Acute low back pain: diagnostic and therapeutic practices reported by Brazilian rheumatologists

Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review

OBJECTIVES

Low back pain (LBP) is the leading cause of disability and work absenteeism globally, and it poses significant clinical and economic burden to individuals, health systems and the society. This study aimed to synthesise the clinical and economic burden of LBP in low-income and middle-income countries (LMICs).

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. PubMed, Medline, CINAHL, PsycINFO, AMED, Embase and Scopus databases were systematically searched for studies that examined the clinical and economic burden of LBP in LMICs, published from inception to 10 December 2021. Only studies with clearly stated methodologies and published in English were eligible for review.

RESULTS

Nine studies met the inclusion criteria and were reviewed. Of these, three of them were clinical burden studies. The mean Newcastle-Ottawa Quality Assessment Scale (NOS) score of the included studies was 4, with an average from 3 to 6. The included studies were conducted in Argentina, Brazil, China, Ethiopia, Nigeria and Republic of Serbia. The rates of hospitalisation due to LBP ranged between 13.4% and 18.7%. Due to variation of methodological approaches, the reported cost estimates were inconsistent across the studies. A total cost of US$2.2 billion per population and US$1226.25 per patient were reported annually due to LBP.

CONCLUSION

This systematic literature review suggests that LBP is associated with significantly high rates of hospitalisation and costs. As LBP is an important threat to the population, health professionals and policymakers are to put in place appropriate programmes to reduce the clinical and economic burden associated with LBP and improve the health outcomes of individuals with this condition in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42020196335.

Tackling low back pain in Brazil: a wake-up call

BACKGROUND

Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society.

OBJECTIVE

This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.

Prevention and treatment of low back pain: evidence, challenges, and promising directions

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists

AIM

To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients.

METHODS

Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ² tests.

RESULTS

The survey was divided into three subsections; PTs’ attitudes on LBP assessment, patients’ attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a “privilege” which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as “executers”, being unable to interfere with treatment plan, possibly implying lack of autonomy.

CONCLUSION

Although similarities on history taking methods and on patients’ attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

The Alberta Health Technology Assessment (HTA) Ambassador Program: The Development of a Contextually Relevant, Multidisciplinary Clinical Practice Guideline for Non-specific Low Back Pain: A Review

PURPOSE

To describe the development of a contextually relevant multidisciplinary clinical practice guideline (CPG) for non-specific low back pain (LBP) and to discuss its value to the management of LBP and the practice of physiotherapy.

METHOD

To mitigate an identified knowledge gap for Alberta primary-care practitioners in the management of non-specific LBP, a collaborative process was developed to engage multidisciplinary health care providers in designing a primary-care CPG for non-specific LBP. A comprehensive review of published LBP guidelines identified the seven highest-quality CPGs; these were used to inform a multidisciplinary guideline development group (GDG) as they developed the CPG.

RESULTS

The GDG constructed a CPG for non-specific LBP along with point-of-care decision-support and patient-education tools.

CONCLUSIONS

The Ambassador Program on Low Back Pain worked with front-line clinicians from across Alberta to review the best available evidence in developing a CPG responsive to the Alberta context. This CPG is intervention specific and provides a wide range of primary-care practitioners with the best available evidence to inform their clinical decisions in managing non-specific LBP.

Managing low back pain in the primary care setting: the know-do gap

OBJECTIVE

To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP) in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta's primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline.

METHODS

English language studies, published from 1996 to 2008, comparing the clinical practice patterns of primary care practitioners with guideline recommendations were identified by systematically searching literature databases, the websites of various health technology assessment agencies and libraries, and the Internet. Data were synthesized qualitatively.

RESULTS

The literature search identified 14 relevant studies. Knowledge gaps were reported among various primary care practitioner groups in the assessment of red flags, use of diagnostic imaging, provision of advice regarding sick leave and continuing activity, administration of some medications (muscle relaxants, oral steroids and opioids) and recommendation of particular treatments (acupuncture, physiotherapy, spinal manipulation, traction, ultrasound, transcutaneous electrical nerve stimulation and spinal mobilization).

CONCLUSIONS

A know-do gap clearly exists among primary care practitioners with respect to the diagnosis and treatment of LBP. The information on know-do gaps will be used to construct a survey tool for unearthing the local knowledge gaps extant among Alberta's primary care practitioners, and to develop a dissemination strategy for a locally produced multidisciplinary LBP guideline, with the aim of ensuring that the know-do gaps inherent within each primary practice discipline are specifically targeted.

Which are the most important discriminatory items for subclassifying non-specific low back pain? A Delphi study among Greek health professionals

RATIONALE, AIMS AND OBJECTIVES

Developing homogenous low back pain (LBP) classification groups is recommended for enhancing clinical outcomes. However, an important step towards the development of specific subgroups is the selection and consensus agreement among health professionals on the discriminatory clinical items (sings and symptoms) that should be included in the classification process. Thus, this study's objective was to develop a list of clinical features for the assessment of LBP by health care providers within Greece, which are believed to be discriminatory in identifying LBP subgroups.

METHODS

A random sample stratified by geographical region and work status of 150 Greek physiotherapists (PTs) participated in a two-round Delphi study. PTs were asked to obtain consensus and hierarchy, the most important items out of a list of evaluating/diagnostic features believed to be discriminatory for LBP patients. These items included 80 clinical features and were generated in by PTs and doctors previous work.

RESULTS

Second-round questionnaires were returned by 112 PTs (74.6% response rate). A total of 66 clinical features were rated as important discriminatory items in LBP assessment. Clinical items included characteristics of present symptoms and the history's condition, general medical history, information regarding patient function, patients' attitudes regarding movement, diagnosis, expectations, fear-avoidance beliefs as well as aspects of a physical examination including observation, active and passive movements, neurological and muscular examination.

CONCLUSIONS

This is the first study identifying important clinical items for LBP patients in Greece. It may be that these features are 'discriminatory' for different LBP subsets; however, further research is needed.

Efficacy of etoricoxib 60 mg/day and diclofenac 150 mg/day in reduction of pain and disability in patients with chronic low back pain: results of a 4-week, multinational, randomized, double-blind study

BACKGROUND AND METHODS

The efficacy and safety of etoricoxib 60 mg/day in patients with established chronic low back pain (CLBP) were compared with those of diclofenac 150 mg/day in a 4-week, multicentre, randomized, double-blind, parallel-group trial. Four hundred and forty-six adult patients with CLBP (Quebec Task Force on Spinal Disorders Class 1 or 2) and with worsening pain upon discontinuation of pre-study analgesic medication were enrolled in the study. The study primary efficacy endpoint was change from baseline in Low Back Pain Intensity Scale (LBP-IS) score over the 4-week treatment period. Secondary and other efficacy endpoints included: changes in Roland and Morris Disability Questionnaire (RMDQ), Patient Global Assessment of Response to Therapy (PGART) and Low Back Pain Bothersomeness Scale (LBP-BS) scores. Early efficacy was assessed using PGART and LBP-IS scores 4 h after the first dose on the mornings of Days 1, 2 and 3. The overall safety and tolerability of etoricoxib 60 mg/day during 4 weeks of treatment were also assessed.

RESULTS

The least-squares mean time-weighted change from baseline LBP-IS score over 4 weeks was -32.94 mm (95% CI -36.25, -29.63) for etoricoxib, indicating substantial efficacy in relief of pain. The treatment difference for the primary outcome was 2.51 mm (95% CI -1.50, 6.51), fulfilling the prespecified equivalence criterion of 95% confidence interval wholly within +/- 10 mm. Etoricoxib improved all secondary and other efficacy outcomes. There were no statistically significant between-group differences in the proportion of patients with one or more clinical adverse events (AEs) (etoricoxib 35%, diclofenac 39%), or the proportion of patients who discontinued due to AEs (etoricoxib 7%, diclofenac 5%).

CONCLUSIONS

The results of this study confirm that, for adult patients with CLBP, etoricoxib 60 mg once daily over 4 weeks is effective for relief of pain and improvement of physical function and comparable to high-dose diclofenac 150 mg daily.