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Duarte ST, Moniz A, Costa D, Donato H, Heleno B, Aguiar P, Cruz EB. Low back pain management in primary healthcare: findings from a scoping review on models of care. BMJ Open 2024; 14:e079276. [PMID: 38754873 PMCID: PMC11097853 DOI: 10.1136/bmjopen-2023-079276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services. OBJECTIVE To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP. DESIGN Scoping review. DATA SOURCES Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted. ELIGIBILITY CRITERIA Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings. DATA EXTRACTION AND SYNTHESIS Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach. RESULTS 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported. CONCLUSIONS This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
| | - Alexandre Moniz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Department of Physiotherapy, Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Bruno Heleno
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Pedro Aguiar
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
| | - Eduardo B Cruz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA University Lisbon, Lisboa, Portugal
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Jess MA, Ryan C, Wellburn S, Atkinson G, Greenough C, Peat G, Coxon A, Roper H, Fatoye F, Ferguson D, Dickson A, Ridley H, Martin D. Does pain duration and other variables measured at baseline predict re-referral of low back pain patients managed on an evidence-based pathway? A cohort study. Physiotherapy 2023; 121:5-12. [PMID: 37591028 DOI: 10.1016/j.physio.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 04/02/2023] [Accepted: 07/26/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE To explore the association between baseline pain duration and the likelihood of re-referral of patients with low back pain (LBP) managed on the evidence-based North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). STUDY DESIGN Longitudinal, observational cohort study. METHODS In all, 12,509 adults with LBP were identified as having been discharged from the pathway, between May 2015 and December 2019. To quantify any association between baseline pain duration and the likelihood of re-referral, two statistical modelling approaches, were used: logistic regression models for odds ratios and generalised linear models with a binomial link function in order to quantify risk differences. RESULTS Twenty-five percent of patients with LBP, who were discharged, re-referred for management over a 4.5-year period. A large difference in pain duration of 2 SD days was statistically associated with re-referral, with an odds ratio of 1.22 (95% CI: 1.03, 1.44) and a risk difference of 3.6% (95% CI: 0.6, 6.6). Nevertheless, the predictive value of an individual's pain duration was found to be weak for re-referral. Higher baseline disability [odds ratio of 1.40 (95% CI: 1.07, 1.83)] and a younger age at baseline [odds ratio of 0.73 (95% CI 0.61, 0.86)] were also associated with an increased risk of re-referral. CONCLUSIONS Baseline pain duration, disability and younger age are statistically associated with re-referral onto the NERBPP. However, the value of these variables for predicting an individual's risk of re-referral is weak. CONTRIBUTION OF PAPER.
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Affiliation(s)
- Mary-Anne Jess
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK.
| | - Cormac Ryan
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Shaun Wellburn
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Greg Atkinson
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | | | - Glynis Peat
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Andrew Coxon
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Helena Roper
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Francis Fatoye
- Department of Health Professions, Faculty of Health and Education, Manchester Metropolitan University, UK
| | - Diarmaid Ferguson
- Northumbria Healthcare NHS Trust, North Tyneside General Hospital, North Shields, UK; Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK
| | - Alastair Dickson
- Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK; The North of England Low Back Pain Pathway, NIHR Applied Research Collaboration (ARC) North East and North Cumbria, St Nicolas' Hospital, Newcastle Upon Tyne, UK; AD Outcomes Ltd, York, UK
| | - Helen Ridley
- Getting It Right First Time (GIRFT): Clinically led improvement programme delivered in partnership with the Royal National Orthopaedic Hospitals NHS Trust, NHS England and NHS Improvement, UK
| | - Denis Martin
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK; NIHR Applied Research Collaboration for the North East and North Cumbria, UK
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Ghafouri N, Bäckryd E, Dragioti E, Rivano Fischer M, Ringqvist Å, Gerdle B. Effects of interdisciplinary pain rehabilitation programs on neuropathic and non-neuropathic chronic pain conditions - a registry-based cohort study from Swedish Quality Registry for Pain Rehabilitation (SQRP). BMC Musculoskelet Disord 2023; 24:357. [PMID: 37149571 PMCID: PMC10163768 DOI: 10.1186/s12891-023-06462-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 04/25/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND AND AIM Neuropathic pain arises as a direct consequence of a lesion or disease affecting the somatosensory system. Pharmacological treatments for neuropathic pain often fail despite following guidelines. Interdisciplinary Pain Rehabilitation Programs (IPRP) are an effective intervention for chronic pain conditions. Little research has investigated whether IPRP can benefit patients with chronic neuropathic pain compared to other chronic pain conditions. This study assesses the real-world effects of IPRP on patients with chronic neuropathic pain compared to non-neuropathic patients using Patient-Reported Outcome Measures (PROMs) available in the Swedish Quality Registry for Pain Rehabilitation (SQRP). METHODS A neuropathic group of patients (n = 1,654) were identified in two steps. This group was compared to a non-neuropathic group (n = 14,355) composed of common diagnoses (low back pain, fibromyalgia, whiplash associated disorders, and Ehlers-Danlos Syndrome) in relation to background variables, three overall outcome variables, and mandatory outcome variables (pain intensity, psychological distress symptoms, activity/participation aspects and health-related quality of life variables). Of these patients 43-44% participated in IPRP. RESULTS At assessment, the neuropathic group reported significantly (with small effect sizes (ES)) more physician visits the previous year, older age, shorter pain durations, and less spatial extent of the pain (moderate ES). Moreover, for the 22 mandatory outcome variables, we found only clinically insignificant differences according to ESs between the groups. For patients participating in IPRP, the neuropathic group displayed equal or in some cases slightly superior results compared to the non-neuropathic group. DISCUSSION AND CONCLUSION After assessing the real-world effects of IPRP, this large study found that neuropathic pain patients can benefit from the IPRP intervention. Both registry studies and RCTs are needed to better understand which patients with neuropathic pain are most suitable for IPRP and to what extent special considerations need to be made for these patients within the framework of IPRP.
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Affiliation(s)
- Nazdar Ghafouri
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden
| | - Emmanuel Bäckryd
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden
| | - Marcelo Rivano Fischer
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, 221 85, Lund, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Åsa Ringqvist
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, 221 85, Lund, Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden.
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Herman PM, Qureshi N, Arick SD, Edelen MO, Hays RD, Rodriguez A, Weir RL, Coulter ID. Definitions of Chronic Low Back Pain From a Scoping Review, and Analyses of Narratives and Self-Reported Health of Adults With Low Back Pain. THE JOURNAL OF PAIN 2023; 24:403-412. [PMID: 36283654 PMCID: PMC10414544 DOI: 10.1016/j.jpain.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
Abstract
Among those with low back pain (LBP), individuals with chronic LBP (CLBP) face different treatment recommendations and incur the majority of suffering and costs. However, the way CLBP has been defined varies greatly. This study used a scoping review and qualitative and quantitative analyses of data from LBP patients to explore this variation. CLBP in most recent randomized controlled trials (RCTs) was defined by duration of pain, most commonly ≥3 months. However, individuals with LBP most often define CLBP by frequency. CLBP has also been defined using a combination of duration and frequency (16% of RCTs and 20% of individuals), including 6% of recent RCTs that followed the NIH Pain Consortium research task force (RTF) definition. Although not a defining characteristic of CLBP for individuals, almost 15% of recent RCTs required CLBP to have a healthcare provider diagnosis. In our LBP sample moving from ≥3 months to the RTF definition reduced the CLBP group size by 25% and resulted in a group that used more pain management options and reported worse health across all outcome measures. A pain duration definition offers ease of application. However, refinements to this definition (eg, RTF) can identify those who may be better intervention targets. PERSPECTIVE: This article presents the definitions used for CLBP by researchers and individuals, and the impact of these definitions on pain management and health outcomes. This information may help researchers choose better study inclusion criteria and clinicians to better understand their patients' beliefs about CLBP.
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Affiliation(s)
| | | | | | | | - Ron D Hays
- RAND Corporation, Santa Monica, California; Department of Medicine, University of California, Los Angeles, California
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Clinical pathways for the management of low back pain from primary to specialised care: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1846-1865. [PMID: 35378631 DOI: 10.1007/s00586-022-07180-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components. METHODS Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented. RESULTS From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary. CONCLUSIONS The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.
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Is Chronic Pain Temporal Pattern Associated with Middle-Aged and Older Adults’ Perceptions of their Futures? HEALTH PSYCHOLOGY BULLETIN 2021; 5:136-144. [PMID: 35425865 PMCID: PMC9007559 DOI: 10.5334/hpb.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A psychological consequence of chronic pain may be an inappropriately limited future time perspective (FTP) for middle-aged and older adults. FTP is defined as one’s perception of time as limited or expansive. Potentially meaningful measures, like pain temporal pattern, are often ignored in the chronic pain literature. The present study uses secondary data to assess the association between pain temporal pattern and FTP, and the moderating effect of pain duration. Among 140 individuals with chronic pain, there was no significant association between pain pattern and FTP. However, both pain-related activity interference and pain duration were associated with FTP where greater interference predicted more limited FTP (b = −0.16, p = .03) and longer pain duration contributed to more expansive FTP (b = 0.001, p = .03). The temporal pattern x pain duration interaction terms were non-significant. We discuss implications, limitations, and future directions of these findings.
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Jess MA, Hamilton S, Ryan C, Wellburn S, Alexanders J, Spence D, Martin D. Exploring the origin of pain subclassification, with emphasis on low back pain: a scoping review. JBI Evid Synth 2021; 19:308-340. [PMID: 32881730 DOI: 10.11124/jbisrir-d-19-00383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This scoping review aimed to explore the different working definitions for the duration of acute, subacute, and chronic pain, with emphasis on low back pain, and to establish where these definitions originated and the rationale provided for the time frames used. INTRODUCTION From a global perspective, low back pain is a major social and economic problem. One of the most commonly used methods to stratify and manage low back pain is the traditional duration-based classification (acute, subacute, and chronic). Where these time points lie to differentiate these transitions continues to be debated within the scientific community, which may engender a degree of heterogeneity in study findings. Therefore, applying these findings to clinical practice may be somewhat challenging. This review encapsulates the historical origins of the different duration categories to provide an understanding of how these variations were derived. INCLUSION CRITERIA Studies that included participants with low back pain were the focus of this review. Sources that included children or other specific pain pathologies, such as cancer pain, were excluded. The main concept of interest was that the publication proposed an original definition of the duration of acute, subacute, or chronic low back pain. All study designs were included provided they gave a rationale for the duration that they used. METHODS The following databases were searched: MEDLINE, Embase, CINAHL, and PsycINFO, from the inception of each database until September 18, 2019. This review was limited to studies published in English. Two independent reviewers screened the retrieved articles against the eligibility criteria. Additional studies were searched from the reference lists of studies to find the original source. Some original sources overlapped with general pain duration literature. This led to a deviation from the scoping review protocol, which originally intended to focus on definitions of low back pain duration only. Data extraction was undertaken using a charting table developed specifically for the review objectives. The findings were presented using narrative synthesis. RESULTS Nineteen records were included in this review, and comprised three book chapters, four review articles, four articles that arose following pain expert group discussions, seven primary research studies, and a spinal guideline. Data were extracted from the included studies and categorized into four themes based on the origin of the classification of the duration. The themes included i) work/employment setting, ii) empirical studies, iii) expert reasoning, and iv) pathophysiological explanation. CONCLUSIONS This scoping review compiled the existing literature on the working definitions of the duration of acute, subacute, and chronic low back pain and found a wide variation. These ranged from seven days, 14 days, and seven weeks for the acute and subacute transition points, and seven weeks to three years for chronic low back pain. The duration definitions specifically referring to the general pain literature focused on three and/or six months for the transition to chronic. Better integration of reasoning between the identified themes could facilitate the establishment of more ideal duration definitions in the future. Although inconclusive, the definition most commonly cited, with most consensus, was three months for the transition to chronic low back pain.
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Affiliation(s)
- Mary-Anne Jess
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Sharon Hamilton
- School of Health and Social Care, Teesside University, Middlesbrough, UK.,Teesside Centre for Evidence-Informed Practice: A JBI Affiliated Group, Middlesbrough, UK
| | - Cormac Ryan
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Shaun Wellburn
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Jenny Alexanders
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Daniel Spence
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Denis Martin
- School of Health and Social Care, Teesside University, Middlesbrough, UK
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