on the 2 NP definitions. At 4-months, using both definitions: 1) approximately 4 out of 10 patients had persistent-NP, 2) mean pain intensity was higher for patients with persistent-NP at all follow-up points compared to those without, 3) only pain self-efficacy was significantly associated with persistent-NP (s-LANSS: OR .98, sciatica: .98), but it did not predict cases of persistent-NP in either multivariable model. Based on factors routinely collected from self-report and clinical examination, it was not possible to predict persistent-NP in this population. PERSPECTIVE: This study provides evidence that neuropathic back-related leg pain in patients consulting in primary care is not always persistent. Patients with persistent neuropathic pain had worse outcomes than those without. Neither leg pain intensity, pain self-efficacy nor MRI scan findings predicted cases of persistent neuropathic pain in this patient population.
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Affiliation(s)
- Sarah A Harrisson
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, UK; North Staffordshire and Stoke-on-Trent Integrated Musculoskeletal Service (NIMS), Midlands Partnership University NHS Foundation Trust, Staffordshire, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, UK
| | - Kate M Dunn
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, UK; Surgical, Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Hospital and Health Service, Australia
| | - Kika Konstantinou
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, UK; North Staffordshire and Stoke-on-Trent Integrated Musculoskeletal Service (NIMS), Midlands Partnership University NHS Foundation Trust, Staffordshire, UK
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Pesesse P, Vanderthommen M, Durieux N, Zubkov M, Demoulin C. Clinical Value and Reliability of Quantitative Assessments of Lumbosacral Nerve Root Using Diffusion Tensor and Diffusion Weighted MR Imaging: A Systematic Review. J Magn Reson Imaging 2024. [PMID: 38190195 DOI: 10.1002/jmri.29213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Lumbosacral radicular pain diagnosis remains challenging. Diffusion tensor imaging (DTI) and diffusion weighted imaging (DWI) have potential to quantitatively evaluate symptomatic nerve root, which may facilitate diagnosis. PURPOSE To determine the ability of DTI and DWI metrics, namely fractional anisotropy (FA) and apparent diffusion coefficient (ADC), to discriminate between healthy and symptomatic lumbosacral nerve roots, to evaluate the association between FA and ADC values and patient symptoms, and to determine FA and ADC reliability. STUDY TYPE Systematic review. SUBJECTS Eight hundred twelve patients with radicular pain with or without radiculopathy caused by musculoskeletal-related compression or inflammation of a single, unilateral lumbosacral nerve root and 244 healthy controls from 29 studies. FIELD STRENGTH/SEQUENCE Diffusion weighted echo planar imaging sequence at 1.5 T or 3 T. ASSESSMENT An extensive systematic review of the literature was conducted in Embase, Scopus, and Medline databases. FA and ADC values in symptomatic and contralateral lumbosacral nerve roots were extracted and summarized, together with intra- and inter-rater agreements. Where available, associations between DWI or DTI parameters and patient symptoms or symptom duration were extracted. STATISTICAL TESTS The main results of the included studies are summarized. No additional statistical analyses were performed. RESULTS The DTI studies systematically found significant differences in FA values between the symptomatic and contralateral lumbosacral nerve root of patients suffering from radicular pain with or without radiculopathy. In contrast, identification of the symptomatic nerve root with ADC values was inconsistent for both DTI and DWI studies. FA values were moderately to strongly correlated with several symptoms (eg, disability, nerve dysfunction, and symptom duration). The inter- and intra-rater reliability of DTI parameters were moderate to excellent. The methodological quality of included studies was very heterogeneous. DATA CONCLUSION This systematic review showed that DTI was a reliable and discriminative imaging technique for the assessment of symptomatic lumbosacral nerve root, which more consistently identified the symptomatic nerve root than DWI. Further studies of high quality are needed to confirm these results. EVIDENCE LEVEL N/A TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Pierre Pesesse
- Department of Sport and Rehabilitation Sciences, University of Liege, Liège, Belgium
| | - Marc Vanderthommen
- Department of Sport and Rehabilitation Sciences, University of Liege, Liège, Belgium
| | - Nancy Durieux
- Research Unit for a Life-Course Perspective on Health & Education - RUCHE, Faculty of Psychology, Speech and Language Therapy, and Educational Sciences, University of Liege, Liège, Belgium
| | - Mikhail Zubkov
- GIGA-Research - Cyclotron Research Centre-In Vivo Imaging Unit, University of Liege, Liège, Belgium
| | - Christophe Demoulin
- Department of Sport and Rehabilitation Sciences, University of Liege, Liège, Belgium
- Spine Center of the Liege University Hospital (CHU), Liège, Belgium
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Lorio MP, Beall DP, Calodney AK, Lewandrowski KU, Block JE, Mekhail N. Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management. J Pers Med 2023; 13:jpm13050821. [PMID: 37240991 DOI: 10.3390/jpm13050821] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.
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Affiliation(s)
- Morgan P Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Douglas P Beall
- Clinical Radiology of Oklahoma, 1800 S. Renaissance Blvd., Ste. 110, Edmond, OK 73013, USA
| | | | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, 4787 E. Camp Lowell Drive, Tucson, AZ 85712, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
| | - Nagy Mekhail
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Nee RJ, Coppieters MW, Boyd BS. Reliability of the straight leg raise test for suspected lumbar radicular pain: A systematic review with meta-analysis. Musculoskelet Sci Pract 2022; 59:102529. [PMID: 35245880 DOI: 10.1016/j.msksp.2022.102529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/25/2022] [Accepted: 02/08/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability. OBJECTIVES To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain. DESIGN Systematic review with meta-analysis. METHOD MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD95) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles. RESULTS/FINDINGS Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD95 values for different raters measuring SLR range of motion ranged from 13 to 20°. CONCLUSIONS Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.
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Affiliation(s)
- Robert J Nee
- Department of Physical Therapy, Samuel Merritt University, Oakland, CA, USA.
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane & Gold Coast, Australia; Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Benjamin S Boyd
- Department of Physical Therapy, Samuel Merritt University, Oakland, CA, USA
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Kontakiotis N, Rushton AB, Billis E, Papathanasiou G, Gioftsos G. Development of a clinical prediction model to inform clinical decision making for classification of patients with sciatica, based on their clinical characteristics, in the Greek health system: protocol for a prospective predictive exploratory study. BMJ Open 2022; 12:e052119. [PMID: 35105622 PMCID: PMC8804639 DOI: 10.1136/bmjopen-2021-052119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Sciatica is one of the most common reasons for seeking healthcare for musculoskeletal pain. Sciatica is primarily considered as neuropathic in nature when neural tissue in the low back is compromised, but sometimes other non-neural structures may be involved. Appropriate assessment and management are important for patients with sciatica. Therapists use several outcome measures to assess patients to inform selection of the most suitable treatment. There is limited evidence for the best treatment of sciatica, and this is likely contributed to by having no reliable algorithm to categorise patients based on their clinical characteristics to inform physiotherapy treatment. The purpose of this study is to develop a clinical prediction model to categorise patients with sciatica, in terms of early clinical outcome, based on their initial clinical characteristics. METHODS AND ANALYSIS A prospective observational multicentre design will recruit consecutive patients (n=467) with sciatica referred for physiotherapy. Each patient will be evaluated to determine whether or not they will be accepted into the study by answering some questions that will confirm the study's eligibility criteria. Patients' basic characteristics, patient-reported outcome measures and performance-based measures will be collected at baseline from multiple sites in the Greek territory using this same protocol, prior to commencement of treatment. The main researcher of this study will be responsible for data collection in all sites. On completion of the standard referred physiotherapy treatment after 3 weeks' time, participants will be asked by telephone to evaluate their outcome using the Global Perceived Effect Scale. For the descriptive statistical analysis, the continuous variables will be expressed in the form of 'mean' and 'SD'. In order to assess the prognostic value of each predictor, in terms of the level of improvement or worsening of the symptoms, multiple variable regression analysis will be used. ETHICS AND DISSEMINATION Τhis study is approved from the Ethics and Deontology Committee of the University of West Attica, Athens, Greece, protocol number: 38313-09/06/2020, 10226-10/02/2021. The study's findings will be published in a peer-reviewed journal and disseminated at national and international conferences and through social media. PROSPERO REGISTRATION NUMBER CRD42020168467.
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Affiliation(s)
- Nikolaos Kontakiotis
- Physiotherapy Department, Laboratory of Advanced Physiotherapy, Faculty of Health and Caring Sciences, University of West Attica, Athens, Greece
| | - Alison B Rushton
- School of Physical Therapy, Western University Faculty of Health Sciences, London, Ontario, Canada
| | - Evdokia Billis
- Physiotherapy Department, School of Health Rehabilitation Sciences, University of Patras, Patra, Greece
| | - George Papathanasiou
- Physiotherapy Department, Laboratory of Neuromuscular and Cardiovascular Study of Motion, Faculty of Health and Caring Sciences, University of West Attica, Athens, Greece
| | - George Gioftsos
- Physiotherapy Department, Laboratory of Advanced Physiotherapy, Faculty of Health and Caring Sciences, University of West Attica, Athens, Greece
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Prevalence, Characteristics, and Clinical Course of Neuropathic Pain in Primary Care Patients Consulting With Low Back-related Leg Pain. Clin J Pain 2021; 36:813-824. [PMID: 32841967 DOI: 10.1097/ajp.0000000000000879] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Little is known about the epidemiology of neuropathic pain in primary care patients consulting with low back-related leg pain. We aimed to describe prevalence, characteristics, and clinical course of low back-related leg pain patients with and without neuropathic pain, consulting with their family doctor in the United Kingdom. MATERIALS AND METHODS This was a prospective cohort study. Data were collected using a standardized baseline clinical examination and self-report questionnaires at baseline, 4, 12, and 36 months. We identified cases of neuropathic pain using 3 definitions: 2 based on clinical diagnosis (sciatica, with and without evidence of nerve root compression on magnetic resonance imaging), one on the self-report version of Leeds Assessment for Neurological Symptoms and Signs. Differences between patients with and without neuropathic pain were analyzed comparing each definition. Clinical course (mean pain intensity measured as the highest of leg or back pain intensity: mean of 3 Numerical Rating Scales, each 0 to 10) was investigated using linear mixed models over 36 months. RESULTS Prevalence of neuropathic pain varied from 48% to 74% according to definition used. At baseline, patients with neuropathic pain had more severe leg pain intensity, lower pain self-efficacy, more patients had sensory loss than those without. Distinct profiles were apparent depending on neuropathic pain definition. Mean pain intensity reduced after 4 months (6.1 to 3.9 [sciatica]), most rapidly in cases defined by clinical diagnosis. DISCUSSION This research provides new information on the clinical course of neuropathic pain and a better understanding of neuropathic pain in low back-related leg pain patients consulting in primary care.
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7
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The ambiguity of sciatica as a clinical diagnosis: A case series. J Am Assoc Nurse Pract 2019; 32:589-593. [PMID: 31567779 DOI: 10.1097/jxx.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.
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Fernandez M, Moore C, Peng W, de Luca K, Pohlman KA, Swain M, Adams J. The profile of chiropractors managing patients with low back-related leg pain: analyses of 1907 chiropractors from the ACORN practice-based research network. Chiropr Man Therap 2019; 27:19. [PMID: 31015956 PMCID: PMC6469207 DOI: 10.1186/s12998-019-0239-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
Background Approximately 60% of people with low back pain also have associated leg pain symptoms. Guidelines for low back pain recommend non-pharmacological approaches, including spinal manipulation - a therapy provided by chiropractors. However, limited empirical data has examined the characteristics of chiropractors managing patients with low back-related leg pain (LBRLP). Our objective is to describe the prevalence, profile and practice characteristics of Australian chiropractors who often treat LBRLP, compared to those who do not often treat LBRLP. Methods This is a cross-sectional analysis of a nationally representative sample from the Australian Chiropractic Research Network (ACORN). This study investigated the demographic and practice characteristics as well as clinical management of chiropractors who ‘often’ treated patients with LBRLP compared to those who treated LBRLP ‘never/rarely/sometimes’. Multiple logistic regression models identified independent factors associated with chiropractors who ‘often’ treated patients with LBRLP. Results A total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. Chiropractors who ‘often’ treated LBRLP were more likely to manage patients with multi-site pain including axial low back pain (OR = 21.1), referred/radicular neck pain (OR = 10.8) and referred/radicular thoracic pain (OR = 3.1). While no specific management strategies were identified, chiropractors who ‘often’ treated LBRLP were more likely to discuss medication (OR = 1.8), manage migraine (OR = 1.7) and degenerative spine conditions (OR = 1.5), and treat women during pregnancy (OR = 1.6) and people with work-related injuries (OR = 1.5), compared to those not treating LBRLP frequently. Conclusions Australian chiropractors frequently manage LBRLP, although the nature of specific management approaches for this condition remains unclear. Further research on the management of LBRLP can better inform policy makers and educators interested in upskilling chiropractors to deliver safe and effective treatment of LBRLP.
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Affiliation(s)
- Matthew Fernandez
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Level 3, Room 369, 17 Wally's Walk, Sydney, NSW Australia.,Chiropractic Academy for Research Leadership (CARL), Sydney, Australia
| | - Craig Moore
- Chiropractic Academy for Research Leadership (CARL), Sydney, Australia.,3Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
| | - Wenbo Peng
- 3Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
| | - Katie de Luca
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Level 3, Room 369, 17 Wally's Walk, Sydney, NSW Australia.,Chiropractic Academy for Research Leadership (CARL), Sydney, Australia
| | - Katherine A Pohlman
- Chiropractic Academy for Research Leadership (CARL), Sydney, Australia.,4Research Institute, Parker University, Dallas, Texas USA
| | - Michael Swain
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Level 3, Room 369, 17 Wally's Walk, Sydney, NSW Australia.,Chiropractic Academy for Research Leadership (CARL), Sydney, Australia
| | - Jon Adams
- 3Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
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Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J 2018; 18:1030-1040. [PMID: 29174459 PMCID: PMC5984249 DOI: 10.1016/j.spinee.2017.10.071] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/18/2017] [Accepted: 10/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Evidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions. PURPOSE The present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica. STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE The present study included adults visiting their family doctor with back-related leg pain in the United Kingdom. OUTCOME MEASURES Information about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). METHODS Participants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. RESULTS A total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19-0.90), higher identity score (OR 0.70; CI 0.53-0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13-0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. CONCLUSIONS The present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.
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Affiliation(s)
- Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom.
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
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10
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Stynes S, Konstantinou K, Ogollah R, Hay EM, Dunn KM. Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PLoS One 2018; 13:e0191852. [PMID: 29621243 PMCID: PMC5886387 DOI: 10.1371/journal.pone.0191852] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 01/12/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Identification of sciatica may assist timely management but can be challenging in clinical practice. Diagnostic models to identify sciatica have mainly been developed in secondary care settings with conflicting reference standard selection. This study explores the challenges of reference standard selection and aims to ascertain which combination of clinical assessment items best identify sciatica in people seeking primary healthcare. METHODS Data on 394 low back-related leg pain consulters were analysed. Potential sciatica indicators were seven clinical assessment items. Two reference standards were used: (i) high confidence sciatica clinical diagnosis; (ii) high confidence sciatica clinical diagnosis with confirmatory magnetic resonance imaging findings. Multivariable logistic regression models were produced for both reference standards. A tool predicting sciatica diagnosis in low back-related leg pain was derived. Latent class modelling explored the validity of the reference standard. RESULTS Model (i) retained five items; model (ii) retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests and neurological deficit. Model (i) was well calibrated (p = 0.18), discrimination was area under the receiver operating characteristic curve (AUC) 0.95 (95% CI 0.93, 0.98). Model (ii) showed good discrimination (AUC 0.82; 0.78, 0.86) but poor calibration (p = 0.004). Bootstrapping revealed minimal overfitting in both models. Agreement between the two latent classes and clinical diagnosis groups defined by model (i) was substantial, and fair for model (ii). CONCLUSION Four clinical assessment items were common in both reference standard definitions of sciatica. A simple scoring tool for identifying sciatica was developed. These criteria could be used clinically and in research to improve accuracy of identification of this subgroup of back pain patients.
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Affiliation(s)
- Siobhán Stynes
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
- * E-mail:
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
| | - Elaine M. Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
| | - Kate M. Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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11
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Stynes S, Konstantinou K, Ogollah R, Hay EM, Dunn KM. Novel approach to characterising individuals with low back-related leg pain: cluster identification with latent class analysis and 12-month follow-up. Pain 2018; 159:728-738. [PMID: 29319608 PMCID: PMC6485623 DOI: 10.1097/j.pain.0000000000001147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traditionally, low back-related leg pain (LBLP) is diagnosed clinically as referred leg pain or sciatica (nerve root involvement). However, within the spectrum of LBLP, we hypothesised that there may be other unrecognised patient subgroups. This study aimed to identify clusters of patients with LBLP using latent class analysis and describe their clinical course. The study population was 609 LBLP primary care consulters. Variables from clinical assessment were included in the latent class analysis. Characteristics of the statistically identified clusters were compared, and their clinical course over 1 year was described. A 5 cluster solution was optimal. Cluster 1 (n = 104) had mild leg pain severity and was considered to represent a referred leg pain group with no clinical signs, suggesting nerve root involvement (sciatica). Cluster 2 (n = 122), cluster 3 (n = 188), and cluster 4 (n = 69) had mild, moderate, and severe pain and disability, respectively, and response to clinical assessment items suggested categories of mild, moderate, and severe sciatica. Cluster 5 (n = 126) had high pain and disability, longer pain duration, and more comorbidities and was difficult to map to a clinical diagnosis. Most improvement for pain and disability was seen in the first 4 months for all clusters. At 12 months, the proportion of patients reporting recovery ranged from 27% for cluster 5 to 45% for cluster 2 (mild sciatica). This is the first study that empirically shows the variability in profile and clinical course of patients with LBLP including sciatica. More homogenous groups were identified, which could be considered in future clinical and research settings.
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Affiliation(s)
- Siobhán Stynes
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Elaine M. Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Kate M. Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
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Foster NE, Konstantinou K, Lewis M, Ogollah R, Dunn KM, van der Windt D, Beardmore R, Artus M, Bartlam B, Hill JC, Jowett S, Kigozi J, Mallen C, Saunders B, Hay EM. The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581). BMC Musculoskelet Disord 2017; 18:172. [PMID: 28441971 PMCID: PMC5405475 DOI: 10.1186/s12891-017-1513-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Sciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of ‘wait and see’ for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care. Methods/Design Multicentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the acceptability of stratified care. Discussion This paper presents the details of the rationale, design and processes of the SCOPiC trial. Results from this trial will contribute to the evidence base for management of patients with sciatica consulting in primary care. Trial registration ISRCTN75449581, date: 20.11.2014.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Ruth Beardmore
- Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Majid Artus
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Bernadette Bartlam
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Jonathan C Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Health Economics Unit Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jesse Kigozi
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Health Economics Unit Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Benjamin Saunders
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
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