Coordination of primary health care for back pain. A randomized controlled trial

Botulinum toxin type A for treating chronic low back pain: A double blinded randomized control study

BACKGROUND

Low back pain (LBP) is a prevalent issue that orthopedic surgeons frequently address in the outpatient setting. LBP can arise from various causes, with stiffness in the paraspinal muscles being a notable contributor. The administration of Botulinum toxin type A (BoNT-A) has been found to alleviate back pain by relaxing these stiff muscles. While BoNT-A is approved for use in numerous conditions, a limited number of randomized clinical trials (RCTs) validate its efficacy specifically for treating LBP.

AIM

To study the safety and the efficacy of BoNT-A in minimizing pain and improving functional outcomes in patients of chronic LBP (CLBP).

METHODS

In this RCT, adults aged 18-60 years with mechanical LBP persisting for at least six months were enrolled. Participants were allocated to either the Drug group, receiving 200 Ipsen Units (2 mL) of BoNT-A, or the Control group, which received a 2 mL placebo. Over a 2-month follow-up period, both groups were assessed using the Visual Analog Scale (VAS) for pain intensity and the Oswestry Disability Index (ODI) for disability at the start and conclusion of the study. A decrease in pain by 50% was deemed clinically significant.

RESULTS

The study followed 40 patients for two months, with 20 in each group. A clinically significant reduction in pain was observed in 36 participants. There was a statistically significant decrease in both VAS and ODI scores in the groups at the end of two months. Nonetheless, when comparing the mean score changes, only the reduction in ODI scores (15 in the placebo group vs 16.5 in the drug group, clinically insignificant) was statistically significant (P = 0.012), whereas the change in mean VAS scores was not significant (P = 0.45).

CONCLUSION

The study concludes that BoNT-A does not offer a short-term advantage over placebo in reducing pain or improving LBP scores in CLBP patients.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Intervention targeted at physicians' treatment of musculoskeletal disorders and sickness certification: an interrupted time series analysis

OBJECTIVE

An intervention was carried out at the occupational healthcare services (OHS) of the City of Helsinki beginning in 2016. We investigated the association between the intervention and employee sick leaves using interrupted time series analysis.

DESIGN

Register-based cohort study with a quasi-experimental study design.

SETTING

Employees of the City of Helsinki.

PARTICIPANTS

We analysed individual-level register-based data on all employees who were employed by the city for any length of time between 2013 and 2018 (a total 86 970 employees and 3 014 075 sick leave days). Sick leave days and periods that were OHS-based constituted the intervention time series and the rest of the sick leave days and periods contributed to the comparison time series.

INTERVENTION

Recommendations provided to physicians on managing pain and prescribing sick leave for low back, shoulder and elbow pain.

OUTCOME MEASURES

Number of sick leave days per month and sick leave periods per year.

RESULTS

For all sick leave days prescribed at OHS, there was no immediate change in sick leave days, whereas a gradual change showing decreasing number of OHS-based sick leave days was detected. On average, the intervention was estimated to have saved 2.5 sick leave days per year per employee. For other sick leave days, there was an immediate increase in the level of sick leave days after the intervention and a subsequent gradual trend showing decreasing number of sick leave days.

CONCLUSIONS

The intervention may have reduced employee sick leaves and therefore it is possible that it had led to direct cost savings. However, further evidence for causal inferences is needed.

Management of Low back pain in Saudi Arabia healthcare system. A Qualitative Study

Background

Patients with chronic low back pain can contribute to a global socioeconomic burden. Current international recommendations emphasize that low back pain management should occur at the primary-care level. However, there is a lack of essential services for low back pain management at the primary-care level in Saudi Arabia. We explored the current state of low back pain management in Saudi Arabia from the perspective of spine surgeons and physiotherapists.

Methods

A qualitative study with semi-structured interviews was conducted on spine surgeons and physiotherapists. A total of 17 healthcare workers, 8 spine surgeons (age range 28–49 years) and 9 physiotherapists (age range 30–49 years) participated in the study. Data were recorded and analyzed thematically.

Results

Three main themes were identified from the interview data that outlined current low back pain management in Saudi Arabia: clinical guideline availability and pathways of care, utilization of primary care services, and overutilization of secondary care resources.

Conclusions

This study suggests underutilization of primary care services and overutilization of secondary care services in Saudi Arabia. Therefore, the implementation of local clinical guidelines could improve patient care as well as reduce the cost of low back pain management.

Identifying Acute Low Back Pain Episodes in Primary Care Practice From Clinical Notes: Observational Study

BACKGROUND

Acute and chronic low back pain (LBP) are different conditions with different treatments. However, they are coded in electronic health records with the same International Classification of Diseases, 10th revision (ICD-10) code (M54.5) and can be differentiated only by retrospective chart reviews. This prevents an efficient definition of data-driven guidelines for billing and therapy recommendations, such as return-to-work options.

OBJECTIVE

The objective of this study was to evaluate the feasibility of automatically distinguishing acute LBP episodes by analyzing free-text clinical notes.

METHODS

We used a dataset of 17,409 clinical notes from different primary care practices; of these, 891 documents were manually annotated as acute LBP and 2973 were generally associated with LBP via the recorded ICD-10 code. We compared different supervised and unsupervised strategies for automated identification: keyword search, topic modeling, logistic regression with bag of n-grams and manual features, and deep learning (a convolutional neural network-based architecture [ConvNet]). We trained the supervised models using either manual annotations or ICD-10 codes as positive labels.

RESULTS

ConvNet trained using manual annotations obtained the best results with an area under the receiver operating characteristic curve of 0.98 and an F score of 0.70. ConvNet's results were also robust to reduction of the number of manually annotated documents. In the absence of manual annotations, topic models performed better than methods trained using ICD-10 codes, which were unsatisfactory for identifying LBP acuity.

CONCLUSIONS

This study uses clinical notes to delineate a potential path toward systematic learning of therapeutic strategies, billing guidelines, and management options for acute LBP at the point of care.

Mapping first-line health care providers' roles, practices, and impacts on care for workers with compensable musculoskeletal disorders in four jurisdictions: A critical interpretive synthesis

BACKGROUND

First-line health care providers are the primary access point for workers' benefits. However, little is known about their impact on quality of care and return-to-work. Our objective was to critically compare literature on the practices of first-line providers for workers with musculoskeletal injuries in Ontario and Quebec (Canada), Washington State (United States), and Victoria (Australia).

METHODS

A critical interpretive synthesis of peer-reviewed scientific literature was conducted. The search across six databases yielded 59 relevant publications that were critically appraised.

RESULTS

Three themes emerged: 1) how policies about first-line health care providers' modulate worker access to care, 2) how these providers' roles, practices, and training shape disability management, and 3) how the quality of care and disability outcomes are evaluated.

CONCLUSIONS

First-line health care providers have a critical influence on workers' trajectories of care. A focus on their role while taking the complexity of the context into account will help orient future policy changes.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

BACKGROUND

Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP.

METHODS

We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach.

RESULTS

Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies).

CONCLUSIONS

Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption.

REGISTRATION

PROSPERO 2017, CRD42017070703.

The Modified Low Back Pain Disability Questionnaire: Reliability, Validity, and Responsiveness of a Dutch Language Version

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The goal of this study is to translate the English version of the Modified Low Back Pain Disability Questionnaire (MDQ) into a Dutch version and investigate its clinimetric properties for patients with nonspecific chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

Fritz et al (2001) developed a modified version of the Oswestry Disability Questionnaire (ODI) to assess functional status and named it the MDQ. In this version, a question regarding employment and homemaking ability was substituted for the question related to sex life. Good clinimetric properties for the MDQ were identified but up until now it is not clear whether the clinimetric properties of the MDQ would change if it was translated into a Dutch version.

METHODS

Translation of the MDQ into Dutch was done in 4 steps. Test-retest reliability was investigated using the intraclass correlation coefficient (ICC) model. Validity was calculated using Pearson correlations and a 2-way analysis of variance for repeated measures. Finally, responsiveness was calculated with the area under the curve (AUC), minimal detectable change (MDC), and the standardized response mean (SRM).

RESULTS

A total of 80 completed questionnaires were collected in 3 different hospitals and a total of 43 patients finished a 9 weeks intervention period, completing the retest. Test-retest reliability was excellent with an ICC of 0.89 (95% confidence interval [CI], 0.74-0.95). To confirm the convergent validity, the MDQ answered all predefined hypothesises (r = -0.65-0.69/P = 0.01-0.00) and good results for construct validity were found (P = 0.02). The MDQ had an AUC of 0.64 (95% confidence interval [CI], 0.47-0.81), an MDC of 8.80 points, and a SRM of 0.65.

CONCLUSION

The Dutch version of the MDQ shows good clinimetric properties and is shown to be usable in the assessment of the functional status of Dutch-speaking patients with nonspecific CLBP.

LEVEL OF EVIDENCE

3.

Comparing multidisciplinary and brief intervention in employees with different job relations on sick leave due to low back pain: protocol of a randomised controlled trial

BACKGROUND

Low back pain (LBP) is a common problem that affects the lives of many individuals and is a frequent cause of sickness absence. To help this group of individuals resume work, several interventions have been studied. However, not all individuals may profit from the same intervention and the effect of a given intervention on return to work (RTW) may depend on their work situation. The aim of this study is to evaluate whether employees on sick leave due to LBP and with poor job relations will benefit more from a multidisciplinary intervention, while patients with strong job relations will benefit more from a brief intervention.

METHODS

The study is designed as a randomised controlled trial with up to five years of follow-up comparing brief intervention with brief intervention plus multidisciplinary intervention. Employees, aged 18-60 years, are included in the study from March 2011 to August 2016 if they have been on sick leave for 4-12 weeks due to LBP with or without radiculopathy. They are divided into two groups, a group with poor job relations and a group with strong job relations based on their answers in the baseline questionnaire. Each group is randomised 1:1 to receive the brief intervention or brief intervention plus multidisciplinary intervention. The brief intervention comprises a clinical examination and advice offered by a rheumatologist and a physiotherapist, whereas the supplementary multidisciplinary intervention comprises the assignment of a case manager who draws up a rehabilitation plan in collaboration with the participant and the multidisciplinary team. The primary outcome is duration of sickness absence measured by register data. Secondary outcomes include sustainable RTW and questionnaire-based measures of functional capacity. Outcomes will be assessed at one, two and five years of follow-up.

DISCUSSION

This trial will evaluate the effect of brief and multidisciplinary intervention on RTW and functional capacity among employees on sick leave due to LBP with poor or strong job relations. This will indicate whether work-related characteristics should be considered when providing treatment of LBP patients in the health care sector.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14136384 . Registered 4 August 2015.

Are paraspinous intramuscular injections of botulinum toxin a (BoNT-A) efficient in the treatment of chronic low-back pain? A randomised, double-blinded crossover trial

BACKGROUND

Treatment for patients with chronic low-back pain (LBP) is a public health issue. Intramuscular injections of botulinum toxin A (BoNT-A) have shown an analgesic effect on LBP in two previous randomized controlled studies. The objective of the study was to verify the efficacy of paravertebral injections of BoNT-A in patients with LBP.

METHODS

Patients were included in this phase 3 randomized double-blinded trial comparing the efficacy of BoNT-A versus placebo in a crossover study on LBP. Both groups received 200 units of BoNT-A in paravertebral muscles or a placebo, and vice versa at Day 120. The main judgment criterion was LBP intensity 1 month after the injections, evaluated by using a visual pain scale (VAS). Secondary assessment criteria included: LBP intensity 90 and 120 days after injection day; number of days when an allowed antalgic oral treatment was needed in between each evaluation; functional disability measured by the Quebec Back Pain Disability Scale; quality of life; inability to work; patient satisfaction in relation to the treatment's effect; spinal mobility; and strength of spinal muscles, measured by isokinetic technique.

RESULTS

Nineteen patients completed the study. There was no significant difference between the groups' average LBP during the last 8 days at Day30 (p = 0.97). There was no significant difference between the two groups regarding the secondary assessment criteria (p > 0.05).

CONCLUSIONS

Injections of BoNT-A in the paravertebral muscles were not found to be effective to relieve chronic LBP. The limits of the study are that the dose of BoNT-A used was lower than in other studies, and that the limited number of patients included may explain the negative results.

TRIAL REGISTRATIONS

Identifiers: NCT03181802 . Unique Protocol ID: CHUBX2003.

Developing implementation science to improve the translation of research to address low back pain: A critical review

The evidence base regarding treatment for back pain does not align with clinical practice. Currently there is relatively little evidence to guide health decision-makers on how to improve the use, uptake or adoption of evidence-based recommended practice for low back pain. Improving the design, conduct and reporting of strategies to improve the implementation of back pain care will help address this important evidence-practice gap. In this paper, we.

Return-to-work coordination programmes for improving return to work in workers on sick leave

BACKGROUND

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

OBJECTIVES

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.We found no benefits for return-to-work coordination programmes on return-to-work outcomes.For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) -16.18 work days per year, 95% CI -32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD -14.84 work days per year, 95% CI -38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI -15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

AUTHORS' CONCLUSIONS

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

Chapter 6. Sickness absence due to back and neck disorders

The scientific evidence on the causes for sick leave attributed to back and neck disorders was reviewed. Categories were established for acute, recurring, and chronic problems based on the duration of the sick leave period. Forty-eight articles were found to be relevant, whereof two were of high quality and 26 were of medium or low quality. Quality was assessed exclusively in relation to the aim of this systematic review. The results reveal limited published research on causes for sick leave from back and neck disorders. The generalisability of the findings is also limited since most of the subjects were men and employees in manufacturing industries. Women, white-collar workers, employees in the public sector (care, social services, schools, etc) were underrepresented in the studies. Hence, these groups and areas should be studied further to verify conclusions and enhance knowledge about the causes for sick leave from back and neck disorders. The following factors were found to have consistent, but limited, support as regards their influence on the risk for sick leave due to back and neck disorders: (a) heavy physical workload, bent or twisted working position, and low work satisfaction increases the risk for short-term and long-term sick leave; (b) specific back diagnoses and previous sick leave due to back disorders increases the risk for short-term and long-term sick leave; (c) female gender, smoking, exposure to vibration, and deficient social support were not found to significantly increase the risk for short-term and long-term sick leave; (d) self-reported pain and functional impairments were associated with a high risk for long-term sick leave; (e) longer employment periods reduced the risk for short-term sick leave; (f) perceived demands at work did not influence short-term sick leave; (g) female gender and higher age increases the risk for disability pension.

Effectiveness of multifaceted implementation strategies for the implementation of back and neck pain guidelines in health care: a systematic review

BACKGROUND

For the optimal use of clinical guidelines in daily practice, mere distribution of guidelines and materials is not enough, and active implementation is needed. This review investigated the effectiveness of multifaceted implementation strategies compared to minimal, single, or no implementation strategy for the implementation of non-specific low back and/or neck pain guidelines in health care.

METHODS

The following electronic databases were searched from inception to June 1, 2015: MEDLINE, Embase, PsycInfo, the Cochrane Library, and CINAHL. The search strategy was restricted to low back pain, neck pain, and implementation research. Studies were included if their design was a randomized controlled trial, reporting on patients (age ≥18 years) with non-specific low back pain or neck pain (with or without radiating pain). Trials were eligible if they reported patient outcomes, measures of healthcare professional behaviour, and/or outcomes on healthcare level. The primary outcome was professional behaviour. Guidelines that were evaluated in the studies had to be implemented in a healthcare setting. No language restrictions were applied, and studies had to be published full-text in peer-reviewed journals, thus excluding abstract only publications, conference abstracts, and dissertation articles. Two researchers independently screened titles and abstract, extracted data from included studies, and performed risk of bias assessments.

RESULTS

After removal of duplicates, the search resulted in 4750 abstracts to be screened. Of 43 full-text articles assessed for eligibility, 12 were included in this review, reporting on 9 individual studies, and separate cost-effectiveness analyses of 3 included studies. Implementation strategies varied between studies. Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls.

CONCLUSION

This review showed that multifaceted strategies for the implementation of neck and/or back pain guidelines in health care do not significantly improve professional behaviour outcomes. No effects on patient outcomes or cost of care could be found. More research is necessary to determine whether multifaceted implementation strategies are conducted as planned and whether these strategies are effective in changing professional behaviour and thereby clinical practice.

"Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England

STUDY DESIGN

A qualitative study in south-west England primary care.

OBJECTIVE

To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care.

SUMMARY OF BACKGROUND DATA

Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians' perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice.

METHODS

We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis.

RESULTS

Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology-"non-specific LBP"-unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments.

CONCLUSION

The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients.

LEVEL OF EVIDENCE

N/A.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

BACKGROUND

Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the 'biopsychosocial model', has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.

OBJECTIVES

To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review.

SELECTION CRITERIA

All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds.

DATA COLLECTION AND ANALYSIS

Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity.

MAIN RESULTS

From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions.Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity.

AUTHORS' CONCLUSIONS

Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.

The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies

Background

Evidence suggests that the course of low back pain (LBP) symptoms in randomised clinical trials (RCTs) follows a pattern of large improvement regardless of the type of treatment. A similar pattern was independently observed in observational studies. However, there is an assumption that the clinical course of symptoms is particularly influenced in RCTs by mere participation in the trials. To test this assumption, the aim of our study was to compare the course of LBP in RCTs and observational studies.

Methods

Source of studies CENTRAL database for RCTs and MEDLINE, CINAHL, EMBASE and hand search of systematic reviews for cohort studies. Studies include individuals aged 18 or over, and concern non-specific LBP. Trials had to concern primary care treatments. Data were extracted on pain intensity. Meta-regression analysis was used to compare the pooled within-group change in pain in RCTs with that in cohort studies calculated as the standardised mean change (SMC).

Results

70 RCTs and 19 cohort studies were included, out of 1134 and 653 identified respectively. LBP symptoms followed a similar course in RCTs and cohort studies: a rapid improvement in the first 6 weeks followed by a smaller further improvement until 52 weeks. There was no statistically significant difference in pooled SMC between RCTs and cohort studies at any time point:- 6 weeks: RCTs: SMC 1.0 (95% CI 0.9 to 1.0) and cohorts 1.2 (0.7to 1.7); 13 weeks: RCTs 1.2 (1.1 to 1.3) and cohorts 1.0 (0.8 to 1.3); 27 weeks: RCTs 1.1 (1.0 to 1.2) and cohorts 1.2 (0.8 to 1.7); 52 weeks: RCTs 0.9 (0.8 to 1.0) and cohorts 1.1 (0.8 to 1.6).

Conclusions

The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. In addition to a shared ‘natural history’, enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design.

A systematic review of the effectiveness of knowledge translation interventions for chronic noncancer pain management

BACKGROUND

Reliable evidence detailing effective treatments and management practices for chronic noncancer pain exists. However, little is known about which knowledge translation (KT) interventions lead to the uptake of this evidence in practice.

OBJECTIVES

To conduct a systematic review of the effectiveness of KT interventions for chronic noncancer pain management.

METHODS

Comprehensive searches of electronic databases, the gray literature and manual searches of journals were undertaken. Randomized controlled trials, controlled clinical trials and controlled before-and-after studies of KT interventions were included. Data regarding interventions and primary outcomes were categorized using a standard taxonomy; a risk-of-bias approach was adopted for study quality. A narrative synthesis of study results was conducted.

RESULTS

More than 8500 titles and abstracts were screened, with 230 full-text articles reviewed for eligibility. Nineteen studies were included, of which only a small proportion were judged to be at low risk of bias. Interactive KT education for health care providers has a positive effect on patients' function, but its benefits for other health provider- and patient-related outcomes are inconsistent. Interactive education for patients leads to improvements in knowledge and function. Little research evidence supports the effectiveness of structural changes in health systems and quality improvement processes or coordination of care.

CONCLUSIONS

KT interventions incorporating interactive education in chronic noncancer pain led to positive effects on patients' function and knowledge about pain. Future studies should provide implementation details and use consistent theoretical frameworks to better estimate the effectiveness of such interventions.

Economic evaluation of active implementation versus guideline dissemination for evidence-based care of acute low-back pain in a general practice setting

INTRODUCTION

The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice.

METHODS

Cost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone.

RESULTS

The base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that--irrespective of willingness to pay (WTP)--we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination.

CONCLUSIONS

Our findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.

Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial

INTRODUCTION

This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice.

METHODS

General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation.

RESULTS

47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan.

CONCLUSIONS

The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN012606000098538.

Fear of injury predicts self-reported and behavioral impairment in patients with chronic low back pain

Fear of injury has been posited as crucial in pain-related anxiety and in the development of chronic pain; however, research has only measured fear of injury indirectly through other constructs (eg, fear of illness and fear of movement). The current study tested fear of injury as an independent contributor to pain-related anxiety and impairment. Patients (n = 78; 37% women) in a work-hardening treatment program for chronic low back pain completed self-report measures of pain-related anxiety, anxiety sensitivity, fear of injury, current pain, and impairment. Behavioral measures of impairment included lifting capacity, treatment outcomes, and days absent from treatment. Structural equation modeling tested the role of fear of injury within contemporary theory. Fit for the theoretical model was excellent and superior to an alternative model. Variance accounted for in pain-related anxiety by fear of injury, anxiety sensitivity, and current pain was 64%, while pain-related anxiety and current pain predicted 49% of variance in latent impairment. Fear of injury directly predicted pain-related anxiety (β = .42) and indirectly predicted impairment through pain-related anxiety (β = .19). Fear of injury may warrant theoretical and clinical consideration as an important contributor to pain-related anxiety and impairment; however, research is needed to explore how it may be causally related with other constructs.

PERSPECTIVE

Fear of injury directly predicts pain-related anxiety and indirectly predicts self-reported and behavioral impairment. Fear of injury may warrant inclusion in contemporary theories of chronic pain. Clinicians may benefit from considering the construct in interventions for chronic pain.

Return to work coordination programmes for work disability: a meta-analysis of randomised controlled trials

Background

The dramatic rise in chronically ill patients on permanent disability benefits threatens the sustainability of social security in high-income countries. Social insurance organizations have started to invest in promising, but costly return to work (RTW) coordination programmes. The benefit, however, remains uncertain. We conducted a systematic review to determine the long-term effectiveness of RTW coordination compared to usual practice in patients at risk for long-term disability.

Methods and Findings

Eligible trials enrolled employees on work absence for at least 4 weeks and randomly assigned them to RTW coordination or to usual practice. We searched 5 databases (to April 2, 2012). Two investigators performed standardised eligibility assessment, study appraisal and data extraction independently and in duplicate. The GRADE framework guided our assessment of confidence in the meta-analytic estimates. We identified 9 trials from 7 countries, 8 focusing on musculoskeletal, and 1 on mental complaints. Most trials followed participants for 12 months or less. No trial assessed permanent disability. Moderate quality evidence suggests a benefit of RTW coordination on proportion at work at end of follow-up (risk ratio = 1.08, 95% CI = 1.03 to 1.13; absolute effect = 5 in 100 additional individuals returning to work, 95% CI = 2 to 8), overall function (mean difference [MD] on a 0 to 100 scale = 5.2, 95% CI = 2.4 to 8.0; minimal important difference [MID] = 10), physical function (MD = 5.3, 95% CI = 1.4 to 9.1; MID = 8.4), mental function (MD = 3.1, 95% CI = 0.7 to 5.6; MID = 7.3) and pain (MD = 6.1, 95% CI = 3.1 to 9.2; MID = 10).

Conclusions

Moderate quality evidence suggests that RTW coordination results in small relative, but likely important absolute benefits in the likelihood of disabled or sick-listed patients returning to work, and associated small improvements in function and pain. Future research should explore whether the limited effects persist, and whether the programmes are cost effective in the long term.

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

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

One-year follow-up in employees sick-listed because of low back pain: randomized clinical trial comparing multidisciplinary and brief intervention

STUDY DESIGN

Randomized clinical trial comparing two interventions in employees sick-listed 3 to 16 weeks because of low back pain (LBP).

OBJECTIVE

To compare 1-year return to work (RTW), pain, disability and physical and mental health dimensions in subjects offered a hospital-based multidisciplinary intervention or a brief intervention.

SUMMARY OF BACKGROUND DATA

Previous studies in sick-listed employees with LBP have indicated efficacy of both brief and more comprehensive multidisciplinary interventions. However, it remains unknown, which is the more effective, and which elements are instrumental in furthering RTW, and improving health.

METHODS

The brief intervention comprised clinical examination and advice offered by a rehabilitation physician and a physiotherapist. In the multidisciplinary intervention, this intervention was supplemented with the expertise of a team and the assignment of a case manager who drew up a rehabilitation plan in collaboration with the patient and the multidisciplinary team. One-year RTW was estimated by data from a comprehensive national database of social transfer payments. Questionnaires were used to obtain baseline and 1-year data on Roland Morris disability score, LBP Rating Scale, SF36, and fear-avoidance.

RESULTS

A total of 351 patients were included and randomized and 344 (98%) patients participated in all the consultations according to the study protocol. RTW was achieved by 125 (71.0%) participants in the multidisciplinary and 133 (76.0%) participants in the brief intervention group. The hazard ratio was 0.84 after adjustment for sex, age, smoking, compensation claims, disability score, and diagnosis (95% confidence interval [CI]: 0.65-1.08,P = 0.18). Multiple linear regression analysis displayed no differences in secondary outcomes, except for the mental health score (SF36), which was a little higher in the multidisciplinary intervention group than in the brief intervention group.

CONCLUSION

Hospital-based multidisciplinary intervention may be no better than brief intervention to increase RTW and improve health in sick-listed employees with low back pain.

Back pain outcomes in primary care following a practice improvement intervention:- a prospective cohort study

BACKGROUND

Back pain is one of the UK's costliest and least understood health problems, whose prevalence still seems to be increasing. Educational interventions for general practitioners on back pain appear to have had little impact on practice, but these did not include quality improvement learning, involve patients in the learning, record costs or document practice activities as well as patient outcomes.

METHODS

We assessed the outcome of providing information about quality improvement techniques and evidence-based practice for back pain using the Clinical Value Compass. This included clinical outcomes (Roland and Morris Disability Questionnaire), functional outcomes, costs of care and patient satisfaction. We provided workshops which used an action learning approach and collected before and after data on routine practice activity from practice electronic databases. In parallel, we studied outcomes in a separate cohort of patients with acute and sub-acute non-specific back pain recruited from the same practices over the same time period. Patient data were analysed as a prospective, split-cohort study with assessments at baseline and eight weeks following the first consultation.

RESULTS

Data for 1014 patients were recorded in the practice database study, and 101 patients in the prospective cohort study. We found that practice activities, costs and patient outcomes changed little after the intervention. However, the intervention was associated with a small, but statistically significant reduction in disability in female patients. Additionally, baseline disability, downheartedness, self-rated health and leg pain had small but statistically significant effects (p < 0.05) on follow-up disability scores in some subgroups.

CONCLUSIONS

GP education for back pain that both includes health improvement methodologies and involves patients may yield additional benefits for some patients without large changes in patterns of practice activity. The effects in this study were small and limited and the reasons for them remain obscure. However, such is the impact of back pain and its frequency of consultation in general practice that this kind of improvement methodology deserves further consideration.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN30420389.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol

BACKGROUND

Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition.

AIMS

This study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP.

METHODS

The design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609001022257 (date registered 25th November 2009).

The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners (chiropractors, osteopaths, and musculoskeletal physiotherapists) across the United Kingdom.

SUMMARY OF BACKGROUND DATA

A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations.

METHODS

In total, 1758 practitioners were randomly allocated to either of the 2 study arms. One arm was posted a printed information package containing guideline recommendations for the management of LBP (n = 876) and the other received no intervention (n = 882). The primary outcome measure consisted of 3 "quality indicators" (activity, work, and bed-rest) relating to a vignette of a patient with LBP, in which responses were dichotomized into either "guideline-inconsistent" or "guideline-consistent." The secondary outcome was the practitioners' LBP-related beliefs, measured using the Health Care Providers Pain and Impairment Relationship Scale. Outcomes were measured at baseline and at 6 months.

RESULTS

Follow-up at 6 months was 89%. The changes in reported behavior on the quality indicators were as follows: activity, odds ratio (OR) 1.29 (95% confidence interval, 1.03-1.61) and number needed to be treated (NNT), 19 (15-28); work, OR 1.35 (1.07-1.70) and NNT 19 (14-29); and bed-rest, OR 1.31 (0.97-1.76) and NNT 47 (33-103). The composite NNT for a change from guideline-inconsistent to guideline-consistent behavior on at least 1 of the 3 quality indicators was 10 (9-14). LBP-related beliefs were significantly improved in those who were sent the information package (P = 0.002), but only to a small degree (mean difference, 0.884 scale points; 95% confidence interval, 0.319-1.448).

CONCLUSION

Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners, toward practice that is more in line with guideline recommendations.

Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review

BACKGROUND

A central element in the current debate about best practice management of non-specific low back pain (NSLBP) is the efficacy of targeted versus generic (non-targeted) treatment. Many clinicians and researchers believe that tailoring treatment to NSLBP subgroups positively impacts on patient outcomes. Despite this, there are no systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise. This systematic review was undertaken in order to determine the efficacy of such targeted treatment in adults with NSLBP.

METHOD

MEDLINE, EMBASE, Current Contents, AMED and the Cochrane Central Register of Controlled Trials were electronically searched, reference lists were examined and citation tracking performed. Inclusion criteria were randomized controlled trials of targeted manual therapy and/or exercise for NSLPB that used trial designs capable of providing robust information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials needed to be hypothesis-testing studies published in English, Danish or Norwegian. Method quality was assessed using the criteria recommended by the Cochrane Back Review Group.

RESULTS

Four high-quality randomized controlled trials of targeted manual therapy and/or exercise for NSLBP met the inclusion criteria. One study showed statistically significant effects for short-term outcomes using McKenzie directional preference-based exercise. Research into subgroups requires much larger sample sizes than traditional two-group trials and other included studies showed effects that might be clinically important in size but were not statistically significant with their samples sizes.

CONCLUSIONS

The clinical implications of these results are that they provide very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes. The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings. The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities.

Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions

BACKGROUND

Imaging is commonly performed for musculoskeletal conditions. Identifying interventions to improve the appropriate use of imaging for musculoskeletal conditions could potentially result in improved health outcomes for patients and reduced health care costs.

OBJECTIVES

To determine the effects of interventions that aim to improve the appropriate use of imaging for people with musculoskeletal conditions.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (June 2007), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (January 1966 to June 2007), EMBASE (January 1980 to June 2007) and CINAHL (January 1982 to June 2007). We also searched reference lists of included studies and relevant reviews. We undertook citation searches of all included studies, contacted authors of included studies, and contacted other experts in the field of effective professional practice.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled clinical trials and interrupted time-series analyses that evaluated interventions designed to improve the use of imaging for musculoskeletal symptoms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty eight studies met our inclusion criteria. The majority of the studies were for the management of osteoporosis or low back pain, and most evaluated interventions aimed at health professionals. To improve the use of imaging in the management of osteoporosis, the effect of any type of intervention compared to no-intervention controls was modest (absolute improvement in bone mineral density test ordering +10%, IQR 0.0 to +27.7). Patient mediated, reminder, and organisational interventions appeared to have most potential for improving imaging use in osteoporosis. For low back pain studies, the most common intervention evaluated was distribution of educational materials and this showed varying effects. Other interventions in low back pain studies also showed variable effects. For other musculoskeletal conditions, distribution of educational materials, educational meetings and audit and feedback were not shown to be effective for changing imaging ordering behaviour. Across all conditions, increasing the number of intervention components did not increase effect.

AUTHORS' CONCLUSIONS

For improving the use of imaging in osteoporosis, most professional interventions demonstrated benefit, and patient mediated, reminder, and organisational interventions appeared to have most potential for benefit. For low back pain studies interventions showed varying effects. For other musculoskeletal conditions, no firm conclusions can be drawn.

GP attitudes and self-reported behaviour in primary care consultations for low back pain

BACKGROUND

The implementation of guideline recommendations in primary care has become widespread. The treatment of low back pain (LBP) has followed suite. Research shows that the use of LBP guidelines is influenced by the believability of the underlying evidence, the GPs consultation style and uncertainties surrounding diagnosis and treatment.

OBJECTIVE

To qualitatively examine the attitudes and self-reported behaviour of GPs in relation to guideline adherence for patients with LBP.

METHOD

A mixed-method design combining a national UK-based survey of GPs and physiotherapists with an embedded qualitative study. This report focuses only on the GP interviews. We explored GPs' experience of managing LBP patients and the rationale for treatment offered to a patient described in a written vignette. All interviews were digitally recorded, fully transcribed and analysed using the constant comparative method.

RESULTS

GPs encountered difficulties adhering to guideline recommendations for LBP patients. They experienced particular tensions between recommendations to stay active versus the expectation of being prescribed rest. GPs expressed that chronic LBP often poses an intractable problem requiring specialist advice. The perception that guideline recommendations are 'imposed' may create resistance, and the evidence base is not always considered believable.

CONCLUSIONS

GPs acknowledge guideline recommendations but divergence occurs in implementation. This is due to GPs focussing on the whole person-not just one condition-and the importance of maintaining the doctor-patient relationship, which relies on effective negotiation of mutual perceptions and expectations. Further exploration on how consultation processes can be constructed to effectively combine evidence with patient-centred care is needed.

Designing a workplace return-to-work program for occupational low back pain: an intervention mapping approach

Background

Despite over 2 decades of research, the ability to prevent work-related low back pain (LBP) and disability remains elusive. Recent research suggests that interventions that are focused at the workplace and incorporate the principals of participatory ergonomics and return-to-work (RTW) coordination can improve RTW and reduce disability following a work-related back injury. Workplace interventions or programs to improve RTW are difficult to design and implement given the various individuals and environments involved, each with their own unique circumstances. Intervention mapping provides a framework for designing and implementing complex interventions or programs. The objective of this study is to design a best evidence RTW program for occupational LBP tailored to the Ontario setting using an intervention mapping approach.

Methods

We used a qualitative synthesis based on the intervention mapping methodology. Best evidence from systematic reviews, practice guidelines and key articles on the prognosis and management of LBP and improving RTW was combined with theoretical models for managing LBP and changing behaviour. This was then systematically operationalized into a RTW program using consensus among experts and stakeholders. The RTW Program was further refined following feedback from nine focus groups with various stakeholders.

Results

A detailed five step RTW program was developed. The key features of the program include; having trained personnel coordinate the RTW process, identifying and ranking barriers and solutions to RTW from the perspective of all important stakeholders, mediating practical solutions at the workplace and, empowering the injured worker in RTW decision-making.

Conclusion

Intervention mapping provided a useful framework to develop a comprehensive RTW program tailored to the Ontario setting.

The need for knowledge translation in chronic pain

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.

Psychometric properties of commonly used low back disability questionnaires: are they useful for older adults with low back pain?

OBJECTIVES

To evaluate the psychometric properties of two commonly used low back pain (LBP) disability questionnaires in a sample solely comprising community-dwelling older adults.

DESIGN

Single-group repeated measures design.

SETTING

Four continuing care retirement communities in Maryland and in Virginia. Participants. Convenience sample of 107 community-dwelling men and women (71.9%) aged 62 years or older with current LBP. Outcome Measures. All participants completed modified Oswestry Disability (mOSW) and Quebec Back Pain Disability (QUE) questionnaires, as well as the Medical Outcomes Survey Short-Form 36 questionnaire at baseline. At follow-up, 56 participants completed the mOSW and the QUE for reliability assessment.

RESULTS

Test-retest reliability of the mOSW and QUE were excellent with intraclass correlation coefficients of 0.92 (95% confidence interval [CI]: 0.86, 0.95) and 0.94 (95% CI: 0.90, 0.97), respectively. Participants with high pain severity and high levels of functional limitation had higher scores on the mOSW (P < 0.0001) and QUE (P < 0.001) scales than other participants, which represents good construct validity for both scales. The threshold for minimum detectable change is 10.66 points for the mOSW and 11.04 points for the QUE. Both questionnaires had sufficient scale width to accurately measure changes in patient status.

CONCLUSIONS

It appears that both questionnaires have excellent test-retest reliability and good construct validity when used to evaluate LBP-related disability for older adults with varying degrees of LBP. Neither questionnaire appears to have superior psychometric properties; therefore, both the Oswestry and Quebec can be recommended for use among geriatric patients with LBP.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

Content and outcome of usual primary care for back pain: a systematic review

BACKGROUND

Most patients seeking help for back pain are managed in primary care.

AIM

To describe the content and outcome of 'usual care' for low back pain in primary care trials.

DESIGN OF STUDY

A systematic review of randomised controlled trials published since 1998.

SETTING

Primary care.

METHOD

Randomised controlled trials of back pain in adults were scrutinised to obtain data on treatment and outcome measures in groups receiving usual primary care. A narrative review of the resulting heterogeneous data was undertaken.

RESULTS

Thirty-three papers were identified for analysis. Overall the exact nature of the treatment received in the 'usual' primary care group was poorly recorded. Medication was frequently used, and there were suggestions that levels of opioid prescription were higher than might be expected from clinical guidelines. Requesting of plain-film X-rays occurred more often than recommended. There was very little information to suggest that doctors were promoting physical activity for patients with back pain. Disability scores (Roland-Morris Disability Questionnaire) and pain scores improved over time for patients with acute or subacute back pain, but not for those with chronic pain.

CONCLUSION

Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and X-ray investigation. The content of the 'usual care' arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the 'usual care' arm.

A prospective study of the effectiveness of early intervention with high-risk back-injured workers--a pilot study

INTRODUCTION

It was postulated that workers, at the sub-acute stage after injury, respond differently to clinical and occupational interventions offered in a workers' compensation environment. Individual worker risk of disability, it was further believed, would influence the effectiveness of early intervention. The objective of the current pilot study was to evaluate return to work (RTW) outcomes following proactive, combined clinical, occupational and case management-based interdisciplinary early intervention, provided in a workers' compensation environment 4-10 weeks of onset of back pain, to workers with medium and high risk for disability.

METHODS

The project was a controlled study comparing conventional workers' compensation case management with integrated, interdisciplinary and multimodal early intervention (hereinafter referred to as "EI"). At baseline, risk status was determined by a validated Risk for Disability Questionnaire by Carragee et al. (Spine 5(1):24-35, 2005). Seventeen workers at high risk of protracted disability and 20 workers at moderate risk of disability received conventional case management, and 17 workers assessed at high risk of protracted disability and 18 workers at moderate risk of disability received the Early Intervention.

RESULTS

At 3 months post back pain onset, no statistically significant differences were identified in RTW outcomes between conventional case management and the Early Intervention. However, by 6 months post back pain onset, workers at high risk of work disability who received the Early Intervention were significantly more likely to RTW than high risk workers who received conventional case management. In contrast, moderate risk workers continued to exhibit no statistically significant differences in RTW outcomes.

CONCLUSION

Multimodal Early Intervention in the workers' compensation case management context is likely effective for workers with sub-acute back pain who are at high risk of occupational disability. The comprehensive Early Intervention is, however, likely redundant for workers who are not at high risk for disability and should not be applied indiscriminately. Further studies are required to determine longer-term Early Intervention outcomes, and to replicate the findings using a randomized control design. Also, with a larger sample size, it will be possible to determine predictors of occupational outcomes.

Advice for the management of low back pain: A systematic review of randomised controlled trials

To synthesise the evidence relating to the effectiveness of advice, the relevance of its content and frequency, and to compare the advice being offered to acute, subacute and chronic low back pain (LBP) patients. A systematic review of Randomised Controlled Trials (RCTs) using advice, either alone or with another intervention. The QUOROM guidelines and the Cochrane Collaboration Back Review Group Guidelines for Systematic Reviews were followed throughout: methodological assessment identified RCTs of 'high' or 'medium' methodological quality, based on their inclusion of at least 50% of the specified internal validity criteria. Outcome measures were analysed based on five recommended core outcome domains; pain, work disability, back-specific function, generic health status and satisfaction with care. Relevant RCTs (n=56) were scored for methodological quality; 39 RCTs involving 7347 patients qualified for inclusion, based upon their methodological quality. Advice as an adjunct to exercise was most effective for improving pain, back-specific function and work disability in chronic LBP but, for acute LBP, was no more effective for improving these outcomes than simple advice to stay active. Advice as part of a back school was most effective for improving back-specific function in subacute LBP; these trials generally demonstrated long-term positive results. Advice as an adjunct to exercise was the most common form of treatment for acute and chronic LBP; advice as part of a back school was most commonly used for subacute LBP. Fifteen percent of acute LBP trials had a positive outcome, compared to 86% and 74% of subacute and chronic LBP trials respectively. A wide variety of outcome measures were used, making valid comparisons between treatment outcomes difficult. The advice provided to patients with LBP within RCTs varied considerably depending on symptom duration. The findings of this review have important implications for clinical practice, and for the design of further clinical trials in this area. Advice to stay active is sufficient for acute LBP; however, it appears that RCTs do not commonly reflect these recommendations. No conclusions could be drawn as to the content and frequency of advice that is most effective for subacute LBP, due to the limited number and poor quality of RCTs in this area: this review provides preliminary support for advice as part of a back school approach. Given that the effectiveness of treatment for subacute symptoms will directly influence the development of chronicity, these results would suggest that education and awareness of the causes and consequences of back pain may be a valuable treatment component for this patient subgroup. For chronic LBP there is strong evidence to support the use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities to promote active self-management. More investigation is needed into the role of follow-up advice for chronic LBP patients.

Musculoskeletal work disability for clinicians: Time course and effectiveness of a specialized intervention program by diagnosis

OBJECTIVE

To evaluate how an intervention program modifies the clinical course of work disability in musculoskeletal diagnoses.

METHODS

All patients with temporary work disability related to musculoskeletal disorders (MSDs) in 3 health districts of Madrid, Spain were randomized into standard care (control group) or the intervention group. Intervention consisted of a specific program, run by rheumatologists, following detailed proceedings. Inclusion and followup lasted 12 months each. According to the cause, every temporary work disability episode was classified into 11 syndrome categories. For each we calculated efficacy, as the difference between groups in the number of days on sick leave per temporary work disability episode; relative efficacy, or the percentage of days saved in the intervention group; and time of maximum program effect. Analyses were performed on an intent-to-treat basis. Survival techniques were run and results were expressed as the hazard ratio (HR) in the intervention versus control group.

RESULTS

A total of 13,077 patients were included, generating 16,297 temporary work disability episodes. The most frequent cause was back pain. Temporary work disability episodes were significantly shorter in the intervention group than in the controls in all syndrome categories except knee pain (excluding osteoarthritis). Program relative efficacy varied from 28-72%. The program was highly efficacious in carpal tunnel syndrome (HR 2.09, 95% confidence interval [95% CI] 1.17-3.75), peripheral osteoarthritis (HR 1.58, 95% CI 1.14-2.19), and inflammatory diseases (HR 1.52, 95% CI 1.09-2.12). The maximum effect of the program always took place within the first 2 months.

CONCLUSION

The implementation of this type of specialist-run, protocol-based early intervention program would be very beneficial in the treatment of patients with work disability related to MSDs, except for those with knee pain (excluding osteoarthritis).

Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial

QUESTION

Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash?

DESIGN

Cluster-randomised trial.

PARTICIPANTS

Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients (4 dropouts) who presented to them with acute whiplash.

INTERVENTION

The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them.

OUTCOME MEASURES

The primary outcome was patient disability, measured using the Functional Rating Index, collected on admission to the trial and at 1.5, 3, 6 and 12 months. Physiotherapist knowledge about the guidelines was measured using a custom-made questionnaire. Physiotherapist practice and cost of care were measured by audit of patient notes.

RESULTS

There were no significant differences between groups for any of the patient outcomes at any time. The implementation patients had 0.6 points (95% CI -7.8 to 6.6) less disability than the dissemination patients at 12 months; 44% more physiotherapists in the implementation group reported that they prescribed two out of the five guideline-recommended treatments; and 32% more physiotherapists actually prescribed them. The cost of care for patients in the implementation group was $255 (95% CI -1505 to 996) less than for patients in the dissemination group.

CONCLUSION

Although the active implementation program increased guideline-consistent practice, patient outcomes and cost of care were not affected.

Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain

BACKGROUND AND PURPOSE

The treatment for patients with low back pain varies considerably. The Dutch Physiotherapy Association issued an evidence-based physiotherapy guideline for non-specific low back pain. To establish changes in daily practice an active implementation strategy was developed. We evaluated the cost-effectiveness of this implementation strategy.

SUBJECTS

113 physiotherapists included 500 patients with low back pain.

METHODS

In the intervention group the guideline was implemented actively, in the control group the standard method of dissemination was used. The patients filled in questionnaires at baseline and 6, 12, 26 and 52 weeks later. Direct medical costs, productivity costs (due to absenteeism) and quality of life (EQ-5D) were calculated.

RESULTS

During the 1-year follow up, no differences were found in the quality of life, direct medical costs and productivity costs.

CONCLUSION

The active implementation strategy appears not to be cost effective as compared to the standard strategy.

Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence

BACKGROUND

The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. One reason for limited dissemination of evidence is the complexity of the problem, as it is subject to multiple legal, administrative, social, political, and cultural challenges.

PURPOSE AND METHODS

A literature review and collection of experts' opinion is presented, on the current evidence for work disability prevention, and barriers to evidence implementation. Recommendations are presented for enhancing implementation of research results.

CONCLUSION

The current evidence regarding work disability prevention shows that some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. Future studies should involve all relevant stakeholders and aim at developing new strategies that are effective, efficient, and have a potential for successful implementation. These studies should be based upon a clearer conceptualization of the broader context and inter-relationships that determine return to work outcomes.

Evidence-Based Medicine and the Challenge of Low Back Pain: Where Are We Now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: the UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761]

BACKGROUND

Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines. Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level.

METHODS

The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.

A trial of an activating intervention for chronic back pain in primary care and physical therapy settings

In primary care and physical therapy settings, we evaluated an intervention for chronic back pain patients which incorporated fear reducing and activating techniques. Primary care patients seen for back pain in primary care were screened to identify persons with significant activity limitations 8-10 weeks after their visit. Eligible and willing patients were randomized (N=240). A brief, individualized program to reduce fear and increase activity levels was delivered by a psychologist and physical therapists. Over a 2 year follow-up period, intervention patients reported greater reductions in pain-related fear (P<0.01), average pain (P<0.01) and activity limitations due to back pain (P<0.01) relative to control patients. The percent with greater than a one-third reduction in Roland Disability Questionnaire scores at 6 months was 42% among Intervention patients and 24% among control patients (P<0.01). Over the 2 year follow-up, fewer intervention patients reported 30 or more days unable to carry out usual activities in the prior 3 months (P<0.01). The adjusted mean difference in activity limitation days was 4.5 days at 6 months, 2.8 days at 12 months, and 6.9 days at 24 months. No differences were observed in the percent unemployed or the percent receiving worker's compensation or disability benefits, but these outcomes were relatively uncommon. We conclude that an intervention integrating fear reducing and activating interventions into care for chronic back pain patients produced sustained reductions in patient fears, common activity limitations related to back pain, and days missed from usual activities due to back pain.

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review

PURPOSE

To assess the clinical and economic effects of disease management in patients with chronic diseases.

METHODS

Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group.

RESULTS

Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%).

CONCLUSION

Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.