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Simula AS, Malmivaara A, Booth N, Karppinen J. Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial. J Rehabil Med 2024; 56:jrm28321. [PMID: 38643363 PMCID: PMC11151494 DOI: 10.2340/jrm.v56.28321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/03/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. DESIGN A benchmarking controlled trial design was used. SUBJECTS/PATIENTS Three primary healthcare areas and 654 low back pain patients with or without sciatica. METHODS Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. RESULTS No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003). Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of General
Medicine, Wellbeing services county of South Savo (ELOISA), Mikkeli, Finland.
| | - Antti Malmivaara
- Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedic Hospital, Helsinki, Finland
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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2
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Vervaeke R, Lafrance S, Demont A. Core competencies for first contact physiotherapists in a direct access model of care for adults with musculoskeletal disorders: A scoping review. Musculoskeletal Care 2023; 21:1353-1363. [PMID: 37641476 DOI: 10.1002/msc.1813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION To optimise the management of Musculoskeletal disorders (MSKDs), many countries have implemented direct access to physiotherapy; however, the core competencies required for first contact physiotherapists (PTs) have not been precisely defined. The aim of this scoping review is to identify and describe the core competencies required for first contact PTs treating adults with MSKDs. METHODS We conducted a scoping review of the literature by searching eight databases and grey literature up to July 2023. We performed a thematic analysis of the competencies identified based on predefined themes relevant to first contact physiotherapy in direct access models in primary or emergency care settings. RESULTS Sixty-five articles were included. Seventeen core competencies were identified and grouped into 5 themes: (1) Assessment and examination; (2) Management and interventions; (3) Communication; (4) Cooperation and collaboration; and (5) Professionalism and leadership. CONCLUSIONS Our findings provide an international perspective on the core competencies required for first contact PTs.
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Affiliation(s)
| | - Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, Quebec, Canada
| | - Anthony Demont
- INSERM UMR-S 1153, Centre de Recherche Épidémiologique et Statistique Sorbonne Paris Cité, Paris, France
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3
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Lemmers GPG, Bier JD, van Lankveld W, Westert GP, Staal JB, van der Wees PJ. Guideline adherence of physiotherapists in the treatment of patients with low back pain: A qualitative study. J Eval Clin Pract 2022; 28:1147-1156. [PMID: 35615965 PMCID: PMC9796459 DOI: 10.1111/jep.13703] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
RATIONALE Adherence rates to guidelines show room for improvement, and increase in adherence to guidelines may potentially lead to better outcomes and reduced costs of treatment. To improve adherence, it is essential to understand the considerations of physiotherapists regarding the assessment and management of low back pain (LBP). The purpose of this study is to gain insight in the considerations of Dutch physiotherapists on adherence to the national physiotherapy guideline in the treatment of patients with LBP. METHODS This is a qualitative study, using an interpretive approach of semi-structured interviews with 14 physiotherapists who regularly treat patients with LBP. Thematic analysis was conducted with open coding using an existing framework. This framework distinguishes five components to adherence based on patient factors, provider factors, guideline characteristics, institutional factors and the implementation process. RESULTS Participating physiotherapists mentioned that the guideline should provide more information about psychosocial prognostic factors and psychosocial treatment options. The participants experienced difficulties in addressing patient expectations that conflict with guideline recommendations. The implementation process of the guideline was considered insufficient. Physiotherapists might rely too much on their experience, and knowledge of evidence-based treatment might be improved. In general, the interviewed physiotherapists thought they were mainly non-adherent to the guidelines. However, when comparing their considerations with the actual guideline recommendations they were mainly adherent. CONCLUSION To improve adherence, the guideline should provide more information about addressing psychosocial prognostic factors, and Dutch physiotherapists might be trained in communication skills to better address patient expectations. A more extensive implementation process is warranted for the next guideline to increase the physiotherapists' knowledge of evidence-based treatment.
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Affiliation(s)
- Gijs Petrus Gerardus Lemmers
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Research & Development, Fysius Back Experts, Nijverdal, The Netherlands.,School for Allied Health, Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Jasper Daniël Bier
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands.,Department of Physiotherapy, FS Fysio, Capelle aan den IJssel, The Netherlands
| | - Wim van Lankveld
- School for Allied Health, Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Gerard Pieter Westert
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jacobus Bart Staal
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,School for Allied Health, Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Philip Jan van der Wees
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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4
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Belavy DL, Tagliaferri SD, Buntine P, Saueressig T, Ehrenbrusthoff K, Chen X, Diwan A, Miller CT, Owen PJ. Interventions for promoting evidence-based guideline-consistent surgery in low back pain: a systematic review and meta-analysis of randomised controlled trials. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2851-2865. [PMID: 36114891 DOI: 10.1007/s00586-022-07378-6] [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: 05/15/2022] [Revised: 07/09/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Examine the effectiveness of interventions to approach guideline-adherent surgical referrals for low back pain assessed via systematic review and meta-analysis. METHODS Five databases (10 September 2021), Google Scholar, reference lists of relevant systematic reviews were searched and forward and backward citation tracking of included studies were implemented. Randomised controlled/clinical trials in adults with low back pain of interventions to optimise surgery rates or referrals to surgery or secondary referral were included. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random effects meta-analysis with a Paule Mandel estimator plus Hartung-Knapp-Sidik-Jonkman method was used to calculate the odds ratio and 95% confidence interval, respectively. RESULTS Of 886 records, 6 studies were included (N = 258,329) participants; cluster sizes ranged from 4 to 54. Five studies were rated as low risk of bias and one as having some concerns. Two studies reporting spine surgery referral or rates could only be pooled via combination of p values and gave evidence for a reduction (p = 0.021, Fisher's method, risk of bias: low). This did not persist with sensitivity analysis (p = 0.053). For secondary referral, meta-analysis revealed a non-significant odds ratio of 1.07 (95% CI [0.55, 2.06], I2 = 73.0%, n = 4 studies, Grading of Recommendations Assessment, Development and Evaluation [GRADE] evidence certainty: very low). CONCLUSION Few RCTs exist for interventions to improve guideline-adherent spine surgery rates or referral. Clinician education in isolation may not be effective. Future RCTs should consider organisational and/or policy level interventions. PROSPERO REGISTRATION CRD42020215137.
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Affiliation(s)
- Daniel L Belavy
- Division of Physiotherapy, Department of Applied Health Sciences, Hochschule Für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801, Bochum, Germany.
| | - Scott D Tagliaferri
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | | | - Katja Ehrenbrusthoff
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
| | - Xiaolong Chen
- Department of Orthopaedic Surgery, Spine Service, St. George Hospital, University of New South Wales, Sydney, Australia
| | - Ashish Diwan
- Department of Orthopaedic Surgery, Spine Service, St. George Hospital, University of New South Wales, Sydney, Australia
| | - Clint T Miller
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
| | - Patrick J Owen
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
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Demont A, Benaïssa L, Recoque V, Desmeules F, Bourmaud A. Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France. PLoS One 2022; 17:e0274021. [PMID: 36067139 PMCID: PMC9447922 DOI: 10.1371/journal.pone.0274021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives
To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.
Methods
This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.
Results
Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).
Conclusions
We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.
Trial registration
ClinicalTrials.gov: NCT04177121
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Affiliation(s)
- Anthony Demont
- Université Paris Cité, Inserm, ECEVE, Paris, France
- AP-HP, Hôpital Robert Debré, Paris, France
- * E-mail:
| | - Leila Benaïssa
- Physiotherapy School, University of Orléans, Orléans, France
| | | | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada
| | - Aurélie Bourmaud
- Université Paris Cité, Inserm, ECEVE, Paris, France
- AP-HP, Hôpital Robert Debré, Paris, France
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6
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Demont A, Quentin J, Bourmaud A. [Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review]. Rev Epidemiol Sante Publique 2020; 68:306-313. [PMID: 32893028 DOI: 10.1016/j.respe.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/08/2020] [Accepted: 08/01/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Musculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France. METHODS A literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies. RESULTS Thirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality. CONCLUSION The studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients' access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.
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Affiliation(s)
- A Demont
- Inserm 1123 ECEVE, faculté de médecine, université Paris-Diderot, Paris, France; École universitaire de kinésithérapie, université d'Orléans, Orléans, France.
| | - J Quentin
- Pôle Saint-Hélier, centre de médecine physique et réadaptation, Rennes, France
| | - A Bourmaud
- Inserm 1123 ECEVE, faculté de médecine, université Paris-Diderot, Paris, France
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7
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Logan GS, Pike A, Copsey B, Parfrey P, Etchegary H, Hall A. What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews. PLoS One 2019; 14:e0225414. [PMID: 31805073 PMCID: PMC6894771 DOI: 10.1371/journal.pone.0225414] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/03/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Since 2000, guidelines have been consistent in recommending when diagnostic imaging for low back pain should be obtained to ensure patient safety and reduce unnecessary tests. This systematic review and meta-analysis was conducted to determine the pooled proportion of CT and x-ray imaging of the lumbar spine that were considered appropriate in primary and emergency care. METHODS Pubmed, CINAHL, The Cochrane Database of Systematic Reviews and Embase were searched for synonyms of "low back pain", "guidelines", and "adherence" that were published after 2000. Titles, abstracts, and full texts were reviewed for inclusion with forward and backward tracking on included studies. Included studies had data extracted and synthesized. Risk of bias was performed on all studies, and GRADE was performed on included studies that provided data on CT and x-ray separately. A random effect, single proportion meta-analysis model was used. RESULTS Six studies were included in the descriptive synthesis, and 5 studies included in the meta-analysis. Five of the 6 studies assessed appropriateness of x-rays; two of the six studies assessed appropriateness of CTs. The pooled estimate for appropriateness of x-rays was 43% (95% CI: 30%, 56%) and the pooled estimate for appropriateness of CTs was 54% (95% CI: 51%, 58%). Studies did not report adequate information to fulfill the RECORD checklist (reporting guidelines for research using observational data). Risk of bias was high in 4 studies, moderate in one, and low in one. GRADE for x-ray appropriateness was low-quality and for CT appropriateness was very-low-quality. CONCLUSION While this study determined a pooled proportion of appropriateness for both x-ray and CT imaging for low back pain, there is limited confidence in these numbers due to the downgrading of the evidence using GRADE. Further research on this topic is needed to inform our understanding of x-ray and CT appropriateness in order to improve healthcare systems and decrease patient harms.
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Affiliation(s)
| | - Andrea Pike
- Primary Healthcare Research Unit, Memorial University, St. John’s, NL, Canada
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Patrick Parfrey
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Amanda Hall
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
- Primary Healthcare Research Unit, Memorial University, St. John’s, NL, Canada
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Complementing or conflicting? A qualitative study of osteopaths’ perceptions of NICE low back pain and sciatica guidelines in the UK. INT J OSTEOPATH MED 2019. [DOI: 10.1016/j.ijosm.2019.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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9
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Elliott JM, Hancock MJ, Crawford RJ, Smith AC, Walton DM. Advancing imaging technologies for patients with spinal pain: with a focus on whiplash injury. Spine J 2018; 18:1489-1497. [PMID: 28774580 PMCID: PMC6874915 DOI: 10.1016/j.spinee.2017.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/11/2017] [Accepted: 06/16/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Radiological observations of soft-tissue changes that may relate to clinical symptoms in patients with traumatic and non-traumatic spinal disorders are highly controversial. Studies are often of poor quality and findings are inconsistent. A plethora of evidence suggests some pathoanatomical findings from traditional imaging applications are common in asymptomatic participants across the life span, which further questions the diagnostic, prognostic, and theranostic value of traditional imaging. Although we do not dispute the limited evidence for the clinical importance of most imaging findings, we contend that the disparate findings across studies may in part be due to limitations in the approaches used in assessment and analysis of imaging findings. PURPOSE This clinical commentary aimed to (1) briefly detail available imaging guidelines, (2) detail research-based evidence around the clinical use of findings from advanced, but available, imaging applications (eg, fat and water magnetic resonance imaging and magnetization transfer imaging), and (3) introduce how evolving imaging technologies may improve our mechanistic understanding of pain and disability, leading to improved treatments and outcomes. STUDY DESIGN/SETTING A non-systematic review of the literature is carried out. METHODS A narrative summary (including studies from the authors' own work in whiplash injuries) of the available literature is provided. RESULTS An emerging body of evidence suggests that the combination of existing imaging sequences or the use of developing imaging technologies in tandem with a good clinical assessment of modifiable risk factors may provide important diagnostic information toward the exploration and development of more informed and effective treatment options for some patients with traumatic neck pain. CONCLUSIONS Advancing imaging technologies may help to explain the seemingly disconnected spectrum of biopsychosocial signs and symptoms of traumatic neck pain.
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Affiliation(s)
- James M Elliott
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1100, Chicago, IL, USA; School of Health and Rehabilitation Sciences, The University of Queensland, Australia; Zürich University of Applied Sciences, Gertrudstrasse 15, 8401 Winterthur, Switzerland.
| | - Mark J Hancock
- Faculty of Medicine and Health Sciences, Macquarie University, 2 Technology Pl, Macquarie Park, Sydney, NSW 2113, Australia
| | - Rebecca J Crawford
- Zürich University of Applied Sciences, Gertrudstrasse 15, 8401 Winterthur, Switzerland
| | - Andrew C Smith
- Regis University School of Physical Therapy, 3333 Regis Boulevard, Denver, CO 80221, USA
| | - David M Walton
- School of Physical Therapy, Western University, Room 1588, London, Ontario N6G 1H1, Canada
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10
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Bier JD, Kamper SJ, Verhagen AP, Maher CG, Williams CM. Patient Nonadherence to Guideline-Recommended Care in Acute Low Back Pain. Arch Phys Med Rehabil 2017; 98:2416-2421. [PMID: 28690076 DOI: 10.1016/j.apmr.2017.05.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the magnitude of patient-reported nonadherence with guideline-recommended care for acute low back pain. DESIGN Secondary analysis of data from participants enrolled in the Paracetamol for Acute Low Back Pain study trial, a randomized controlled trial evaluating the effectiveness of paracetamol for acute low back pain. SETTING Primary care, general practitioner. PARTICIPANTS Data from participants with acute low back pain (N=1643). INTERVENTIONS Guideline-recommended care, including reassurance, simple analgesia, and the advice to stay active and avoid bed rest. Also, advice against additional treatments and referral for imaging. MAIN OUTCOME MEASURES Proportion of nonadherence with guideline-recommended care. Nonadherence was defined as (1) failure to consume the advised paracetamol dose, or (2) receipt of additional health care, tests, or medication during the trial treatment period (4wk). Multivariable logistic regression analysis was performed to determine the factors associated with nonadherence. RESULTS In the first week of treatment, 39.7% of participants were classified as nonadherent. Over the 4-week treatment period, 70.0% were nonadherent, and 57.5% did not complete the advised paracetamol regimen. Higher perceived risk of persistent pain, lower level of disability, and not claiming workers' compensation were associated with nonadherence, with odds ratios ranging from .46 to 1.05. CONCLUSIONS Adherence to guideline-recommended care for acute low back pain was poor. Most participants do not complete the advised paracetamol regimen. Higher perceived risk of persistence of complaints, lower baseline disability, and participants not claiming workers' compensation were independently associated with nonadherence.
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Affiliation(s)
- Jasper D Bier
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands.
| | - Steven J Kamper
- School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Pain, Health and Lifestyle, Australia
| | | | | | - Christopher M Williams
- Centre for Pain, Health and Lifestyle, Australia; Hunter Medical Research Institute and School of Medicine and Public Health, University of Newcastle, NSW, Australia; Hunter New England Population Health, Wallsend, Australia
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11
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Elliott JM, Courtney DM. Clinician's Commentary on Belot et al. 1. Physiother Can 2017; 69:290-291. [PMID: 30371682 DOI: 10.3138/ptc.2016-32-cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- James M Elliott
- Professor, Faculty of Health Sciences, The University of Sydney and Northern Sydney Local Health District, St Leonards, Sydney, NSW, Australia; Adjunct Professor, Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA;
| | - D Mark Courtney
- Associate Professor, Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL;
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12
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Lorenzo A, Schildt P, Lorenzo M, Falcoff H, Noel F. Acute low back pain management in primary care: a simulated patient approach. Fam Pract 2015; 32:436-41. [PMID: 26060210 DOI: 10.1093/fampra/cmv030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent medical guidelines for acute low back pain (aLBP) are unevenly followed. Based on financial criteria or associated with a desirability bias, studies incompletely describe the actual management provided by general practitioners (GPs) in terms of diagnosis, treatment and prevention of progression towards chronicity. OBJECTIVE To compare actual practices of French GPs for aLBP management with clinical guidelines. METHODS A young simulated patient (SP) consulted, using a single scenario of aLBP, in 30 primary care practices in the Paris region. RESULTS Heterogeneous data were collected according to the grid items: during the questioning, 29 GPs (97%) asked for age and 1 GP (3%) for pregnancy; during the clinical examination, 21 GPs (70%) asked for spinal stiffness and 3 GPs (10%) for cauda equina syndrome. Non-steroidal anti-inflammatory drugs were prescribed by 27 GPs (90%). Imaging (2 GPs or 7%) and physiotherapy (3 GPs or 10%) was rarely prescribed. A sick leave was prescribed by 22 GPs (73%). Twenty-seven GPs (90%) reassured the patient. CONCLUSION aLBP management was in line with international guidelines in terms of clinical examination, physiotherapy and imaging prescriptions and some risk factors for chronicity were taken into account. However, patient questioning was brief, and drug and sick leave prescriptions did not meet international guidelines. The SP approach seems to be a useful tool for assessing actual GP practices.
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Affiliation(s)
- Alain Lorenzo
- Faculty of Medicine, Department of General Practice, Université Paris Descartes, Sorbonne Paris Cité, Paris and
| | - Pauline Schildt
- Faculty of Medicine, Department of General Practice, Université Paris Descartes, Sorbonne Paris Cité, Paris and
| | - Mathieu Lorenzo
- Faculty of Medicine, Department of General Practice, Université de Strasbourg, Strasbourg, France
| | - Hector Falcoff
- Faculty of Medicine, Department of General Practice, Université Paris Descartes, Sorbonne Paris Cité, Paris and
| | - Fréderique Noel
- Faculty of Medicine, Department of General Practice, Université Paris Descartes, Sorbonne Paris Cité, Paris and
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Piccoliori G, Engl A, Gatterer D, Sessa E, in der Schmitten J, Abholz HH. Management of low back pain in general practice - is it of acceptable quality: an observational study among 25 general practices in South Tyrol (Italy). BMC FAMILY PRACTICE 2013; 14:148. [PMID: 24090155 PMCID: PMC3850994 DOI: 10.1186/1471-2296-14-148] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/20/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND There are several guidelines dealing with the management of low back pain (LBP), but only few studies on the quality of care provided within General Practices as judged against those guidelines.The objective of this study is to analyse the management of LBP in Italian General Practice and compare it with guideline recommendations. METHODS In this observational study, all patients visiting their General Practitioners (GPs) for treatment of LBP within a 8-week period were monitored for at least four weeks with regard to symptoms and diagnostic and therapeutic interventions. Management of LBP was judged by pre-defined quality indicators based on guideline recommendations. RESULTS Twenty-five of 114 eligible GPs participated in the study, representing a total of 43,012 registered patients. Of the 475 patients complaining of LBP and monitored for four weeks, 55.8% were diagnosed as having acute lumbar pain, 13.5% chronic lumbar pain, 17.1% acute sciatica, and 12.6% chronic sciatica; 76.0% underwent no technical investigations, 21.7% underwent x-rays, 5.5% MRI and 4% CT scans; 20.4% were referred to secondary care; 93.3% of all patients received some medication. In those receiving a medication, in 88.3% it was an NSAID, in 6.3% Paracetamol, in 10.4% Paracetamol combined with Codeine, and in 9% a muscle relaxants. When physiotherapy was prescribed (17,1%), it was mostly massage. Hardly more than 50% of GPs (partially) followed locally established guidelines, while the remainder seemed not to follow guidelines at all. CONCLUSIONS Our study reveals gross deviations of GP management of LBP from current guidelines and points to two different types of deviators: those who partially follow guidelines, and those who do not follow them at all. Further research should evaluate whether these two types of deviation are best addressed by different foci of education, i.e. on knowledge versus attitudes, respectively.
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Affiliation(s)
| | - Adolf Engl
- Accademia Altoatesina di Medicina Generale (AcAMG), Bolzano, Italy
| | - Doris Gatterer
- Accademia Altoatesina di Medicina Generale (AcAMG), Bolzano, Italy
| | - Emiliano Sessa
- Statistics, Agenzia Regionale di Sanità Toscana, Florence, Italy
| | - Jürgen in der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Heinz-Harald Abholz
- Accademia Altoatesina di Medicina Generale (AcAMG), Bolzano, Italy
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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Kier A, George M, McCarthy PW. Survey based investigation into general practitioner referral patterns for spinal manipulative therapy. Chiropr Man Therap 2013; 21:16. [PMID: 23718217 PMCID: PMC3668299 DOI: 10.1186/2045-709x-21-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 05/16/2013] [Indexed: 11/20/2022] Open
Abstract
Background In the UK Physiotherapy, Chiropractic and Osteopathy are all statutory regulated professions. Though guidelines have supported the use of Spinal Manipulative Therapy (SMT) for low back pain (LBP), General Practitioners (GP) referral patterns to the 3 registered professions that perform SMT are generally unknown. Method A short questionnaire was designed and piloted. Demographic information, patient referral to SMT and the GPs own personal utilisation of SMT were obtained. 385 GP’s were contacted representing approximately 20% of the GP’s in Wales Autumn 2007. Results and discussion 182 (50.8%) completed questionnaires were returned. Profile characteristics: 2/3 of respondents were male, 79% were 40 years old or older (statistically reflective of the total population of GPs in Wales at that time) and 62% had 20 years or less in practise. Personal use of SMT by GP’s: 48 respondents had sought SMT treatment and a further 56% of those that had not previously sought SMT indicated that they would consider doing so. Patient referral to SMT by GP’s: 131 respondents (72%) had referred patients to SMT and of those who had not a further 13% would consider referring. The general referral pattern and utilisation pattern was Physiotherapy: Osteopathy: Chiropractic. 21% who had never referred patients neither had, nor would consider it for themselves. A small subgroup appeared to manage personal choice differently from patient referral: 5 individuals who had not referred patients either had or would consider it for themselves and 23 of the group that would refer patients neither had nor would seek it for themselves. Conclusions This limited investigation indicates that GP’s do practise consistently with guidelines on back pain and utilise SMT as a care option. Although the main option for referral was physiotherapy, slightly over 40% of respondents who expressed a preference would refer to either osteopathy or chiropractic, or both in preference to physiotherapy. There was a small proportion that did not and would not refer patients for SMT regardless of personal use of SMT; these suggested use of acupuncture. Further investigation is needed to determine the alternatives to SMT offered to patients and the decision-making criteria for patient referral to subtypes of SMT practitioner.
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Affiliation(s)
- Annabel Kier
- Welsh Institute of Chiropractic, University of South Wales, Treforest, Pontypridd CF38 2TE, UK
| | | | - Peter W McCarthy
- Welsh Institute of Chiropractic, University of South Wales, Treforest, Pontypridd CF38 2TE, UK
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Murphy S, Blake C, Power CK, Fullen BM. The role of clinical specialist physiotherapists in the management of low back pain in a spinal triage clinic. Ir J Med Sci 2013; 182:643-50. [PMID: 23564519 DOI: 10.1007/s11845-013-0945-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 03/25/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Traditional care pathways for patients with low back pain (LBP) where general practitioners (GPs) refer to consultant specialists can lead to excessive waiting times for patients and questionable use of health care resources. The evaluation of more cost effective pathways is a priority. AIMS The study aims to determine if clinical specialist physiotherapists can allocate patients into the three distinct diagnostic triage categories in line with international guidelines. A secondary aim is to examine the utility of baseline domains to inform clinical decision making. METHODS A review of LBP patients (n = 1,532) consecutively referred between 2008 and 2010 to a physiotherapy led spinal triage clinic was undertaken. Baseline demographics, pain severity (Visual Analogue Scale), disability (Roland Morris Disability Questionnaire), distress (Distress and Risk Assessment Method), mobility and function were assessed. Relationships between these factors were analysed. RESULTS Eighty-five percent of the population were deemed suitable for conservative management and were referred for either group exercise intervention (n = 1,125, 73 %) or individual treatment (n = 178, 12 %), in line with clinical guidelines. Fourteen percent were discharged and only 1 % required a specialist opinion. Patients allocated to the three management streams could be clearly discriminated by baseline measures of pain, distress, disability and function (p < 0.01). CONCLUSION Clinical Specialist physiotherapists are effective in assessing and selecting appropriate care pathways for LBP patients in line with international LBP clinical guidelines. The utility of the physical and psychological measures to differentiate between groups of varying clinical severity has important implications for treatment selection and management.
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Affiliation(s)
- S Murphy
- School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, Ireland,
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16
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Physiotherapists' knowledge, attitudes, and intolerance of uncertainty influence decision making in low back pain. Clin J Pain 2012; 28:467-74. [PMID: 22673478 DOI: 10.1097/ajp.0b013e31825bfe65] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low back pain (LBP) remains a common health problem that is characterized by ambiguity and can progress to chronic disability. In recent years researchers have started to focus on understanding whether and how the attitudes and beliefs of the health care providers influence the management and the outcome of LBP. OBJECTIVES The purpose of this study was to characterize Quebec physiotherapists' (PTs') knowledge, attitudes, and beliefs about LBP and their intolerance of uncertainty (IU) to determine whether and how these characteristics predict judgments of assessment and treatment recommendations. METHODS A total of 108 PTs from Quebec, Canada completed the Pain Attitudes and Beliefs Scale for Physiotherapists, the Fear of Pain Questionnaire, and the Intolerance of Uncertainty Scale. Participants also read 2 vignettes that described patients with LBP and reported their assessment and treatment recommendations. RESULTS Only 13 PTs (12%) were able to identify clinical practice guidelines for LBP. In addition, PTs did not generally agree with recommendations to return to work or activity. A biomedical orientation was a significant predictor of clinical judgments of spinal pathology and was associated with an increased sense of IU. In contrast, a behavioral approach better predicted treatment recommendations for return-to-work or activity. Finally, the association between IU and treatment decisions was mediated by treatment orientation. DISCUSSION Health care practitioners play a significant role in the management of LBP. Research on the process of knowledge translation, clinical decision making, and dealing with uncertainty to avoid aggravating LBP disability is clearly warranted.
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Acute low back pain information online: An evaluation of quality, content accuracy and readability of related websites. ACTA ACUST UNITED AC 2012; 17:318-24. [DOI: 10.1016/j.math.2012.02.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 02/20/2012] [Accepted: 02/24/2012] [Indexed: 11/19/2022]
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Guidelines on low back pain disability: interprofessional comparison of use between general practitioners, occupational therapists, and physiotherapists. Spine (Phila Pa 1976) 2012; 37:1252-9. [PMID: 22310094 DOI: 10.1097/brs.0b013e31824b6adf] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Individual semistructured qualitative interviews. OBJECTIVE To evaluate barriers to use of management recommendations, aimed at preventing low back pain (LBP) disability, with general practitioners (GPs), occupational therapists (OTs), and physiotherapists (PTs) working in Quebec (Canada), and identify areas of convergence and divergence between health professions. SUMMARY OF BACKGROUND DATA Studies have demonstrated inadequacies of practices of clinicians with regard to LBP management and prevention of persistent disability. Barriers to use of evidence by clinicians should be evaluated to understand these inadequacies and develop implementation strategies. METHODS Sixteen PTs, 8 OTs, and 8 GPs were recruited with different levels of experience and practice location (urban or rural). They were asked to follow management recommendations (Clinic on Low-back Pain in Interdisciplinary Practice [CLIP] guidelines), with a minimum of 2 patients. Individual semistructured interviews were used to identify barriers to use of management recommendations aimed at preventing LBP disability. Barriers between health professions were compared. RESULTS Barriers to use were lesser for OTs and greater for GPs, with divergences among PTs. OTs agreed with the guidelines, found them compatible with their current practice, and thought that using them would prevent persistent disability. GPs and PTs thought that the guidelines did not provide enough information on the pathophysiological management of LBP. GPs thought that it would be difficult to implement the guidelines in everyday practice. All 3 groups thought that management recommendations could conflict with patient expectations. CONCLUSION To address identified barriers, a process of care is proposed by fitting tasks to the most compatible providers. The task of GPs could focus on pain management through medication, red flag screening, encouragement to stay active, and reassurance. The tasks of PTs could center on pain management, general exercise, and encouragement to stay active. The tasks of OTs could focus on disability prognosis, yellow flags management, and return to activity parameters. The efficacy of this process of care to prevent persistent LBP disability should be assessed in a trial.
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Slater H, Davies SJ, Parsons R, Quintner JL, Schug SA. A policy-into-practice intervention to increase the uptake of evidence-based management of low back pain in primary care: a prospective cohort study. PLoS One 2012; 7:e38037. [PMID: 22662264 PMCID: PMC3360643 DOI: 10.1371/journal.pone.0038037] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 04/30/2012] [Indexed: 11/18/2022] Open
Abstract
Background Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs). Methods To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 = nil and 5 = excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale). Results Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention. Conclusion An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.
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Affiliation(s)
- Helen Slater
- School of Physiotherapy, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia.
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20
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Abstract
STUDY DESIGN Pragmatic randomized clinical trial. OBJECTIVE This study investigated differences in the clinical outcomes of public physiotherapy (public PT) versus private physiotherapy (private PT) for general practitioner-referred patients with acute and chronic low back pain (LBP). SUMMARY OF BACKGROUND DATA Health care setting (i.e., public or private) has been found to influence the course and clinical outcome of common diseases. Despite the international burden of LBP, the effect of health care setting on clinical outcomes has not been investigated in this population. METHODS One hundred sixty consenting patients, who were referred for physiotherapy for LBP by their general practitioner, completed the Roland Morris Disability Questionnaire (primary outcome), Short-Form 36 v2, Fear Avoidance Beliefs Questionnaire, Back Beliefs Questionnaire, EuroQol EQ5D, and Patient Satisfaction Questionnaires. The patients were stratified (acute LBP: ≤ 3 months, n = 55; chronic LBP: > 3 months, n = 105), randomly allocated to receive public PT (n = 3 hospitals) or private PT (n = 12 clinics), and followed up at 3, 6, and 12 months postrandomization. RESULTS Repeated measures analysis of variance showed significant improvement over time for 9 predominantly biomedical outcomes: (i) Roland Morris Disability Questionnaire at 3 and 6 months, (ii) Short-Form 36 v2 Physical Component Score, Bodily Pain, Role Physical, General Health, Vitality, EQ5D visual analogue scale, and weighted health index scores at 3 months, and (iii) the Back Beliefs Questionnaire at 6 months. The remaining 7 biopsychosocial outcomes showed no change over time, and the "between within" repeated measures analysis of variance showed no significant differences between groups over time for any outcome measures (P > 0.05). Independent samples t tests found no significant differences between groups in the mean changes in outcome measures from baseline at 12 months, apart from SF-36 v2 Role Physical (mean difference, 95% CI = 5.64 [0.860-10.428]; t = 2.337; P = 0.021) in favor of the private PT group. There were significantly higher levels of satisfaction with outcome of treatment in the private PT group (median [IQR]: public PT: 5.0 [2.0]; private PT: 6.0 [2.0]; Mann-Whitney U test = 1324.50; P = 0.020), but no differences in satisfaction with treatment or global perceived improvement (P > 0.05). The private PT group had a significantly shorter waiting time (mean difference = 39.79 days; 95% CI: 26.88-52.69; t = 6.121; P < 0.001) and treatment duration (mean difference: 23.48 days; 95% CI: 7.43-39.52; t = 2.909; P = 0.005) than public PT. Participants in both groups were treated with advice/education, manipulative therapy, and exercise therapy, with minimal use of cognitive behavioral approaches in either group. Physiotherapists in the private PT group had significantly more experience and more postgraduate qualifications than the public PT group (P < 0.005). CONCLUSION Despite differences between public and private PT regarding waiting times for treatment and therapist experience, there were no significant differences between groups in the majority of clinical outcome measure scores at follow-up, apart from SF-36 Role Physical and satisfaction with treatment outcome in favor of the private PT group.
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Derghazarian T, Simmonds MJ. Management of low back pain by physical therapists in quebec: how are we doing? Physiother Can 2011; 63:464-73. [PMID: 22942525 DOI: 10.3138/ptc.2010-04p] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE In this study, we characterized physiotherapists' attitudes and beliefs about the bio-psychosocial problem of low back pain (LBP), their use of clinical practice guidelines (CPGs), and the extent to which their advice and treatment is in line with best-evidence CPGs. METHODS One hundred eight physiotherapists completed an online survey that included questionnaires exploring the strength of physiotherapists' biomedical and bio-psychosocial orientations toward the management of LBP: the Pain Attitudes and Beliefs Scale for Physiotherapists and the Attitudes to Back Pain Scale for musculoskeletal practitioners. In addition, participants responded to questions about treatment recommendations for patients in two vignettes. RESULTS Only 12% of respondents were aware of CPGs. Physiotherapists with a stronger biomedical orientation scored the severity of spinal pathology higher in the patient vignettes. A stronger biomedical orientation was also associated with disagreement with recommendations to return to usual activity or work. CONCLUSIONS The results suggest limited awareness by physiotherapists of best-evidence CPGs and contemporary understandings of LBP that support early activation and self-management. Research to better understand and facilitate the implementation of best-evidence professional education and clinical practice is an urgent priority.
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Affiliation(s)
- Tamar Derghazarian
- School of Physical and Occupational Therapy, McGill University, Montreal, QC
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22
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Dionne CE, Le Sage N, Franche RL, Dorval M, Bombardier C, Deyo RA. Five questions predicted long-term, severe, back-related functional limitations: evidence from three large prospective studies. J Clin Epidemiol 2011; 64:54-66. [DOI: 10.1016/j.jclinepi.2010.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 02/08/2010] [Accepted: 02/13/2010] [Indexed: 11/27/2022]
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Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10:514-29. [PMID: 20494814 DOI: 10.1016/j.spinee.2010.03.032] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 02/24/2010] [Accepted: 03/29/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Low back pain (LBP) is a prevalent, costly, and challenging condition to manage. Clinicians must choose among numerous assessment and management options. Several recent clinical practice guidelines (CPGs) on LBP have attempted to inform these decisions by evaluating and summarizing the best available supporting evidence. The quality and consistency of recommendations from these CPGs are currently unknown. PURPOSE To conduct a systematic review of recent CPGs and synthesize their recommendations on assessing and managing LBP for clinicians. STUDY DESIGN/SETTING Systematic review. METHODS Literature search using MEDLINE, National Guidelines Clearinghouse, National Institute for Clinical Excellence, Internet search engines, and references of known articles. Only CPGs related to both assessment and management of LBP written in English were eligible; CPGs that summarized evidence from before the year 2000 were excluded. Data related to methods and recommendations for assessment and management of LBP were abstracted independently by two reviewers. Methodological quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument by two reviewers. RESULTS The search uncovered 669 citations, of which 95 were potentially relevant and 10 were included in the review; 6 discussed acute LBP, 6 chronic LBP, and 6 LBP with neurologic involvement. Methods used to develop CPGs varied, but the overall methodological quality was high as defined by AGREE scores. Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested. Management of LBP with neurologic involvement was similar, with additional consideration given to magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful. CONCLUSIONS Recommendations from several recent CPGs regarding the assessment and management of LBP were similar. Clinicians who care for patients with LBP should endeavor to adopt these recommendations to improve patient care. Future CPGs may wish to invite coauthors from targeted clinician user groups, increase patient participation, update their literature searches before publication, conduct their own quality assessment of studies, and consider cost-effectiveness and other aspects in their recommendations more explicitly.
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Clarke A, Blundell N, Forde I, Musila N, Spitzer D, Naqvi S, Browne J. Can guidelines improve referral to elective surgical specialties for adults? A systematic review. Qual Saf Health Care 2010; 19:187-94. [PMID: 20211956 PMCID: PMC2989157 DOI: 10.1136/qshc.2008.029918] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim To assess effectiveness of guidelines for referral for elective surgical assessment. Method Systematic review with descriptive synthesis. Data sources Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites. Selection of studies Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults. Outcome measures Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs. Results 24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change. Conclusions Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.
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Affiliation(s)
- Aileen Clarke
- Warwick Medical School, University of Warwick, Health Sciences Research Institute, Coventry CV4 7AL, UK.
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25
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Machado LAC, Maher CG, Herbert RD, Clare H, McAuley JH. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med 2010; 8:10. [PMID: 20102596 PMCID: PMC2842230 DOI: 10.1186/1741-7015-8-10] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 01/26/2010] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Low back pain is a highly prevalent and disabling condition worldwide. Clinical guidelines for the management of patients with acute low back pain recommend first-line treatment consisting of advice, reassurance and simple analgesics. Exercise is also commonly prescribed to these patients. The primary aim of this study was to evaluate the short-term effect of adding the McKenzie method to the first-line care of patients with acute low back pain. METHODS A multi-centre randomized controlled trial with a 3-month follow-up was conducted between September 2005 and June 2008. Patients seeking care for acute non-specific low back pain from primary care medical practices were screened. Eligible participants were assigned to receive a treatment programme based on the McKenzie method and first-line care (advice, reassurance and time-contingent acetaminophen) or first-line care alone, for 3 weeks. Primary outcome measures included pain (0-10 Numeric Rating Scale) over the first seven days, pain at 1 week, pain at 3 weeks and global perceived effect (-5 to 5 scale) at 3 weeks. Treatment effects were estimated using linear mixed models. RESULTS One hundred and forty-eight participants were randomized into study groups, of whom 138 (93%) completed the last follow-up. The addition of the McKenzie method to first-line care produced statistically significant but small reductions in pain when compared to first-line care alone: mean of -0.4 points (95% confidence interval, -0.8 to -0.1) at 1 week, -0.7 points (95% confidence interval, -1.2 to -0.1) at 3 weeks, and -0.3 points (95% confidence interval, -0.5 to -0.0) over the first 7 days. Patients receiving the McKenzie method did not show additional effects on global perceived effect, disability, function or on the risk of persistent symptoms. These patients sought less additional health care than those receiving only first-line care (P = 0.002). CONCLUSIONS When added to the currently recommended first-line care of acute low back pain, a treatment programme based on the McKenzie method does not produce appreciable additional short-term improvements in pain, disability, function or global perceived effect. However, the McKenzie method seems to reduce health utilization although it does not reduce patient's risk of developing persistent symptoms. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12605000032651.
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Affiliation(s)
- Luciana AC Machado
- The George Institute for International Health, PO Box M201 Missenden Rd Sydney, NSW 2050, Australia
- Escola de Educação Física, Fisioterapia e Terapia Ocupacional, Universidade Federal de Minas Gerais, Av Antônio Carlos 6627, Pampulha, Belo Horizonte, MG 31270-901, Brazil
| | - Chris G Maher
- The George Institute for International Health, PO Box M201 Missenden Rd Sydney, NSW 2050, Australia
| | - Rob D Herbert
- The George Institute for International Health, PO Box M201 Missenden Rd Sydney, NSW 2050, Australia
| | - Helen Clare
- Focus on Backs 1/124 Shirley Road, Crows Nest, NSW 2065, Sydney, Australia
| | - James H McAuley
- The George Institute for International Health, PO Box M201 Missenden Rd Sydney, NSW 2050, Australia
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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Wilson IM, Kerr DP, Lennon S. Low back pain in people with a stoma: A postal survey. Disabil Rehabil 2009; 31:1937-42. [DOI: 10.1080/09638280902850238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
One in five Canadians suffers from some form of persistent or chronic pain. The impact on individual lives, families and friends, the health services sector and the economy is huge. Reliable evidence is available that the burden of persistent pain can be markedly reduced when available knowledge is applied. Bridging the quality chasm between chronic pain and the care process will require a unique confluence of opinion from all stakeholders committed within a focused community of practice to address the impact of pain. Various levels of success in this regard have been demonstrated when there is exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. It is now critical to accelerate the capture of the benefits of research for Canadians through improved health, more effective and responsive services and products, and a strengthened health care system to bring about health reform and health care reform across Canada as it pertains to the one in five Canadians living with chronic, disabling pain. The overarching outcome of such an initiative needs to be promoted to sustain a balanced portfolio of curiosity- and needs-based research, which along with existing knowledge, can be mobilized and applied for the benefit of Canadians, the health care system and the economy.
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Affiliation(s)
- Michael M Kochen
- Department of General Practice, University of Goettingen, D-37073 Göttingen, Germany.
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Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly LE, Hurley DA. Factors impacting on doctors' management of acute low back pain: a systematic review. Eur J Pain 2008; 13:908-14. [PMID: 19110456 DOI: 10.1016/j.ejpain.2008.11.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Revised: 11/02/2008] [Accepted: 11/11/2008] [Indexed: 12/12/2022]
Abstract
The aim of this review was to determine the factors that impact on doctors' management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales. The search generated a total of 28 papers [quantitative (n=27), qualitative (n=1) methodologies]. Themes were identified from the accepted papers: education (n=18), knowledge of clinical guidelines and impact on management (n=7), and doctors' demographics (n=4). There was consistent evidence that doctors did not adhere to clinical guidelines when performing a spinal assessment. There was inconsistent evidence that education increased adherence with acute LBP guideline recommendations in terms of referral rates to physiotherapy, for investigations, to secondary care and for maintaining patients at work. Strategies to address the factors impacting on doctors' management of acute LBP are required; these would lead to improvement in patient outcomes and reduce healthcare costs.
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Affiliation(s)
- Brona M Fullen
- School of Physiotherapy and Performance Science, University College Dublin, Ireland.
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Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly L, Hurley DA. Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review. Pain 2008; 136:388-396. [PMID: 18395982 DOI: 10.1016/j.pain.2008.01.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 12/21/2007] [Accepted: 01/04/2008] [Indexed: 01/22/2023]
Abstract
The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n=3) and quantitative (n=12) methodologies. Themes that emerged included doctors' attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors' specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors' specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors' attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient-care, and reduce costs to health services.
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Affiliation(s)
- B M Fullen
- UCD School of Physiotherapy and Performance Science, Health Sciences Centre, University College Dublin, Dublin, Ireland Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, New Zealand Department of General Practice, NUI Galway, Ireland UCD School of Public Health and Population Science, Dublin, Ireland
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