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Dickson C, de Zoete RMJ, Stanton TR. From Where We've Come to Where We Need to Go: Physiotherapy Management of Chronic Whiplash-Associated Disorder. FRONTIERS IN PAIN RESEARCH 2022; 2:795369. [PMID: 35295440 PMCID: PMC8915571 DOI: 10.3389/fpain.2021.795369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Cameron Dickson
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
- *Correspondence: Cameron Dickson
| | - Rutger M. J. de Zoete
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
| | - Tasha R. Stanton
- Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, SA, Australia
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Hayden JA, Ogilvie R, Stewart SA, French S, Campbell S, Magee K, Slipp P, Wells G, Stiell I. Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol. Diagn Progn Res 2019; 3:1. [PMID: 31093571 PMCID: PMC6460553 DOI: 10.1186/s41512-019-0047-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available. METHODS This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users. DISCUSSION Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.
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Affiliation(s)
- Jill A. Hayden
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Rachel Ogilvie
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Samuel Alan Stewart
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Simon French
- 0000 0004 1936 8331grid.410356.5School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George St, Kingston, ON K7L 3N6 Canada
- 0000 0001 2158 5405grid.1004.5Department of Chiropractic, Macquarie University, Sydney, NSW 2109 Australia
| | - Samuel Campbell
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kirk Magee
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Patrick Slipp
- 0000 0004 0407 789Xgrid.413292.fDepartment of Radiology, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - George Wells
- 0000 0001 2182 2255grid.28046.38Epidemiology and Community Medicine, University of Ottawa, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON K1Y 4W7 Canada
| | - Ian Stiell
- 0000 0001 2182 2255grid.28046.38Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
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Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Briggs AM, Wluka AE. Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review. Health Expect 2018; 21:824-847. [PMID: 29983004 PMCID: PMC6186543 DOI: 10.1111/hex.12676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP. METHODS A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated. RESULTS Forty-four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed-methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short-term duration of these therapies. CONCLUSIONS Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient-centred guidelines and service models for LBP. Understanding patients' concerns regarding active-based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health-care system.
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Affiliation(s)
- Louisa Chou
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
| | - Tom A. Ranger
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
| | - Waruna Peiris
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
| | - Flavia M. Cicuttini
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
| | - Donna M. Urquhart
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
| | - Andrew M. Briggs
- School of Physiotherapy and Exercise ScienceCurtin UniversityPerthWAAustralia
- Move: Muscle, Bone & Joint HealthMelbourneVicAustralia
| | - Anita E. Wluka
- Department of Epidemiology and Preventative MedicineSchool of Public Health and Preventative MedicineMonash UniversityMelbourneVicAustralia
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Bandong AN, Leaver A, Mackey M, Ingram R, Shearman S, Chan C, Cameron ID, Moloney N, Mitchell R, Doyle E, Leyten E, Rebbeck T. Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia. BMC Health Serv Res 2018; 18:622. [PMID: 30089495 PMCID: PMC6083615 DOI: 10.1186/s12913-018-3439-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.
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Affiliation(s)
- Aila Nica Bandong
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- College of Allied Medical Professions, University of the Philippines, Manila, Philippines
- Musculoskeletal Lab/Refshauge Lab (S218), Faculty of Health Sciences, The University of Sydney – Cumberland Campus, 75 East Street, Lidcombe, NSW 2141 Australia
| | - Andrew Leaver
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Martin Mackey
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Rodney Ingram
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Samantha Shearman
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Christen Chan
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
| | - Niamh Moloney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Macquarie University, Australian Institute of Health Innovation, Sydney, Australia
| | - Eoin Doyle
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Emma Leyten
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Trudy Rebbeck
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
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Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain 2018; 158:1860-1868. [PMID: 28708761 DOI: 10.1097/j.pain.0000000000000998] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.
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Abstract
Synopsis Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain-related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear-avoidance model. However, there is evidence that pain-related fear can also be seen as a common-sense response to deal with low back pain, for example, when one is told that one's back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common-sense response to protect a "damaged" back. While the fear-avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear-avoidance cycle is less clear. Understanding pain-related fear from a common-sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain-related fear in people with low back pain, this clinical commentary illustrates how Leventhal's common-sense model may assist physical therapists to understand the broader sense-making processes involved in the fear-avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature. J Orthop Sports Phys Ther 2017;47(9):628-636. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7434.
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Caneiro JP, Smith A, O'Sullivan K, O'Keeffe M, Dankaerts W, Fersum K, Gibson W, Wand BM, O'Sullivan P. RE: "Low back pain misdiagnosis or missed diagnosis: Core principles" (Monie AP, Fazey PJ, Singer KP. Manual Therapy 22 (2016) 68-71). Musculoskelet Sci Pract 2017; 28:e1-e2. [PMID: 27720322 DOI: 10.1016/j.math.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 10/21/2022]
Affiliation(s)
- J P Caneiro
- School of Physiotherapy & Exercise Science, Curtin University, Perth, Australia; Body Logic Physiotherapy Clinic, Perth, Australia.
| | - Anne Smith
- School of Physiotherapy & Exercise Science, Curtin University, Perth, Australia
| | - Kieran O'Sullivan
- Sports Spine Centre, Qatar Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar
| | - Mary O'Keeffe
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Wim Dankaerts
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Belgium
| | - Kjartan Fersum
- Physiotherapy Research Group, Department of Public Health and Primary Health Care, University of Bergen, Norway
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Benedict M Wand
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Peter O'Sullivan
- School of Physiotherapy & Exercise Science, Curtin University, Perth, Australia; Body Logic Physiotherapy Clinic, Perth, Australia
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Patel VV, Andersson GBJ, Garfin SR, Resnick DL, Block JE. Utilization of CT scanning associated with complex spine surgery. BMC Musculoskelet Disord 2017; 18:52. [PMID: 28143506 PMCID: PMC5282647 DOI: 10.1186/s12891-017-1420-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Due to the risk associated with exposure to ionizing radiation, there is an urgent need to identify areas of CT scanning overutilization. While increased use of diagnostic spinal imaging has been documented, no previous research has estimated the magnitude of follow-up imaging used to evaluate the postoperative spine. Methods This retrospective cohort study quantifies the association between spinal surgery and CT utilization. An insurance database (Humana, Inc.) with ≈ 19 million enrollees was employed, representing 8 consecutive years (2007–2014). Surgical and imaging procedures were captured by anatomic-specific CPT codes. Complex surgeries included all cervical, thoracic and lumbar instrumented spine fusions. Simple surgeries included discectomy and laminectomy. Imaging was restricted to CT and MRI. Postoperative imaging frequency extended to 5-years post-surgery. Results There were 140,660 complex spinal procedures and 39,943 discectomies and 49,889 laminectomies. MRI was the predominate preoperative imaging modality for all surgical procedures (median: 80%; range: 73–82%). Postoperatively, CT prevalence following complex procedures increased more than two-fold from 6 months (18%) to 5 years (≥40%), and patients having a postoperative CT averaged two scans. For simple procedures, the prevalence of postoperative CT scanning never exceeded 30%. Conclusions CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery. There is emerging evidence of an increased cancer risk due to ionizing radiation exposure with CT. In the setting of complex spine surgery, actions to mitigate this risk should be considered and include reducing nonessential scans, using the lowest possible radiation dose protocols, exerting greater selectivity in monitoring the developing fusion construct, and adopting non-ferromagnetic implant biomaterials that facilitate MRI postoperatively. Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1420-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vikas V Patel
- The Spine Center, University of Colorado Hospital, Denver, CO, USA
| | | | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California, San Diego, CA, USA
| | - Donald L Resnick
- Department of Radiology, University of California, San Diego, CA, USA
| | - Jon E Block
- , 2210 Jackson Street, Ste. 401, San Francisco, CA, 94115, USA.
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McAuliffe S, McCreesh K, Culloty F, Purtill H, O'Sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med 2016; 50:1516-1523. [DOI: 10.1136/bjsports-2016-096288] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 12/22/2022]
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Brijnath B, Bunzli S, Xia T, Singh N, Schattner P, Collie A, Sterling M, Mazza D. General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: implications for patient care. BMC FAMILY PRACTICE 2016; 17:82. [PMID: 27440111 PMCID: PMC4955143 DOI: 10.1186/s12875-016-0491-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 07/13/2016] [Indexed: 11/18/2022]
Abstract
Background In Australia, general practitioners (GPs) see around two-thirds of people injured in road traffic crashes. Road traffic crash injuries are commonly associated with diverse physical and psychological symptoms that may be difficult to diagnose and manage. Clinical guidelines have been developed to assist in delivering quality, consistent care, however the extent to which GPs knowledge and practice in diagnosing and managing road traffic crash injuries concords with the guidelines is unknown. This study aimed to explore Australian GPs knowledge, attitudes and practices regarding the diagnosis and management of road traffic crash injuries, specifically whiplash associated disorders (WAD) and post-traumatic stress disorder (PTSD). Method A cross-sectional survey of 423 GPs across Australia conducted between July and December 2014. We developed a questionnaire to assess their knowledge of WAD and PTSD, confidence in diagnosing and managing WAD and PTSD, frequency of referral to health providers, barriers to referral, and attitudes towards further education and training. Factor analysis, Spearman’s correlation, and multiple ordered logistic regressions were performed. Results Overall, GPs have good level knowledge of WAD and PTSD; only 9.6 % (95 % CI: 7.1 %, 12.8 %) and 23.9 % (95 % CI: 20.8 %, 28.2 %) of them were deemed to have lower level knowledge of WAD and PTSD respectively. Key knowledge gaps included imaging indicators for WAD and indicators for psychological referral for PTSD. GPs who were male, with more years of experience, working in the urban area and with higher knowledge level of WAD were more confident in diagnosing and managing WAD. Only GPs PTSD knowledge level predicted confidence in diagnosing and managing PTSD. GPs most commonly referred to physiotherapists and least commonly to vocational rehabilitation providers. Barriers to referral included out-of-pocket costs incurred by patients and long waiting times. Most GPs felt positive towards further education on road traffic crash injury management. Conclusion This study has enhanced understanding of the knowledge skills and attitudes of GPs towards road traffic crash injury care in Australia, and has identified areas for further education and training. If delivered, this training has the potential to reduce unnecessary imaging for WAD and optimise the early referral of patients at risk of delayed recovery following a road traffic crash.
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Affiliation(s)
- Bianca Brijnath
- Department of General Practice, School of Primary Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia. .,School of Occupational Therapy and Social Work, Curtin University, Perth, WA, 6152, Australia.
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Australia
| | - Ting Xia
- Department of General Practice, School of Primary Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Nabita Singh
- Department of General Practice, School of Primary Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Peter Schattner
- Department of General Practice, School of Primary Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Alex Collie
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia.,Institute for Safety Compensation and Recovery Research, Monash University, Melbourne, Australia
| | - Michele Sterling
- Recover Injury Research Centre, NHMRC CRE in Road Traffic Injury Recovery, Menzies Health Institute, Griffith University, Gold Coast, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
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Psychological Symptom Amplification: Are Psychological Symptoms Subject to "Somatization"-Like Processes? Harv Rev Psychiatry 2016; 24:302-7. [PMID: 27384399 DOI: 10.1097/hrp.0000000000000104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Many patients demonstrate amplified somatic symptom experiences that are felt by providers to cause excessive distress and functional impairment, and that can be diagnostically misleading. Terms attached to these presentations include somatization, medically unexplained symptoms, and, most recently, somatic symptom disorder. The analogous amplification of psychological symptoms has not been considered. Accordingly, this column makes a case for discussion and investigation of psychological symptom amplification (PSA), a process made possible by the medical legitimization of certain types of human suffering. As various forms of psychological suffering gain greater medical legitimacy, PSA becomes increasingly relevant. Circumstantial evidence suggests that unrecognized PSA may distort research findings and clinical efficacy in psychiatry. The largely symptom-based nature of psychiatric diagnosis makes PSA a challenging, but necessary, object of further scientific and clinical scrutiny.
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Lin IB, Coffin J, O'Sullivan PB. Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study. BMC FAMILY PRACTICE 2016; 17:44. [PMID: 27068773 PMCID: PMC4828772 DOI: 10.1186/s12875-016-0441-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 03/24/2016] [Indexed: 12/02/2022]
Abstract
Background Low back pain (LBP) care is frequently discordant with research evidence. This pilot study evaluated changes in LBP care following a systematic, theory informed intervention in a rural Australian Aboriginal Health Service. We aimed to improve three aspects of care; reduce inappropriate LBP radiological imaging referrals, increase psychosocial oriented patient assessment and, increase the provision of LBP self-management information to patients. Methods Three interventions to improve care were developed using a four-step systematic implementation approach. A mixed methods pre/post cohort design evaluated changes in the three behaviours using a clinical audit of LBP care in a six month period prior to the intervention and then following implementation. In-depth interviews elicited the perspectives of involved General Practitioners (GPs). Qualitative analysis was guided by the theoretical domains framework. Results The proportion of patients who received guideline inconsistent imaging referrals (GICI) improved from 4.1 GICI per 10 patients to 0.4 (95 % CI for decrease in rate: 1.6 to 5.6) amongst GPs involved in the intervention. Amongst non-participating GPs (locum/part-time GPs who commenced post-interventions) the rate of GICI increased from 1.5 to 4.4 GICI per 10 patients (95 % CI for increase in rate: .5 to 5.3). There was a modest increase in the number of patients who received LBP self-management information from participating GPs and no substantial changes to psychosocial oriented patient assessments by any participants; however GPs qualitatively reported that their behaviours had changed. Knowledge and beliefs about consequences were important behavioural domains related to changes. Environmental and resource factors including protocols for locum staff and clinical tools embedded in patient management software were future strategies identified. Conclusions A systematic intervention model resulted in partial improvements in LBP care. Determinants of practice change amongst GPs were increased knowledge of clinical guidelines, education delivered by someone considered a trusted source of information, and awareness of the negative consequences of inappropriate practices, especially radiological imaging on patient outcomes. Inconsistent and non-evidence based practices amongst locum GPs was an issue that emerged and will be a significant future challenge. The systematic approach utilised is applicable to other services interested in improving LBP care.
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Affiliation(s)
- Ivan B Lin
- WA Centre for Rural Health, University of Western Australia, PO Box 109, Geraldton, 6531, Western Australia.
| | - Juli Coffin
- Geraldton Regional Aboriginal Medical Service, PO Box 4109, Rangeway, 6531, Western Australia.,Telethon Kids Institute, PO Box 855, West Perth, 6872, Western Australia
| | - Peter B O'Sullivan
- School of Physiotherapy, Curtin University, GPO Box U1987, Perth, 6845, Western Australia
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Elleuch M, El Maghraoui A, Griene B, Nejmi M, Ndongo S, Serrie A. [Formalized consensus: clinical practice recommendations for the management of acute low back pain of the African patient]. Pan Afr Med J 2015; 22:240. [PMID: 26955427 PMCID: PMC4761241 DOI: 10.11604/pamj.2015.22.240.8120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/26/2015] [Indexed: 12/03/2022] Open
Abstract
La lombalgie aiguë est la pathologie rhumatismale la plus fréquente en Afrique. L’épidémiologie et la présentation clinique ne diffèrent pas de celles observées sur les autres continents. En revanche, les aspects psycho-sociaux, la disponibilité des traitements, l'accès aux soins et le poids culturel des médecines traditionnelles sont autant de spécificités qui ont conduit à la réalisation du 1er consensus d'experts en rhumatologie pour la prise en charge du patient africain. Destiné aux praticiens, ce travail collaboratif multinational a pour objectif de fournir 11 recommandations de pratiques cliniques simples, fondées sur les preuves, et adaptées aux conditions de l'exercice médical en Afrique. Leur ambition est d'améliorer la prise en charge de la lombalgie aigue par une évaluation initiale clinique pertinente, une diminution des examens radiologiques inutiles, une prescription médicamenteuse adéquate et l'abandon de procédures invasives inappropriées.
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Affiliation(s)
| | | | | | - Mati Nejmi
- Hôpital Cheikh Khalifa Bin Zayed, Casablanca, Maroc
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Abstract
We need to overcome limitations of present assessment and also integrate newer research in our work about sciatica. Inflammation induces changes in the DRG and nerve root. It sensitizes the axons. Nociceptor is a unique axon. It is pseudo unipolar: both its ends, central and peripheral, behave in similar fashion. The nerve in periphery which carries these axons may selectively become sensitive to mechanical pressure--"mechanosensitized," as we coin the phrase. Many pain questionnaires are used and are effective in identifying neuropathic pain solely on basis of descriptors but they do not directly physically correlate nerve root and pain. A thorough neurological evaluation is always needed. Physical examination is not direct pain assessment but testing mobility of nerve root and its effect on pain generation. There is a dogmatic dominance of dermatomes in assessment of leg pain. They are unreliable. Images may not correlate with symptoms and pathology in about 28% of cases. Electrophysiology may be normal in purely inflamed nerve root. Palpation may help in such inflammatory setting to refine our assessment further. Confirmation of sciatica is done by selective nerve root block (SNRB) today but it is fraught with several complications and needs elaborate inpatient and operating room set up. We have used the unique property of the pseudo unipolar axon that both its ends have similar functional properties and so inject along its peripheral end sodium channel blockers to block the basic cause of the mechanosensitization namely upregulated sodium channels in the root or DRG. Thus using palpation we may be able to detect symptomatic nerve in stage of inflammation and with distal end injection, along same inflamed nerve we may be able to abolish and so confirm sciatica. Discussions of sciatica pain diagnosis tend to immediately shift and centre on the affected disc rather than the nerve. Theoretically it may be possible to detect the affected nerve by palpating the nerve and relieve pain moment we desensitize the nerve.
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Long-term Outcomes of 2-Level Total Disc Replacement Using ProDisc-L: Nine- to 10-Year Follow-up. Spine (Phila Pa 1976) 2014; 39:906-910. [PMID: 29504961 DOI: 10.1097/brs.0000000000000148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective clinical data analysis. OBJECTIVE To determine the long-term clinical success of 2-level total disc replacement (TDR) in patients with degenerative disc disease. SUMMARY OF BACKGROUND DATA Early successful clinical results of 2-level TDR have been reported. Few studies exist that have described this procedure's durability in the long term. METHODS Fifteen patients underwent 2-level lumbar TDR with the ProDisc-L as part of a randomized trial, 13 of whom were available for follow-up. The patients were assessed preoperatively and at 2 years, 5 years, and more than 9 years postoperatively using visual Oswestry Disability Index. At the last follow-up visit, 2 additional questions were asked: satisfaction with surgery and willingness to undergo the same treatment. Finally, clinical success was assessed using a previously described definition. RESULTS Mean follow-up time was 9.6 years (range, 9.2-10.3 yr). Postoperatively there was a significant improvement in Oswestry Disability Index score from baseline (70.0 vs. 15.7 at 2 yr, P = 0.002) that remained unchanged during the period of follow-up (19.8 at 5 yr, P = 0.003 and 12.9 at 9-10 yr, P = 0.002). Ninety-two percent of patients were "satisfied" or "somewhat satisfied" with treatment and the same number would undergo treatment again. Eighty-five percent of patients achieved clinical success. CONCLUSION This prospective study demonstrates the durable clinical success of 2-level lumbar TDR as assessed at more than 9 years postoperatively. LEVEL OF EVIDENCE 4.
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el Barzouhi A, Vleggeert-Lankamp CLAM, Lycklama à Nijeholt GJ, Van der Kallen BF, van den Hout WB, Koes BW, Peul WC. Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain. PLoS One 2014; 9:e90800. [PMID: 24637890 PMCID: PMC3956604 DOI: 10.1371/journal.pone.0090800] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 02/04/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with sciatica frequently complain about associated back pain. It is not known whether there are prognostic relevant differences in Magnetic Resonance Imaging (MRI) findings between sciatica patients with and without disabling back pain. METHODS The study population contained patients with sciatica who underwent a baseline MRI to assess eligibility for a randomized trial designed to compare the efficacy of early surgery with prolonged conservative care for sciatica. Two neuroradiologists and one neurosurgeon independently evaluated all MR images. The MRI readers were blinded to symptom status. The MRI findings were compared between sciatica patients with and without disabling back pain. The presence of disabling back pain at baseline was correlated with perceived recovery at one year. RESULTS Of 379 included sciatica patients, 158 (42%) had disabling back pain. Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI, compared to 88% of patients with predominantly sciatica (P<0.001). The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year (Odds ratio [OR] 0.32, 95% Confidence Interval 0.18-0.56, P<0.001). Sciatica patients with disabling back pain in absence of nerve root compression on MRI at baseline reported less perceived recovery at one year compared to those with predominantly sciatica and nerve root compression on MRI (50% vs 91%, P<0.001). CONCLUSION Sciatica patients with disabling low back pain reported an unfavorable outcome at one-year follow-up compared to those with predominantly sciatica. If additionally a clear herniated disc with nerve root compression on MRI was absent, the results were even worse.
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Affiliation(s)
- Abdelilah el Barzouhi
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | | | - Wilbert B. van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart W. Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, the Hague, the Netherlands
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Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013; 347:f7095. [PMID: 24335669 PMCID: PMC3898572 DOI: 10.1136/bmj.f7095] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care. DESIGN Systematic review. DATA SOURCES Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013. INCLUSION CRITERIA Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language. REVIEW METHODS Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag. RESULTS We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%). CONCLUSIONS While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.
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Affiliation(s)
- Aron Downie
- George Institute for Global Health, University of Sydney, Sydney, NSW, 2050, Australia
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