1
|
Heine J, Window P, Hacker S, Young J, Mitchell G, Roffey S, Cottrell M. Adherence to recommended guidelines for low back pain presentations to an Australian emergency department: Barriers and enablers. Australas Emerg Care 2023; 26:326-332. [PMID: 37193622 DOI: 10.1016/j.auec.2023.04.003] [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: 12/17/2022] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE This study sought to evaluate the adherence to guidelines for the management of mechanical Low Back Pain within a single tertiary metropolitan Emergency Department setting. Our objectives were: METHODS: A two-stage multi-methods study design was undertaken. Stage 1 involved a retrospective chart audit of patients presenting with a diagnosis of mechanical Low Back Pain to establish documented adherence to clinical guidelines. Stage 2 explored clinicians' perspectives towards factors influencing adherence to the guidelines via a study-specific survey and follow up focus groups. RESULTS The audit demonstrated low adherence to the following guidelines: (i) appropriate prescription of analgesia, (ii) targeted education and advice, and (iii) attempts to mobilise. Three major themes were identified as factors influencing adherence to the guidelines: (1) clinician driven influences and factors, (2) workflow processes, and (3) patient expectations and behaviours. CONCLUSION There was low adherence to some published guidelines and factors influencing adherence to the guidelines were multi-factorial. Understanding the factors that influence care decisions and developing strategies to address these can improve Emergency Department management of mechanical Low Back Pain.
Collapse
Affiliation(s)
- Janelle Heine
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia.
| | - Peter Window
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia
| | - Sarah Hacker
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia
| | - Jordan Young
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia; University of Queensland, St Lucia, Queensland 4067, Australia
| | - Gary Mitchell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia; Jamieson Trauma Institute, Herston, Queensland 4006, Australia; University of Queensland, St Lucia, Queensland 4067, Australia
| | - Shea Roffey
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia
| | - Michelle Cottrell
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland 4006, Australia
| |
Collapse
|
2
|
Truter P, Attwooll L, Flanagan P, McGinty C, Taylor R, Hince D, Wand BM. Comparing multi-disciplinary low back pain care in the ED to the Australian clinical care standard: The possible influence of profession, experience and back pain beliefs. Int Emerg Nurs 2023; 71:101351. [PMID: 37757581 DOI: 10.1016/j.ienj.2023.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/12/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Piers Truter
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia; School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia.
| | - Lydia Attwooll
- School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - Pippa Flanagan
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia; School of Allied Health, Curtin University, Perth, WA 6845, Australia
| | - Casey McGinty
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia
| | - Rosalind Taylor
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia
| | - Dana Hince
- Institute of Health Research, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - Benedict M Wand
- School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| |
Collapse
|
3
|
Orlando JF, Beard M, Guerin M, Kumar S. Systematic review of predictors of hospitalisation for non-specific low back pain with or without referred leg pain. PLoS One 2023; 18:e0292648. [PMID: 37816006 PMCID: PMC10564130 DOI: 10.1371/journal.pone.0292648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023] Open
Abstract
Significant costs and utilisation of healthcare resources are associated with hospitalisations for non-specific low back pain despite clinical guidelines recommending community-based care. The aim of this systematic review was to investigate the predictors of hospitalisation for low back pain. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42021281827) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Database search of Ovid Medline, Emcare, Embase, PsycINFO, Cochrane Library, PEDro and OTSeeker was conducted. Studies were included if they examined a predictor of hospitalisation for non-specific low back pain with or without referred leg pain. Data was extracted and descriptively synthesised. Risk of bias of included studies was assessed using the Critical Appraisal Skills Programme Checklists. There were 23 studies published over 29 articles which identified 52 predictor variables of hospitalisation for low back pain. The risk of hospitalisation was grouped into themes: personal, health and lifestyle, psychology, socioeconomic, occupational, clinical, and health systems and processes. There was moderate level evidence that arrival to an emergency department via ambulance with low back pain, and older age increase the risk of hospitalisations for low back pain. There was low level evidence that high pain intensity, past history of low back pain, opioid use, and occupation type increase the risk of hospitalisation for low back pain. Further research into psychological and social factors is warranted given the paucity of available studies. Hospital avoidance strategies, improved patient screening and resource utilisation in emergency departments are considerations for practice.
Collapse
Affiliation(s)
- Joseph F. Orlando
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Matthew Beard
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Michelle Guerin
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
| | - Saravana Kumar
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
| |
Collapse
|
4
|
Bise CG, Schneider M, Freburger J, Fitzgerald GK, Switzer G, Smyda G, Peele P, Delitto A. First Provider Seen for an Acute Episode of Low Back Pain Influences Subsequent Health Care Utilization. Phys Ther 2023; 103:pzad067. [PMID: 37379349 DOI: 10.1093/ptj/pzad067] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/03/2022] [Accepted: 03/23/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Costs associated with low back pain (LBP) continue to rise. Despite numerous clinical practice guidelines, the evaluation and treatments for LBP are variable and largely depend on the individual provider. As yet, little attention has been given to the first choice of provider. Early research indicates that the choice of first provider and the timing of interventions for LBP appear to influence utilization. We sought to examine the association between the first provider seen and health care utilization. METHODS Using 2015-2018 data from a large insurer, this retrospective analysis focused on patients (29,806) seeking care for a new episode of LBP. The study identified the first provider chosen and examined the following year of medical utilization. Cox proportional hazards models were calculated using inverse probability weighting on propensity scores to evaluate the time to event and the relationship to the first choice of provider. RESULTS The primary outcome was the timing and use of health care resources. Total health care use was lowest in those who first sought care with chiropractic care or physical therapy. Highest health care use was seen in those patients who chose the emergency department. CONCLUSION Overall, there appears to be an association between the first choice of provider and future health care use. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. The use of physical therapists and chiropractors as entry points into the health system appears related to a decrease in immediate and long-term use of health resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP. IMPACT The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP.
Collapse
Affiliation(s)
- Christopher G Bise
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janet Freburger
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - G Kelley Fitzgerald
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Galen Switzer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Garry Smyda
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
| | - Pamela Peele
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony Delitto
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- School of Health and Rehabilitation Science, Office of the Dean, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
5
|
Custódio LA, Marques YA, de Toledo AM, de Sá Ferreira A, van Tulder M, da Silva EN, Carregaro RL. The care pathway of individuals with spinal disorders in a Health Care Network in the Federal District, Brazil: a retrospective study. Braz J Phys Ther 2023; 27:100553. [PMID: 37862916 PMCID: PMC10692366 DOI: 10.1016/j.bjpt.2023.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/11/2023] [Accepted: 10/04/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Understanding the care pathway is essential to identify how to effectively treat spinal disorders. However, there is no specific data on the pathway of these individuals in the Health Care Networks (HCN) in Brazil. OBJECTIVE To investigate the pathway of individuals with non-specific spinal disorders (NSD) in the HCN in the Federal District, Brazil, and verify the interventions adopted, and to test whether sociodemographic and clinical variables predict the number of imaging tests, prescribed medication, and the first HCN access. METHODS Retrospective study that analysed electronic records of 327 individuals with NSD between 2012 and 2018. Generalized linear models estimated the association between sociodemographic and clinical data and number of drugs prescribed and imaging tests requested. Multinomial logistic regression estimated the association between clinical and demographic variables and setting of first access. RESULTS The median age was 57 years, and 75.5% were women. Emergency Department (ED) was the most accessed setting (43.7%), and back pain was the most prevalent condition (84.5%). Most individuals underwent imaging tests (60%) and drug prescriptions (86%). Physical exercises were prescribed to 13%, and 55% were referred to physical therapy. Women were more likely to first access the ED. CONCLUSION The ED was the most used setting by people with NSD. Few participants received exercise prescriptions and half were referred to physical therapists. Individuals who used outpatient clinics and primary care received less drug prescriptions, and women were more likely to first access the ED. Increasing age was associated with greater chance of first accessing Outpatient Clinics.
Collapse
Affiliation(s)
- Luciana Alves Custódio
- Graduate Program in Rehabilitation Sciences, Universidade de Brasília (UnB), UnB Ceilândia Campus, Brasília, DF, Brazil
- Evidence and Health Technology Center (NETecS), Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, DF, Brazil
- State Health Department of the Federal District (SES/DF), Brasília, DF, Brazil
| | - Yara Andrade Marques
- Graduate Program in Rehabilitation Sciences, Universidade de Brasília (UnB), UnB Ceilândia Campus, Brasília, DF, Brazil
- Evidence and Health Technology Center (NETecS), Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, DF, Brazil
| | - Aline Martins de Toledo
- Graduate Program in Rehabilitation Sciences, Universidade de Brasília (UnB), UnB Ceilândia Campus, Brasília, DF, Brazil
- Evidence and Health Technology Center (NETecS), Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, DF, Brazil
| | - Arthur de Sá Ferreira
- Graduate Program in Rehabilitation Sciences, Centro Universitário Augusto Motta (UNISUAM), Rio de Janeiro, RJ, Brazil
| | - Maurits van Tulder
- Department of Human Movement Sciences, Faculty of Behavioural & Movement Sciences, Vrije Universiteit Amsterdam, the Netherlands
- Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Everton Nunes da Silva
- Evidence and Health Technology Center (NETecS), Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, DF, Brazil
- Graduate Program in Health Sciences and Technologies, Universidade de Brasília (UnB), UnB Ceilândia Campus, Brasília, DF, Brazil
| | - Rodrigo Luiz Carregaro
- Graduate Program in Rehabilitation Sciences, Universidade de Brasília (UnB), UnB Ceilândia Campus, Brasília, DF, Brazil
- Evidence and Health Technology Center (NETecS), Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, DF, Brazil
| |
Collapse
|
6
|
Jermini-Gianinazzi I, Blum M, Trachsel M, Trippolini MA, Tochtermann N, Rimensberger C, Liechti FD, Wertli MM. Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey. BMJ Open 2023; 13:e071893. [PMID: 37541755 PMCID: PMC10407374 DOI: 10.1136/bmjopen-2023-071893] [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: 01/20/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.
Collapse
Affiliation(s)
- Ilaria Jermini-Gianinazzi
- Emergency Department, Ospedale Regionale di Bellinzona e Valli Bellinzona, Bellinzona, Ticino, Switzerland
| | - Manuel Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maurizio Alen Trippolini
- School of Health Professions, Berne University of Applied Sciences, Bern, Switzerland
- Evidence-based Insurance Medicine (EbIM), Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicole Tochtermann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Caroline Rimensberger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Dominik Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Kantonsspital Baden AG, Baden, Aargau, Switzerland
| |
Collapse
|
7
|
Dlott CC, Metcalfe T, Khunte A, Jain S, Bahel A, Hsiang WR, Donnelley CA, Kayani J, Wiznia DH. Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention. Medicine (Baltimore) 2022; 101:e32519. [PMID: 36595864 PMCID: PMC9794202 DOI: 10.1097/md.0000000000032519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.
Collapse
Affiliation(s)
- Chloe C. Dlott
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
- * Correspondence: Chloe C. Dlott, Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, 800 Howard Avenue, New Haven, CT 06519, United States (e-mail: )
| | - Tanner Metcalfe
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Akshay Khunte
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Sanjana Jain
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Anchal Bahel
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Walter R. Hsiang
- University of California San Francisco, Department of Urology, San Francisco, CA, United States
| | - Claire A. Donnelley
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Jehanzeb Kayani
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Daniel H. Wiznia
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| |
Collapse
|
8
|
Dlott CC, Wiznia DH. CORR Synthesis: What Triage Recommendations Are Available for Emergent or Urgent Musculoskeletal Conditions? Clin Orthop Relat Res 2022; 480:1980-1988. [PMID: 35901435 PMCID: PMC9473775 DOI: 10.1097/corr.0000000000002312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/15/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
9
|
Ferreira G, Lobo M, Richards B, Dinh M, Maher C. Hospital variation in admissions for low back pain following an emergency department presentation: a retrospective study. BMC Health Serv Res 2022; 22:835. [PMID: 35818074 PMCID: PMC9275239 DOI: 10.1186/s12913-022-08134-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background One in 6 patients with low back pain (LBP) presenting to emergency departments (EDs) are subsequently admitted to hospital each year, making LBP the ninth most common reason for hospital admission in Australia. No studies have investigated and quantified the extent of clinical variation in hospital admission following an ED presentation for LBP. Methods We used routinely collected ED data from public hospitals within the state of New South Wales, Australia, to identify presentations of patients aged between 18 and 111 with a discharge diagnosis of LBP. We fitted a series of random effects multilevel logistic regression models adjusted by case-mix and hospital variables. The main outcome was the hospital-adjusted admission rate (HAAR). Data were presented as funnel plots with 95% and 99.8% confidence limits. Hospitals with a HAAR outside the 95% confidence limit were considered to have a HAAR significantly different to the state average. Results We identified 176,729 LBP presentations across 177 public hospital EDs and 44,549 hospital admissions (25.2%). The mean (SD) age was 51.8 (19.5) and 52% were female. Hospital factors explained 10% of the variation (ICC = 0.10), and the median odds ratio (MOR) was 2.03. We identified marked variation across hospitals, with HAAR ranging from 6.9 to 65.9%. After adjusting for hospital variables, there was still marked variation between hospitals with similar characteristics. Conclusion We found substantial variation in hospital admissions following a presentation to the ED due to LBP even after controlling by case-mix and hospital characteristics. Given the substantial costs associated with these admissions, our findings indicate the need to investigate sources of variation and to determine instances where the observed variation is warranted or unwarranted. Supplementary information The online version contains supplementary material available at 10.1186/s12913-022-08134-8.
Collapse
Affiliation(s)
- Giovanni Ferreira
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia. .,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,, Camperdown, Australia.
| | - Marina Lobo
- Center for Health Technology and Services Research (CINTESIS), Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Bethan Richards
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Michael Dinh
- The RPA Green Light Institute for Emergency Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Chris Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
10
|
Price MR, Cupler Z, Hawk C, Bednarz EM, Walters SA, Daniels CJ. Systematic review of guideline-recommended medications prescribed for treatment of low back pain. Chiropr Man Therap 2022; 30:26. [PMID: 35562756 PMCID: PMC9101938 DOI: 10.1186/s12998-022-00435-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG). METHODS We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP. RESULTS 316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids. CONCLUSIONS Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.
Collapse
Affiliation(s)
| | | | - Cheryl Hawk
- Texas Chiropractic College, Pasadena, TX USA
| | | | | | | |
Collapse
|
11
|
Oliveira IS, Tomazoni SS, Vanin AA, Araujo AC, de Medeiros FC, Oshima RKA, Costa LOP, Costa LDCM. Management of acute low back pain in emergency departments in São Paulo, Brazil: a descriptive, cross-sectional analysis of baseline data from a prospective cohort study. BMJ Open 2022; 12:e059605. [PMID: 35365544 PMCID: PMC8977796 DOI: 10.1136/bmjopen-2021-059605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe management strategies used in public emergency departments in a middle-income country for patients with acute non-specific low back pain. DESIGN A descriptive, cross-sectional analysis of baseline data from a prospective cohort study. SETTING AND PARTICIPANTS A study with 600 patients with low back pain presenting in four public emergency departments from São Paulo, Brazil was conducted. OUTCOME MEASURES Diagnostic tests, pharmacological interventions, and/or referral to other healthcare professionals were collected. Descriptive analyses were used to report all outcomes. RESULTS Of all patients, 12.5% (n=75) underwent some diagnostic imaging tests. Medication was administered to 94.7% (n=568) of patients. The most common medications were non-steroidal anti-inflammatory drugs (71.3%; n=428), opioids (29%; n=174) and corticosteroids (22.5%; n=135). Only 7.5% (n=45) of patients were referred to another type of care. CONCLUSION There is a need for research data on low back pain from middle-income countries. There was an acceptable rate of prescription for diagnostic imaging tests. However, there were high medication prescriptions and small rates of referrals to other healthcare services. Our findings indicate that there is still a need to implement best practices in the management of acute low back pain at public emergency departments in Brazil.
Collapse
Affiliation(s)
- Indiara Soares Oliveira
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Shaiane Silva Tomazoni
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Adriane Aver Vanin
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Amanda Costa Araujo
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
12
|
Davidson SR, Bolsewicz K, Kamper SJ, Haskins R, Petkovic D, Feenan N, Smith D, O'Flynn M, Pallas J, Williams CM. Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study. Emerg Med Australas 2021; 34:199-208. [PMID: 34549519 DOI: 10.1111/1742-6723.13854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/03/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED. METHODS We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions. RESULTS Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care. CONCLUSION We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.
Collapse
Affiliation(s)
- Simon Re Davidson
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia.,Population Health, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Katarzyna Bolsewicz
- Population Health, Hunter New England Local Health District, Newcastle, New South Wales, Australia.,National Centre for Immunisation Research and Surveillance, Sydney, New South Wales, Australia
| | - Steven J Kamper
- School of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Allied Health Department, Nepean Blue Mountains Local Health District, Penrith, New South Wales, Australia
| | - Robin Haskins
- Outpatient Services, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Dragan Petkovic
- Emergency Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Nicole Feenan
- Emergency Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Damien Smith
- Physiotherapy Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Michael O'Flynn
- Emergency Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Jeremy Pallas
- Emergency Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia.,Population Health, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| |
Collapse
|
13
|
Oliveira CB, Hamilton M, Traeger A, Buchbinder R, Richards B, Rogan E, Maher CG, Machado GC. Do patients with acute low back pain in emergency departments have more severe symptoms than those in general practice? A systematic review with meta-analysis. PAIN MEDICINE 2021; 23:614-624. [PMID: 34480571 DOI: 10.1093/pm/pnab260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/10/2021] [Accepted: 08/14/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice versus those presenting to emergency departments. METHODS Electronic searches were conducted in MEDLINE, EMBASE and CINAHL from inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0-100 scale were the primary outcomes. Risk of bias was evaluated using a validated tool for observational studies and the overall quality of evidence was assessed using GRADE. Meta-analysis using random effects and meta-regression were used to test for differences between the two settings. RESULTS We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice with a mean difference of 17.3 points (95%CI: 8.8 to 25.9 on a 0-100 scale). Similarly, there was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7, 95%CI: 4.6 to 38.7 on a 0-100 scale). CONCLUSION Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice. PROSPERO REGISTRATION NUMBER CRD42017076806.
Collapse
Affiliation(s)
- Crystian B Oliveira
- Physical Therapy Department, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, Sao Paulo, Brazil.,Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil.,Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Melanie Hamilton
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Adrian Traeger
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia.,Rheumatology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Eileen Rogan
- Emergency Department, Canterbury Hospital, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
14
|
Coombs DM, Machado GC, Richards B, Wilson R, Chan J, Storey H, Maher CG. Healthcare costs due to low back pain in the emergency department and inpatient setting in Sydney, Australia. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2021; 7:100089. [PMID: 34327417 PMCID: PMC8315649 DOI: 10.1016/j.lanwpc.2020.100089] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023]
Abstract
Background Low back pain is the leading cause of disability worldwide and a common presentation to emergency departments, often resulting in subsequent admissions to hospital. There have been several studies investigating the cost of low back pain to society, but few specific to the emergency department and inpatient setting, especially in Australia. The aim was to describe the cost of low back pain in Australian public hospital emergency departments, and inpatient settings, and explore healthcare costs associated with different care pathways. Methods In this retrospective observational study, we explored the costs associated with an episode of care for low back pain in adults that attended three emergency departments in Sydney between 1 July 2014 and 30 June 2019. Systematised Nomenclature of Medicine—Clinical Terms (SNOMED) diagnosis codes were used to identify episodes of care where the patients had been diagnosed with non-specific low back pain or lumbosacral radicular syndromes. Serious spinal pathologies were excluded. We determined the costs for different treatment pathways involving the ambulance service, emergency department and inpatient ward care. Hospital costs were adjusted for inflation to 2019 Australian dollars (AUD). Findings There were 12,399 non-serious low back pain episodes of care during the study period. 4006 (32%) arrived by ambulance and 2067 (17%) were admitted for inpatient care. The total costs of inpatient and emergency department care across the 5-year period were AUD$36.7 million, with a mean of AUD$2959 per episode of care. The mean cost for a patient who had a non-ambulance presentation to the emergency department and was discharged was AUD$584. Patients presenting to the emergency department via ambulance and were discharged had a mean cost of AUD$1022. Patients who presented without the need of an ambulance and were admitted had a mean cost of $13,137. The most expensive care pathway was for patients arriving by ambulance with subsequent admission, with a mean cost of AUD$14,949. Interpretation The common practice of admitting patients with non-serious low back pain for inpatient care comes at great cost to the healthcare system. In a resource constrained environment, our data highlights the economic need to implement innovative, evidence-based strategies to reduce the inpatient management of these patients. Funding Nil.
Collapse
Affiliation(s)
- Danielle M Coombs
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,Sydney School of Public, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Physiotherapy Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,Sydney School of Public, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,Sydney School of Public, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Rheumatology Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia
| | - Ross Wilson
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Jimmy Chan
- Performance Monitoring, System Improvement & Innovation Unit, Sydney Local Health District, Sydney, Australia
| | - Hannah Storey
- Performance Monitoring, System Improvement & Innovation Unit, Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,Sydney School of Public, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
15
|
Ashbrook J, Rogdakis N, Callaghan MJ, Yeowell G, Goodwin PC. The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review. Physiotherapy 2020; 109:13-32. [PMID: 32846282 DOI: 10.1016/j.physio.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION An increasing number of patients are attending the Emergency Department (ED) with back pain with or without sciatica. There is evidence to suggest that medical management is varied and inconsistent. OBJECTIVE The purpose of this study was to review the literature to determine the evidence base for the therapeutic management of adults presenting with back pain with or without sciatica in the ED. METHODS A systematic review of the literature included the therapeutic management of patients presenting in the ED. Articles published in peer review journals in English language up to August 2018 were searched for in the following data-bases: MEDLINE, EMBASE, SCOPUS, CINAHL, ZETOC, PubMed, The Cochrane Library (Cochrane Database of Systematic Reviews), Web of Science, Open Grey and ETHOS. A narrative synthesis approach was followed. RESULTS Twenty two studies, including 17 randomised control trials, one randomised control pilot study, two cohort studies, one cohort pilot study and one retrospective audit were included. The Downs and Black methodological quality scores ranged from 16 to 31 with a mean score of 24 out of a possible 32. CONCLUSION Evidence suggests that Naproxen alone should be considered as first line management in cases of back pain without sciatica. Intra-venous corticosteroids should be considered in the management of cases of severe sciatica. More high quality trials are needed to determine an evidence-based management protocol for the treatment of acute low back pain in the ED, specifically focusing on non-pharmacological management and the first line management of patients presenting with LBP with sciatica. Systematic Review Registration Number PROSPERO CRD42016042087.
Collapse
Affiliation(s)
- Jane Ashbrook
- Department of Health Professions, Manchester Metropolitan University, Manchester M15 6GX, UK.
| | - Nikolaos Rogdakis
- Physio Praxis Outpatient Clinic, 14, Ethnikis Aminis St., 54621 Thessaloniki, Greece
| | - Michael J Callaghan
- Department of Health Professions, Manchester Metropolitan University, Manchester M15 6GX, UK; Central Manchester NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Gillian Yeowell
- Department of Health Professions, Manchester Metropolitan University, Manchester M15 6GX, UK
| | - Peter Charles Goodwin
- Department of Health Professions, Manchester Metropolitan University, Manchester M15 6GX, UK
| |
Collapse
|
16
|
Machado GC, Ghinea N, Rogan E, Day RO, Maher CG. Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines? Emerg Med Australas 2020; 32:890-892. [PMID: 32743874 DOI: 10.1111/1742-6723.13593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence-based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non-spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.
Collapse
Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Narcyz Ghinea
- Sydney Health Ethics, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Eileen Rogan
- Emergency Department, Canterbury Hospital, Sydney, New South Wales, Australia
| | - Richard O Day
- Clinical Pharmacology and Toxicology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
17
|
Morris M, Destian S, Chu Y, Klumpp M, Zohrabian VM. Investigation of Whole Spine MRI in the Emergency Department at Two Large Tertiary Care Academic Medical Centers in the United States. Curr Probl Diagn Radiol 2020; 50:637-645. [PMID: 32839068 DOI: 10.1067/j.cpradiol.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES The impact of emergent whole spine magnetic resonance imaging (WS-MRI) on patient management has not been extensively studied to date. Here, we explore indications, results, and outcomes associated with WS-MRI performed through the emergency departments (EDs) of 2 large tertiary care, academic medical centers in the Northeastern United States. We hypothesize that given a relatively low barrier to entry, coupled with lack of appropriateness guidelines, a sizeable proportion of WS-MRI studies performed emergently do not result in spine findings necessitating inpatient admission for immediate treatment. MATERIALS AND METHODS We retrospectively studied 335 adult patients (≥18 years) who underwent WS-MRI through the ED between 2016 and 2019. The demographic data collected included, age, sex, chief complaint, history of spine disease, and date and type of last spine imaging prior to ED presentation. Data compiled from the time of ED visit included WS-MRI result and patient disposition, including reason for hospital admission, by which patients were categorized into groups to allow for ease of comparisons. Hypergeometric tests were used to determine statistically significant associations between random discrete variables. RESULTS Trauma was the most frequent chief complaint, comprising 35% (n = 117) of all presentations, followed by pain (25%, n = 84), motor deficit (16%, n = 55), sensory disturbance (12%, n = 41), bowel, and/or bladder dysfunction (9%, n = 30), and subjective or objective fevers with suspicion for spine infection (2%, n = 8). The largest proportion of WS-MRI studies revealed degenerative disc disease (DDD) as the principal result (41%, n = 139). 52% of all patients were either discharged directly from the ED (41%) or admitted for a non-spine issue after WS-MRI (11%); of these numbers, 61% underwent WS-MRI and no other imaging study in the ED. In patients who presented with a chief complaint of pain, DDD was often the principal WS-MRI finding (54%), albeit this association was not statistically significant. DDD, nonetheless, was positively associated with a discharge from the ED (P <0.001). Trauma was positively associated with fracture or ligamentous/soft tissue injury (P <0.001) on WS-MRI and hospital admission for a spine issue (P <0.01). CONCLUSION That just under half of patients in our study were admitted for spine-related pathology suggests that WS-MRI is valuable in the emergent setting. At the same time, however, that over half of patients were not subsequently admitted for a spine-related issue points to the possibility of further refining which patients would benefit most from WS-MRI. WS-MRI may be less helpful in patients presenting with pain, though may be higher-yield in those with trauma, motor deficits, and bowel/bladder complaints. Although MRI is highly sensitive in ruling out emergent central nervous system pathology, given the resource-intensive nature of the test, it is prudent to carefully select which patients should undergo emergent WS-MRI, especially in instances when more cost-effective, alternative diagnostic approaches, including detailed neurological exam, computed tomography, or localized/targeted MRI, are possible.
Collapse
Affiliation(s)
- Montana Morris
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT
| | - Sylvie Destian
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Youngmin Chu
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Matthew Klumpp
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Vahe M Zohrabian
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT.
| |
Collapse
|
18
|
Urrutia J, Besa P, Meissner-Haecker A, Gonzalez R, Gonzalez J. Management of patients with low back pain in the emergency department: Is it feasible to follow evidence-based recommendations? Emerg Med Australas 2020; 32:1001-1007. [PMID: 32558273 DOI: 10.1111/1742-6723.13544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/21/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Low back pain is frequently seen in patients visiting the ED, but many patients receive medical care with no demonstrable benefits. We studied the clinical characteristics of patients visiting two EDs in Santiago, Chile, and their management to evaluate how it adheres to evidence-based recommendations. METHODS We studied 519 patients and retrieved their demographic and clinical data, imaging testing and treatments. We determined the effect of sex, age, time from initial symptoms, pain measured with the visual analogue scale, presence of nerve radiation and the presence of red flags and neurological impairment on image testing and the management received. RESULTS Mean age was 43.8 years; 57.8% were females. Females presented more often red flags (7.3 vs 3%, P = 0.04) and worse pain (visual analogue scale = 7 vs 6, P = 0.04) than males. Imagings were performed in 18.9% of patients; they were more frequently performed in patients with neurological impairment (P = 0.03) and red flags (P = 0.01). Intravenous non-opioids were administered in 25.6%; opioids were administered in 40.1%. Median time in the ED was 91 min (range 18-591); 16 (3.08%) patients were admitted. Age (odds ratio [OR] 1.04 [1.03-1.05], P < 0.01) and red flags (OR 4.9 [1.60-20.08], P < 0.01) influenced imaging testing; pain intensity influenced opioid use (OR 1.6 [1.29-1.95], P < 0.01), hospital admissions (1.95 [1.14-3.33], P < 0.01) and time in the ED (β = 0.5, P < 0.01). CONCLUSION Older age, the presence of red flags and pain intensity influenced the management of patients with low back pain in the ED. Future strategies should emphasise avoiding costly and ineffective management in these patients.
Collapse
Affiliation(s)
- Julio Urrutia
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Pablo Besa
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Arturo Meissner-Haecker
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rodrigo Gonzalez
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Javiera Gonzalez
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| |
Collapse
|
19
|
Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study. Spine J 2020; 20:874-881. [PMID: 32007652 DOI: 10.1016/j.spinee.2020.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system. PURPOSE Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting. DESIGN/SETTING Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada. PATIENT SAMPLE Adult population aged 18+ years (N=10,841,302). OUTCOME MEASURES Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. METHODS Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. RESULTS Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. CONCLUSIONS Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.
Collapse
|
20
|
Strudwick K, Russell T, Bell AJ, Chatfield MD, Martin-Khan M. Musculoskeletal injury quality outcome indicators for the emergency department. Intern Emerg Med 2020; 15:501-514. [PMID: 31773561 DOI: 10.1007/s11739-019-02234-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/09/2019] [Indexed: 12/26/2022]
Abstract
High standards of care for musculoskeletal injuries presenting to emergency departments (ED) must be maintained despite financial constraints, the model of care in place, or the pressure to reach time-based performance measures. Outcome quality indicators (QIs) provide a tangible way of assessing and improving the outcomes of health-care delivery. This study aimed to develop a set of outcome QIs for musculoskeletal injuries in the ED that are meaningful, valid, feasible to collect, simple to use for clinical quality improvement and chosen by experts in the field. The study used a multi-phase mixed methods design, commencing with a systematic review of available outcome QIs. An expert panel then developed a set of preliminary QIs based on the available scientific evidence. Prospective observational data collection was undertaken across eight EDs with subsequent retrospective chart audits, follow-up phone calls and audit of administrative databases. After statistical analysis, validated results were presented to the expert panel who discussed, refined and formally voted on a final outcome QI set. A total of 41 preliminary outcome QIs were field tested in EDs, with data collected on 633 patients. Using the field study results, the expert panel voted 11 outcome QIs into the final set. These covered effectiveness of pain management, timeliness to discharge, re-presentations to the ED and unplanned visits to health professionals in the community, missed injuries, opioids side effects and the patient experience. An evidence-based set of outcome quality indicators is now available to support clinical quality improvement of musculoskeletal injury care in the ED setting.
Collapse
Affiliation(s)
- Kirsten Strudwick
- Emergency and Physiotherapy Departments, QEII Jubilee Hospital, Metro South Health, Brisbane, QLD, Australia.
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.
| | - Trevor Russell
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Anthony J Bell
- Uniting Care Health, The Wesley Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mark D Chatfield
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| |
Collapse
|
21
|
Akbas I, Kocak AO, Kocak MB, Cakir Z. Comparison of intradermal mesotherapy with systemic therapy in the treatment of low back pain: A prospective randomized study. Am J Emerg Med 2019; 38:1431-1435. [PMID: 31859197 DOI: 10.1016/j.ajem.2019.11.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/20/2019] [Accepted: 11/28/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Musculoskeletal pain such as low back pain (LBP) are routinely encountered in the ED and contribute to ED overcrowding. The aim of our study was to compare the efficiency of mesotherapy with systemic therapy in pain control in patients with lumbar disk herniation. METHODS We conducted this prospective parallel randomized controlled trial with the patients admitted to the emergency department with low back pain related to herniated lumbar disk. Mesotherapy was performed to one group, while intravenous dexketoprofen was administered to the control group. Changes in pain intensity at 15th minute, 30th minute, 60th minute and 24th hours after treatment using Visual Analogue Scale (VAS), need to use analgesic drug within 24 h after treatment, and adverse effect of the treatment methods were compared between groups. RESULTS The decreases in pain intensity were statistically significantly higher in mesotherapy group for all time intervals. The need to use analgesics was statistically significantly three fold higher in the systemic therapy group. There was no statistically significant difference in having any adverse effect between study groups during one-week follow-up period. CONCLUSIONS Changes in medical practices, from the systemic administration of NSAIDs to the minimally invasive techniques such as mesotherapy with potent efficacy and minimal side effects, may enhance the ability of EDs to meet the waiting time targets and improve patient's satisfaction.
Collapse
Affiliation(s)
- Ilker Akbas
- Department of Emergency Medicine, Bingöl State Hospital, Bingöl, Turkey.
| | - Abdullah Osman Kocak
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Meryem Betos Kocak
- Department of Family Medicine, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Zeynep Cakir
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| |
Collapse
|
22
|
Strudwick K, Russell T, Bell AJ, Chatfield M, Martin-Khan M. Process quality indicators for musculoskeletal injuries in the emergency department. Emerg Med J 2019; 36:686-696. [PMID: 31641039 DOI: 10.1136/emermed-2019-208531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 08/06/2019] [Accepted: 08/30/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED. METHODS A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set. RESULTS A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of 'just in case' opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures. CONCLUSION An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.
Collapse
Affiliation(s)
- Kirsten Strudwick
- Emergency and Physiotherapy Departments, QEII Jubilee Hospital, Brisbane, Queensland, Australia .,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Anthony J Bell
- The Wesley Hospital, Uniting Care Health, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Mark Chatfield
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | |
Collapse
|
23
|
Health-care utilisation for low back pain: a systematic review and meta-analysis of population-based observational studies. Rheumatol Int 2019; 39:1663-1679. [DOI: 10.1007/s00296-019-04430-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/20/2019] [Indexed: 01/07/2023]
|
24
|
Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2019; 54:79-86. [PMID: 30826805 DOI: 10.1136/bjsports-2018-099878] [Citation(s) in RCA: 457] [Impact Index Per Article: 91.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs). DESIGN Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations. ELIGIBILITY CRITERIA Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. DATA SOURCES Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. RESULTS 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work. CONCLUSION These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.
Collapse
Affiliation(s)
- Ivan Lin
- WA Centre for Rural Health, University of Western Australia, Geraldton, Western Australia, Australia
| | - Louise Wiles
- Centre for Population Health Research, University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Rob Waller
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Roger Goucke
- Pain Management Centre, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
| | - Yusuf Nagree
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Michael Gibberd
- Emergency Department, Geraldton Hospital, Geraldton, Western Australia, Australia
| | - Leon Straker
- School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Chris G Maher
- School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter P B O'Sullivan
- Department of Physiotherapy, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
25
|
Çakır T, Kayacı S, Aydın MD, Özöner B, Çalık İ, Altınkaynak K. A New Neuropathologic Mechanism of Blood pH Irregularities After Neck Trauma: Importance of Carotid Body-Glossopharyngeal Nerve Network Degeneration. World Neurosurg 2019; 125:e972-e977. [PMID: 30763747 DOI: 10.1016/j.wneu.2019.01.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We created a neck trauma model by injecting blood into the sheath of rabbits' carotid bodies (CBs). Then we determined the relationship between neuronal degeneration of the CB due to hemorrhage of this organ and its clinical effects such as blood pH and heart rhythm. METHODS The present study included 24 adult male New Zealand rabbits. The animals were divided into 3 groups: control (n = 5); sham (0.5 mL saline injected into CBs; n = 5); and study (CB trauma model; n = 14). pH values and heart rhythms were recorded before the experiment to determine the values under normal conditions, and measurements were repeated thrice in the days following the experiment. The number of normal and degenerated neuron density of CBs was counted. The relationship between the blood pH values, heart rhythms, and degenerated neuron densities was analyzed. RESULTS Heart rhythms were 218 ± 20 in the control group, 197 ± 16 in the sham group (P = 0.09), and 167 ± 13 in the study group (P < 0.0005). pH values were 7.40 ± 0.041 in the control group, 7.321 ± 0.062 in the sham group (P = 0.203), and 7.23 ± 0.02 in study group (P < 0.0005). Degenerated neuron densities were 12 ± 4/mm3 in the control group, 430 ± 74/mm3 in the sham group (P < 0.005), and 7434 ± 810/mm3 in the study group (P < 0.0001). CONCLUSIONS A high degenerate neuron density in the CB can decrease blood pH and hearth rhythm after neck trauma, and there might be a close relationship between the number of degenerated neurons and clinical findings (such as heart rhythm and blood pH). This relationship suggests that injury to the glossopharyngeal nerve-CB network can cause acidosis by disturbing the breathing-circulating reflex and results in respiratory acidosis.
Collapse
Affiliation(s)
- Tayfun Çakır
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Selim Kayacı
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Mehmet Dumlu Aydın
- Department of Neurosurgery, Medical Faculty of Ataturk University, Turkey.
| | - Barış Özöner
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - İlknur Çalık
- Department of Pathology, Medical Faculty of Fırat University, Elazığ, Turkey
| | - Konca Altınkaynak
- Department of Biochemistry, Erzurum Research-Training Hospital, Erzurum, Turkey
| |
Collapse
|
26
|
A review of emerging bone tissue engineering via PEG conjugated biodegradable amphiphilic copolymers. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 97:1021-1035. [PMID: 30678893 DOI: 10.1016/j.msec.2019.01.057] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/26/2018] [Accepted: 01/12/2019] [Indexed: 01/19/2023]
Abstract
Defects in bones can be caused by a plethora of reasons, such as trauma or illness, and in many cases, it poses challenges to the current treatment approaches for bone repair. With increasing demand of bone bioengineering in tissue transplant, there is a need to source for sustainable solutions to induce bone regeneration. Polymeric biomaterials have been identified as a promising approach due to its excellent biocompatibility and controllable biodegradability. Specifically, poly(ethylene glycol) (PEG) is one of the most commonly investigated polymer for use in bio-related application due to its bioinertness and versatility. Furthermore, the hydrophilic nature enables it to be incorporated with hydrophobic but biodegradable polymers like, polylactide (PLA) and polycaprolactone (PCL), to create an amphiphilic polymer. This article reviews the recent synthetic strategies available for the construction of PEG conjugated polymeric system, analysis of PEG influence on the material properties, and provides an overview of its application in bone engineering.
Collapse
|
27
|
Abstract
Globally, in 2016, low back pain (LBP) contributed 57.6 million of total years lived with disability. Low Back Pain Guidelines regularly recommend the use of physical exercise for non-specific LBP. Early non-pharmacological treatment is endorsed. This includes education and self-management, and the recommencement of normal activities and exercise, with the addition of psychological programs in those whose symptoms persist. The aim of physical treatments is to improve function and prevent disability from getting worse. There is no evidence available to show that one type of exercise is superior to another, and participation can be in a group or in an individual exercise program. Active strategies such as exercise are related to decreased disability. Passive methods (rest, medications) are associated with worsening disability, and are not recommended. The Danish, United States of America, and the United Kingdom Guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies. These include tai chi, yoga, massage, and spinal manipulation. Public health programs should educate the public on the prevention of low back pain. In chronic low back pain, the physical therapy exercise approach remains a first-line treatment, and should routinely be used.
Collapse
Affiliation(s)
- Edward A Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand.
| |
Collapse
|
28
|
Ferreira GE, Machado GC, Oliver M, Maher CG. Limited evidence for screening for serious pathologies using red flags in patients with low back pain presenting to the emergency department. Emerg Med Australas 2018; 30:436-437. [DOI: 10.1111/1742-6723.12984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/18/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Giovanni E Ferreira
- School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - Gustavo C Machado
- School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - Matthew Oliver
- Emergency Department; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Chris G Maher
- School of Public Health; The University of Sydney; Sydney New South Wales Australia
| |
Collapse
|