Community survey of factors associated with consultation for low back pain

Musculoskeletal Diseases as the Most Prevalent Component of Multimorbidity: A Population-Based Study

Background/Objectives: Due to their high frequency, common risk factors, and similar pathogenic mechanisms, musculoskeletal disorders (MSDs) are more likely to occur with other chronic illnesses, making them a "component disorder" of multimorbidity. Our objective was to assess the prevalence of multimorbidity and to identify the most common clusters of diagnosis within multimorbidity states, with the primary hypothesis that the most common clusters of multimorbidity are MSDs. Methods: The current study employed data from a population-based 2019 European Health Interview Survey (EHIS). Multimorbidity was defined as a ≥2 diagnosis from the list of 17 chronic non-communicable diseases, and to define clusters, the statistical method of hierarchical cluster analysis (HCA) was performed. Results: Out of 13,178 respondents, multimorbidity was present among 4398 (33.4%). The HCA method yielded six multimorbidity clusters representing the most common diagnoses. The primary multimorbidity cluster, which was prevalent among both genders, age groups, incomes per capita, and statistical regions, consisted of three diagnoses: (1) lower spine deformity or other chronic back problem (back pain), (2) cervical deformity or other chronic problem with the cervical spine, and (3) osteoarthritis. Conclusions: Given the influence of musculoskeletal disorders on multimorbidity, it is imperative to implement appropriate measures to assist patients in relieving the physical discomfort and pain they endure. Public health information, programs, and campaigns should be utilized to promote a healthy lifestyle. Policymakers should prioritize the prevention of MSDs by encouraging increased physical activity and a healthy diet, as well as focusing on improving functional abilities.

Treatment of last resort? Psychological therapy seeking in chronic pain patients

OBJECTIVE

Our goal was to assess how many chronic pain patients seek psychological treatment for their condition and what psychological and demographic characteristics are associated with that decision.

METHODS

The association between pain intensity, quality of life and psychological treatment seeking was tested in two hypothetical models which differed according to beliefs about either external or internal control over pain.

RESULTS

A minority of patients had experience with psychological treatment of chronic pain. Patients who had that experience were younger, suffered from more intense pain, and applied many more coping strategies than patients who never tried this kind of treatment. Intense pain and low quality of life motivated chronic pain patients to seek psychological treatment only if they believed that doctors could control their pain.

DISCUSSION

The study results stress the importance of diversifying the methods used to treat chronic pain and educating patients about the benefits of psychological treatment. Low numbers of chronic pain patients who take advantage of psychological treatment indicate that encouragement from medical professionals might be necessary.

Self-Reported Chronic Back Pain and Current Depression in Brazil: A National Level Study

There is limited literature investigating the association between chronic back pain (CBP) and depression in Brazil. This study evaluates the association between CBP, CBP-related physical limitations (CBP-RPL), and self-reported current depression (SRCD), in a nationally representative sample of Brazilian adults. The data for this cross-sectional study came from the 2019 Brazilian National Health Survey (n = 71,535). The Personal Health Questionnaire depression scale (PHQ-8) was used to measure the SRCD outcome. The exposures of interest were self-reported CBP and CBP-RPL (none, slight, moderate, and high limitation). Multivariable weighted and adjusted logistic regression models were used to investigate these associations. The weighted prevalence of SRCD among CBP was 39.5%. There was a significant weighted and adjusted association between CBP and SRCD (weighted and adjusted odds ratio (WAOR) 2.69 (95% CI: 2.45-2.94). The WAOR of SRCD among individuals with high, moderate, and slight levels of physical limitation was significantly greater than for those without physical limitation due to CBP. Among Brazilian adults with high levels of CBP-RPL, there was over a five-fold increased risk of SRCD compared to those without CBP-RPL. These results are important for increasing awareness of the link between CBP and SRCD and for informing health services policies.

Knowledge related to low back pain and its associated factors in patients with low back pain: A cross-sectional study

BACKGROUND

Patients' knowledge about low back pain (LBP) negatively influences LBP prognosis. Studying the extent of patients' knowledge about LBP may help clinicians design effective LBP treatment strategies.

OBJECTIVE

To explore the level of LBP knowledge and its associated factors in patients with LBP.

METHODS

A cross-sectional study with a representative sample. Participants with acute or chronic LBP completed a self-administered questionnaire including sociodemographic and clinical characteristics. We used the Low Back Pain Knowledge Questionnaire (LBP_KQ) to assess knowledge, the Fear-Avoidance Beliefs Questionnaire for LBP (FABQ_LBP) to assess fear of movement, the Oswestry Disability Index (ODI) to assess functional disability, Depression Anxiety Stress Scales (DASS 21) to assess mental health status, and the Numeric Pain Rating Scale (NPRS) to assess pain intensity.

RESULTS

A total of 271 individuals with LBP completed the study. The mean age of participants was 39.86 (± 11.27), the LBP chronicity median was 18 (IQR = 44) months, and 56.5% of the participants were females. The mean LBP_KQ score was 9.29 (± 3.89)/24. An educational level higher than high school (diploma education (β= 1.202 [95%CI: 5.633 to 11.498], p< 0.001), bachelor or higher education (β= 2.270 [95%CI: 1.107 to 3.433], p< 0.001)), and using pain killers (β= 1.180 [95%CI: 0.140 to 2.221], p= 0.026) were significantly associated with higher LBP_KQ score. While being employed (β=-1.422 [95%CI: -2.462 to -0.382], p= 0.008) and having higher DASS Anxiety score (β=-0.144 [95%CI: -0.240 to -0.048], p= 0.003) were significantly associated with lower LBP_KQ score.

CONCLUSIONS

Individuals with chronic LBP in Jordan demonstrated relatively low levels of LBP knowledge related to their condition. Rehabilitation personnel, healthcare stakeholders, and policymakers should carefully monitor the level of LBP knowledge and its associated factors.

Trajectories of Musculoskeletal Healthcare Utilization of People with Chronic Musculoskeletal Pain - A Population-Based Cohort Study

Background and Aim

Chronic musculoskeletal pain is common and associated with more general healthcare-seeking. However, musculoskeletal-related healthcare utilization is under-explored. This study aimed to explore, describe and profile trajectories of long-term musculoskeletal healthcare for people reporting chronic musculoskeletal pain.

Methods

This exploratory prognostic cohort study combined survey and national health register data from a representative group of adult Danes reporting chronic musculoskeletal pain (N = 2929). Trajectories of long-term musculoskeletal healthcare use were generated using latent class growth analysis. Types of healthcare-seeking, individual, sociodemographic, health, belief and work-related factors were used to describe and profile identified trajectories.

Results

We identified five distinct trajectories of long-term musculoskeletal healthcare utilization (low stable, low ascending, low descending, medium stable and high stable). The low stable trajectory group (no or almost no annual contacts) represented 39% of the sample, whereas the high stable trajectory group (consistent high number of annual contacts) represented 8%. Most healthcare-seeking was in primary healthcare settings (GP/physiotherapy/chiropractor). Opioid consumption was primarily in the high stable trajectory group, and surgery was rare. There were statistically significant differences across the five trajectory groups in individual, sociodemographic, health, belief and work-related profiles.

Conclusion

Long-term use of musculoskeletal healthcare services varied in this chronic musculoskeletal pain population. Almost 40% coped without seeking care, whereas 8% had consistent high use of healthcare services. Chronic musculoskeletal pain was mostly managed in primary care settings, which aligns with musculoskeletal guidelines, as did the use of pain medication and surgery. People with different musculoskeletal healthcare trajectories had different individual, sociodemographic, health, belief and work-related profiles.

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Factors associated with care-seeking for low back pain when genetics and the familial environment are considered

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide. Care-seekers for LBP cause substantial economic burden to governments and the healthcare system.

OBJECTIVE

To investigate lifestyle and health-related factors associated with care-seeking (including pain medication use) in individuals experiencing LBP, after controlling for important genetic and early environmental confounders through the use of a within-twin pair case-control design.

DESIGN

A secondary analysis of observational longitudinal data, derived from the Australian Twin low BACK pain (AUTBACK) study, was performed on 66 twin pairs that presented with similar symptoms of LBP at baseline but became discordant for care-seeking behaviour over one month.

METHODS

Subjective and objective assessment of pain intensity, disability, depression, sleep quality, physical activity and body mass index were performed. Data was analysed using stepwise conditional logistic regression in two stages: within-pair case-control for monozygotic and dizygotic twins together; and within-pair case-control analysis of monozygotic twins only. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Higher LBP intensity (OR 2.9; 95% CI 1.3-6.8) and poorer sleep quality (OR 10.9; 95% CI 1.5-77.7) were the main factors that increased the likelihood of care-seeking for LBP. These associations remained significant and increased in magnitude after adjusting for genetic confounding.

CONCLUSIONS

Individuals with higher LBP intensity and worse sleep quality are more likely to seek care for LBP, and this relationship is likely to be causal after adjustment of familial and genetic confounding.

Self-reported use of family physician, chiropractor and physiotherapy services among adult Canadians with chronic back disorders: an observational study

BACKGROUND

Chronic back disorders (CBD) are prevalent, costly, and among the most common reasons for seeking primary care; however, little is known regarding the comparative use of family physician, chiropractic, and physiotherapy services among people with CBD in Canada. Elucidating these differences may identify potential gaps in access to care and inform the development of strategies to improve access. The research objectives were to investigate patterns of health care use and to profile factors associated with self-reported use of family physicians, chiropractors, and physiotherapists among adult Canadians with CBD.

METHODS

The combined 2009 and 2010 Canadian Community Health Surveys conducted by Statistics Canada were used to investigate self-reported health care use among adults with CBD. This complex survey employs population weights and bootstrapping to be representative of the Canadian population. Following descriptive analyses, we used multiple logistic regression to profile self-reported health care use while statistically controlling for possible confounding effects.

RESULTS

The majority of adult respondents with CBD sought care only with a family physician (53.8%), with 20.9% and 16.2% seeking care with combined family physician/chiropractor or family physician/physiotherapist, respectively. Few respondents sought care only with a chiropractor (2.5%) or physiotherapist (1.0%). After adjustment, differential patterns of utilization (p < 0.05) were evident between provider groups with respect to age, gender, socioeconomic status, rural/urban residence, functional limitations, and presence of co-morbidities.

CONCLUSIONS

This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations.

Back Pain – An Integrated Approach in Primary Care

Back pain is common, and although many cases remit quickly, a significant number also continue a relapsing course over many months and years. Psychosocial factors have a significant influence on the condition. The evidence from clinical trials of the effectiveness of various therapies is available in summarised form in several resources, though is often inconclusive. There is good evidence that acute back pain should be managed by staying active and using non-steroidal anti-inflammatory and analgesic drugs, adding cognitive behaviour therapy for subacute pain. For chronic back pain, exercise, pain management programmes, non-steroidal anti-inflammatory and analgesic drugs, and trigger point and ligament injections are also recommended. There appears to be increasing evidence in favour of the use of acupuncture. Acupuncture appears to be useful to treat back pain, but patients should probably be advised to take advantage of any pain relief obtained to maintain or increase their activity. Acupuncturists must be aware of the psychosocial dimensions of back pain, as well as the physical ones, and should be careful to educate their patients about the condition and not make them become dependent on acupuncture to treat every acute episode.

The association between pain characteristics, pain catastrophizing and health care use – Baseline results from the SWEPAIN cohort

Background and aim

Pain is common and adds to the global burden of disease. However, individuals suffering from pain are a heterogeneous group in terms of pain spreading, intensity and duration. While pain influences overall health care consultation not everyone with pain consult health care. To be able to provide health care matching the patients’ needs increased knowledge about what factors determines the decision to consult health care is essential. The aim of this study was to explore the combined importance of pain spreading, intensity, duration and pain catastrophizing for consulting health care.

Methods

In this cross-sectional study we used population based survey data from southeast Sweden (SWEPAIN) including 7792 individuals’ aged 16–85 reporting pain. We used Modified Poisson regressions to analyse factors of importance related to the decision to consult health care.

Results

High and moderate pain intensity, as compared to low, increases the probability of consulting health care (High PR = 1.7 [95% CI 1.51–1.88], moderate PR = 1.2 [1.15–1.41]). Having widespread pain, as compared to localised pain, increased the probability of consulting health (PR = 1.2 [1.03–1.36). Pain duration was not associated with increased probability of consulting health care (PR = 1.0 CI0.88–1.07). However an interaction (p = 0.05) between pain duration and pain catastrophizing beliefs was seen indicating a combined importance of the two when consulting health care.

Conclusion

Our result suggests that pain intensity, pain spreading and pain catastrophizing independently influence the decision to consult health care while there is an interaction effect between pain duration and pain catastrophizing beliefs where the importance of pain catastrophizing believes differ with pain duration; the importance of pain catastrophizing believes differ with pain duration.

Implications

Treatment and rehabilitation strategies should incorporate this finding in order to meet the individual’s needs focusing on the biopsychosocial model within health care focusing not only on actual pain reliefs but also on for example acceptance and behavioural changes.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence of subjective health complaints (SHC) in Norway

Aims : As subjective health complaints are one of the major reasons for short- and long-term sickness absence it is important to know the prevalence of these conditions in the general population. Methods : In this cross-sectional study, 1,240 individuals (aged 15-84 years) from the normal population in Norway answered the Subjective Health Complaint (SHC) inventory in spring 1996. Results : The prevalence of reporting subjective health complaints was high: 80% reported musculoskeletal complaints, 65% reported ``pseudoneurological' ' complaints (tiredness, depression, dizziness), 60% gastrointestinal complaints, 34% allergic complaints, and 54% flu-like complaints. The prevalence of substantial complaints was low: 13% reported musculoskeletal complaints, 5% reported "pseudoneurological' 'complaints, 4% gastrointestinal complaints, 2% allergic complaints, and 18% flu-like complaints. Women had higher prevalence of musculoskeletal, ``pseudoneurological' ' , and allergic complaints compared with men, and reported more substantial complaints on all subscales. Individuals older than 50 years were less likely to report headache, tiredness, eczema, and fl u-like complaints compared with individuals younger than 30 years. However, they had higher risk of arm pain, shoulder pain, palpitations, and several gastrointestinal and allergic complaints. The intensity of musculoskeletal, gastrointestinal, and allergic complaints was signifi cantly higher in the oldest age group. Conclusions: Subjective health complaints are very common in the normal population; there are gender and age differences in both prevalence and degree of complaints. The intensity of subjective health complaints forms a continuum, and there are no obvious cut-off point to indicate what are ``normal' ' complaints and what is illness.

A Subtle Threat to Urban Populations in Developing Countries: Low Back Pain and its Related Risk Factors

STUDY DESIGN

A cross-sectional, population-based survey.

OBJECTIVE

The aim of this study was to estimate the prevalence, and biological and psychological correlates of low back pain (LBP) in large, populated urban areas.

SUMMARY OF BACKGROUND DATA

LBP is a common and costly medical problem all around the world. Currently, there are limited data available on prevalence as well as biological and psychological correlates of LBP in large urban populations in developing countries.

METHODS

Here, in a cross-sectional, population-based survey, we analyzed data obtained from 22,952 subjects living in Tehran.

RESULTS

Chronic, 1-year, and point prevalence of LBP among subjects were 12.2%, 42.1%, and 36.2%, respectively. LBP was more prevalent among older population, women, housewives, and obese people after adjustment for confounding factors using logistic regression models. In addition, persons with a general health questionnaire (GHQ-28) score ≥6 were about 2 times more likely to experience LBP in comparison with others. Both subjects with higher educational levels and those who were never married reported significantly less LBP. Furthermore, we could not find any significant correlation between smoking and physical activity level with LBP.

CONCLUSION

LBP is prevalent among the general population of Tehran. Our findings can help health care providers regarding logical assignment of limited resources, in order to create multidimensional prevention plans according to potentially modifiable associated factors.

LEVEL OF EVIDENCE

3.

Patient-reported disability in the general Japanese population was associated with medical care visits for low back pain, regardless of pain intensity

BACKGROUND

Race/ethnicity is known to affect pain severity and the emotional aspects of pain, with medical care visits also reported to differ according to race/ethnicity. It has been hypothesized that there is an interactive relationship between pain intensity and patient-reported disability and that the interactive relationships are related to medical care visits. However, it remains unclear whether the association between patient-reported disability and medical care visits for low back pain (LBP) are dependent on the pain intensity. The aims of this study were to examine the prevalence of medical care visits among members of the Japanese general population and to analyze the association between patient-reported disability and medical care visits for LBP patients, regardless of the pain intensity.

METHODS

From a random sample of the general Japanese population (n = 2962), we focused on those who experienced LBP within the past month. Subjects were asked about the number of medical care visits (medical clinic or complementary/alternative medical clinic) for LBP. Patient-reported disability was assessed using the Roland-Morris disability questionnaire (RDQ). Pain intensity of LBP was assessed by visual analog scale. To examine the association between RDQ and medical care visits among people with LBP, we used multiple logistic regression analysis and the trend analysis for the RDQ.

RESULTS

Of 841 reporting LBP in the past month, 285 (33.9 %) visited a medical care facility. After adjusting for pain intensity and other confounding factors, the odds ratios for the RDQ categories 1-5, 6-10, 11-15, and ≥ 16 were compared with the RDQ categories 0, 1.13 (95 % CI 0.73-1.73), 2.05 (95 % CI 1.17-3.60), 2.21 (95 % CI 1.06-4.62), and 4.0 (95 % CI 1.60-9.98), respectively (p for trend <0.01).

CONCLUSIONS

Patient-reported disability was associated with medical care visits for LBP, regardless of the pain intensity, with the results similar to those obtained for other races/ethnicities.

Biomechanical constraints remain major risk factors for low back pain. Results from a prospective cohort study in French male employees

BACKGROUND CONTEXT

Low back pain (LBP) is a major public health problem, with a considerable impact on workers.

PURPOSE

To model the risk of LBP in the male general working population.

STUDY DESIGN/SETTING

Repeated cross-sectional surveys in a wide occupational setting.

PATIENT SAMPLE

A random sample of 2,161 men working in various occupations in a French region participated in a first survey in 2002, and 1,313 of these (60.8%) participated in a second survey in 2007.

OUTCOME MEASURE

The self-reported prevalence of LBP during the previous week in the second survey.

METHODS

Twenty-one biomechanical, organizational, psychosocial, and individual factors were assessed in the first survey. The association between these potential risk factors and the prevalence of later LBP (in the second survey) was studied, using multistep logistic regression models.

RESULTS

Three hundred ninety-four men reported LBP in the second survey (prevalence 30.0%). The final multivariate model highlighted four risk factors: frequent bending (odds ratio [OR], 1.45, 95% confidence interval [CI], 1.07-1.97 for bending forward only; and OR, 2.13, 95% CI, 1.52-3.00 for bending both forward and sideways), driving industrial vehicles (OR, 1.35; 95% CI, 1.00-1.81), working more hours than officially planned (OR, 1.38; 95% CI, 1.05-1.81), and reported low support from supervisors (OR, 1.35; 95% CI, 1.02-1.79).

CONCLUSIONS

These results emphasize that biomechanical factors remain worth considering, even when psychosocial factors are taken into account, and provide a significant contribution to preventive strategies.

Reducing complexity: a visualisation of multimorbidity by combining disease clusters and triads

BACKGROUND

Multimorbidity is highly prevalent in the elderly and relates to many adverse outcomes, such as higher mortality, increased disability and functional decline. Many studies tried to reduce the heterogeneity of multimorbidity by identifying multimorbidity clusters or disease combinations, however, the internal structure of multimorbidity clusters and the linking between disease combinations and clusters are still unknown. The aim of this study was to depict which diseases were associated with each other on person-level within the clusters and which ones were responsible for overlapping multimorbidity clusters.

METHODS

The study analyses insurance claims data of the Gmünder ErsatzKasse from 2006 with 43,632 female and 54,987 male patients who were 65 years and older. The analyses are based on multimorbidity clusters from a previous study and combinations of three diseases ("triads") identified by observed/expected ratios ≥ 2 and prevalence rates ≥ 1%. In order to visualise a "disease network", an edgelist was extracted from these triads, which was analysed by network analysis and graphically linked to multimorbidity clusters.

RESULTS

We found 57 relevant triads consisting of 31 chronic conditions with 200 disease associations ("edges") in females and 51 triads of 29 diseases with 174 edges in males. In the disease network, the cluster of cardiovascular and metabolic disorders comprised 12 of these conditions in females and 14 in males. The cluster of anxiety, depression, somatoform disorders, and pain consisted of 15 conditions in females and 12 in males.

CONCLUSIONS

We were able to show which diseases were associated with each other in our data set, to which clusters the diseases were assigned, and which diseases were responsible for overlapping clusters. The disease with the highest number of associations, and the most important mediator between diseases, was chronic low back pain. In females, depression was also associated with many other diseases. We found a multitude of associations between disorders of the metabolic syndrome of which hypertension was the most central disease. The most prominent bridges were between the metabolic syndrome and musculoskeletal disorders. Guideline developers might find our approach useful as a basis for discussing which comorbidity should be addressed.

Reducing complexity: a visualisation of multimorbidity by combining disease clusters and triads

Background

Multimorbidity is highly prevalent in the elderly and relates to many adverse outcomes, such as higher mortality, increased disability and functional decline. Many studies tried to reduce the heterogeneity of multimorbidity by identifying multimorbidity clusters or disease combinations, however, the internal structure of multimorbidity clusters and the linking between disease combinations and clusters are still unknown. The aim of this study was to depict which diseases were associated with each other on person-level within the clusters and which ones were responsible for overlapping multimorbidity clusters.

Methods

The study analyses insurance claims data of the Gmünder ErsatzKasse from 2006 with 43,632 female and 54,987 male patients who were 65 years and older. The analyses are based on multimorbidity clusters from a previous study and combinations of three diseases ("triads") identified by observed/expected ratios ≥ 2 and prevalence rates ≥ 1%. In order to visualise a "disease network", an edgelist was extracted from these triads, which was analysed by network analysis and graphically linked to multimorbidity clusters.

Results

We found 57 relevant triads consisting of 31 chronic conditions with 200 disease associations ("edges") in females and 51 triads of 29 diseases with 174 edges in males. In the disease network, the cluster of cardiovascular and metabolic disorders comprised 12 of these conditions in females and 14 in males. The cluster of anxiety, depression, somatoform disorders, and pain consisted of 15 conditions in females and 12 in males.

Conclusions

We were able to show which diseases were associated with each other in our data set, to which clusters the diseases were assigned, and which diseases were responsible for overlapping clusters. The disease with the highest number of associations, and the most important mediator between diseases, was chronic low back pain. In females, depression was also associated with many other diseases. We found a multitude of associations between disorders of the metabolic syndrome of which hypertension was the most central disease. The most prominent bridges were between the metabolic syndrome and musculoskeletal disorders. Guideline developers might find our approach useful as a basis for discussing which comorbidity should be addressed.

Association between beliefs and care-seeking behavior for low back pain

STUDY DESIGN

Cross sectional population-based survey.

OBJECTIVE

To investigate the relationship between low back pain (LBP) beliefs and care seeking in LBP.

SUMMARY OF BACKGROUND DATA

Not all people experiencing LBP seek care for their problem. Consistent predictors of care-seeking behavior seem to be female sex and high perceived disability; the role of beliefs about LBP has not been investigated sufficiently.

METHODS

A questionnaire booklet was mailed to a random sample of 2860 individuals otherwise participating in an epidemiological study of musculoskeletal health. It contained the Back Beliefs Questionnaire (BBQ), the Fear-Avoidance Beliefs Questionnaire (FABQ; physical activity and work scales), and questions about sociodemographics, LBP characteristics, and LBP-related care seeking in the last month ("yes" = visit to specialist, general practitioner, physiotherapist, or other health care practitioner; "no" = none of these). Logistic regression was used to identify whether beliefs made a significant contribution to care-seeking behavior, beyond known predictors conceptualized in the behavioral model of health services use.

RESULTS

A total of 2507 of 2860 (88%) individuals completed the questionnaire; 1071 (43%) reported current LBP, 301 (28%) of which had sought care. In univariate analyses the following were all significantly related to care seeking (all P < 0.01): female sex; increasing age; not working full time; lower income; greater LBP frequency, LBP intensity, and limitations in activities of daily living; worse general health; higher FABQ-Physical Activity, FABQ-Work, and Back Beliefs Questionnaire scores. In multiple regression, female sex (odds ratio [OR], 1.731; 95% confidence interval [CI], 1.174-2.551; P = 0.006), LBP frequency (OR, 1.492; 95% CI, 1.249-1.783; P < 0.0001), limitations in activities of daily living (OR, 1.010; 95% CI, 1.001-1.020; P = 0.037), and high FABQ-Work Scores (OR, 1.025; 95% CI, 1.005-1.044, P = 0.012) contributed significantly to the final model.

CONCLUSION

That the odds of seeking care are higher in fear-avoidant individuals, even when controlling for other established predictors, emphasizes the importance of addressing such beliefs during the consultation; public health education programs may serve to underpin the delivery of positive messages, ultimately reducing health care demands.

Low back pain and sciatica prevalence and intensity reported in a Mediterranean country: ordinal logistic regression analysis

The objective of this retrospective cross-sectional study was to estimate the 6-month prevalence and severity of low back pain and sciatica in a representative sample of an adult Mediterranean population. The study group comprised a sample of 674 adults aged 20 years or older from a mainly (74.8%) urban population. Information regarding low back pain and sciatica prevalence and severity and its related aspects, as well as socioeconomic and demographic characteristics, was collected by personal interviews with a validated questionnaire. The association between the intensity of low back pain and sciatica with several sociodemographic parameters was tested using ordered univariate and multivariate logistic regression analysis.A total of 266 (39.5%) patients reported low back pain and 166 (24.6%) reported sciatica during the previous 6-month period. A woman living in a Mediterranean country reported low back pain of increased severity if she was a married housewife aged older than 65 years who was a smoker and suffered from depression. More severe sciatic pain was reported by working married women older than 65 years who were smokers.

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs.

SUMMARY OF BACKGROUND DATA

Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed.

METHODS

Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined.

RESULTS

Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care.

CONCLUSION

Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Do work-related factors affect care-seeking in general practice for back pain or upper extremity pain?

OBJECTIVES

Musculoskeletal pain conditions remain a major cause of care-seeking in general practice. Not all patients with musculoskeletal pain (MP) seek care at their general practitioner (GP), but for those who do, the GP's knowledge of what work-related factors might have influenced the patient's decision to seek care could be important in order to give more well-founded advice to our patients. The objective of this study was to elucidate the effects of workloads on care-seeking for back pain or upper extremity pain during an eighteen-month follow-up period.

METHODS

This is a prospective study with a baseline questionnaire and eighteen-month follow-up. Among the registered patients of 8 GPs, we identified 8,517 persons between 17 and 65 years of age, who all received the questionnaire. A total of 5,068 (59.5 %) persons answered. During the eighteen months of follow-up, we used the International Classification for Primary Care (ICPC) to identify all care-seekers with either back pain or upper extremity pain. Of these, all currently employed persons were included in our analysis, in all 4,325 persons. For analysis, we used Cox proportional hazards regression analysis. Analyses were stratified by gender.

RESULTS

High levels of heavy lifting, defined as the upper tertile on a categorical scale, were associated with care-seeking for back pain (HR 1.90 [95 % CI: 1.14-3.15]) and upper extremity pain (HR 2.09 [95 % CI: 1.30-3.38]) among males, but not in a statistically significant way among females. Repetitive work and psychosocial factors did not have any statistically significant impact on care-seeking for neither back pain nor upper extremity pain.

CONCLUSION

Work-related factors such as heavy lifting do, to some extent, contribute to care-seeking with MP. We suggest that asking the patient about physical workloads should be routinely included in consultations dealing with MP.

Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy

Background

Low back pain (LBP) is common and costly and few treatments have been shown to be markedly superior to any other. Effort has been focused on stratifying patients to better target treatment. Recently the STarT Back Screening Tool (SBT) has been developed for use in primary care to enable sub grouping of patients based on modifiable baseline characteristics and has been shown to be associated with differential outcomes. In the UK the SBT is being recommended to assist in care decisions for those presenting to general practitioners with LBP. In the light of growing recommendation for widespread use of this tool, generalisability to other LBP populations is important. However, studies to date have focused only on patients attending physiotherapy whereas LBP patients seeking other treatment have not been investigated.

Aims

This study aims to investigate the utility of the SBT to predict outcomes in LBP patients presenting for chiropractic management.

Methods

A total of 404 patients undergoing chiropractic care were asked to complete the SBT before initial treatment. Clinical outcomes were collected at 14, 30 and 90 days following this initial consultation. The clinical course was described comparing SBT categories and logistic regression analysis performed to examine the tool’s prognostic utility.

Results

Although the high-risk categories had greater pain at baseline this difference rapidly faded, with both change in composite outcome scores and pain scores being statistically insignificant between the risk groups at 30 and 90 days follow up. In addition, both univariate and adjusted analysis showed no prognostic utility of the SBT categorisations to differentiate clinical outcomes between risk groups.

Conclusion

Whilst the SBT appears useful in some back pain populations it does not appear to differentiate outcomes in LBP patients seeking chiropractic care.

The significance of health anxiety and somatization in care-seeking for back and upper extremity pain

BACKGROUND

Patients with musculoskeletal pain account for a large number of consultations in primary care. Improving our understanding of factors that make patients seek care could be of interest in decision making and prevention in the health care system.

OBJECTIVES

Our objectives were to examine if health anxiety, somatization and fear-avoidance beliefs were of importance for care-seeking with either back pain or upper extremity pain and to look at possible differences between the two groups.

METHODS

This is a prospective study with a baseline questionnaire and 18 months follow-up. Using the International Classification for Primary Care (ICPC), we identified care-seekers with either back pain or upper extremity pain among the potential patients of eight GPs. For analysis, we used Cox proportional hazards regression analysis. Analysis was stratified by gender.

RESULTS

We found that previous regional pain was a strong predictor of care-seeking. Somatization was associated with seeking care for back pain. Health anxiety was a predictor among women suffering from back pain. Only previous pain was a predictor of care-seeking for upper extremity pain.

CONCLUSION

The study implies that prevention of back pain and upper extremity pain requires different strategies and that gender and health anxieties should be taken into account.

Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services

STUDY DESIGN

Prospective, longitudinal, observational cohort design.

OBJECTIVE

The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy.

BACKGROUND

Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes.

METHODS

Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables.

RESULTS

Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (-7.9 [95% CI: -13.5, -2.21], -10.9 [95% CI: -15.25, -6.49], and -8.9 [95% CI: -13.65, -4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively).

CONCLUSIONS

Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

Pain characteristic differences between subacute and chronic back pain

Back pain is commonly classified based on duration. There is currently limited information regarding differences in the clinical features of back pain between these duration-based groupings. Here, we compared the pain characteristics of patients with subacute (SBP; pain 6-16 weeks, n = 40) and chronic back pain (CBP; pain ≥1 year, n = 37) recruited from the general population. CBP patients reported significantly higher pain intensity on the Visual Analogue Scale (VAS) compared to SBP patients. Based on this finding, we investigated group differences and their dependence on VAS for the Beck Depression Inventory (BDI), sensory and affective dimensions of the McGill Pain Questionnaire (MPQ-S and MPQ-A), Neuropathic Pain Scale (NPS), and the variability of spontaneous pain. Correction for VAS abolished significant group differences on the MPQ-S, MPQ-A and NPS. Only a significant difference in the variability of spontaneous pain was independent of VAS. Finally, whereas SBP patients displayed a higher incidence of unilateral pain radiating down the legs/buttocks, there was a shift towards more bilateral pain in CBP patients. In summary, SBP and CBP groups differ on 3 independent parameters: VAS ratings, pain location, and temporal dynamics of spontaneous pain.

PERSPECTIVE

The present study reports differences in the characteristics of back pain between duration-based groupings in the general population. The main outcome of the study is the demonstration that a small number of descriptors are required to characterize the difference between SBP and CBP.

Do women consult more than men? A review of gender and consultation for back pain and headache

OBJECTIVES

Because women consult their general practitioners more frequently on average than men, it is commonly assumed that they consult more for all symptoms and conditions. This assumption is reinforced by qualitative studies reporting a widespread reluctance to consult by men. However, few studies directly compare consultation in men and women experiencing similar symptoms or conditions.

METHODS

A systematic review of the evidence on gender and consultation for two common symptoms, back pain and headache. Extensive electronic searches identified 15 papers reporting the relationship between gender and help-seeking for back pain and 11 papers for headache. Two independent reviewers assessed articles for inclusion and extracted data from eligible studies.

RESULTS

Few studies compared consultation patterns for these symptoms among men and women known to have experienced the symptom. The quality of the studies was variable. Overall, evidence for greater consultation by women with back pain was weak and inconsistent. Among those with back pain, the odds ratios for women seeking help, compared with men, ranged from 0.6 (95% confidence intervals 0.3, 1.2, adjusted only for age) to 2.17 (95% confidence intervals 1.35, 3.57, unadjusted), although none of the reported odds ratio, below 1.00 was statistically significant. The evidence for women being more likely to consult for headache was a little stronger. Five studies showed a statistically elevated odds ratio, and none suggested that men with headache symptoms were more likely to consult than women with headache symptoms. Limitations to the studies are discussed.

CONCLUSION

Given the strength of assumptions that women consult more readily for common symptoms, the evidence for greater consultation amongst women for two common symptoms, headache and back pain, was surprisingly weak and inconsistent, especially with respect to back pain.

The influence of socio-demographic characteristics on consultation for back pain--a review of the literature

BACKGROUND

There are several assumptions within clinical practice about who is more or less likely to consult a health care practitioner for particular symptoms, most commonly these focus around socio-demographic characteristics. We aimed to assess the evidence for the impact of socio-demographic characteristics on consultation for back pain.

METHODS

We conducted a review of the literature, using systematic methods, on consultation for back pain. Using systematic searching techniques we identified peer-reviewed publications that focused on health care consultation in response to symptoms of back pain and which included data on both users and non-users of health care.

RESULTS

We identified 23 studies. Definitions of help-seeking were inconsistent across studies. The majority of the 15 studies which considered the relationship between age and help-seeking for back pain did not find evidence of an association between these two factors. Seventeen studies considered whether socio-economic position was associated with help-seeking. The evidence largely supported the conclusion of no association (13 papers). Fifteen studies included gender as a variable in their analyses, and the majority (10 papers) presented the finding of no association.

CONCLUSIONS

The results from this review suggest that there is little evidence to support the common wisdom that socio-demographic characteristics impact on help-seeking in the context of back pain. As these assumptions relating to who is more or less likely to consult will ultimately affect patient care, it is important that they do not go unchallenged.

What lies beyond the pain? A case report

The majority of people have back pain at some point in their lives and most are cured without any intervention. However, some patients develop chronic back pain and persistent disability. There is strong evidence that psychological factors significantly correlate with the development of chronic back pain. Back pain has also emerged as the strongest predictor of major depression. Assessing and treating patients in a manner that integrates psychosocial and biological aspects of care is the essence of excellent family medicine. This case illustrates the importance for primary care physicians of screening for depression and other psychosocial factors in assessing patients with persistent back pain.

Musculoskeletal foot problems in primary care: what influences older people to consult?

Objective. To estimate the incidence of, and factors associated with, consultation for musculoskeletal foot problems in primary care.

Methods. Survey data from 13 986 people aged ≥50 years who took part in the North Staffordshire Osteoarthritis Project were linked to a database of primary care consultations. Foot problems were defined as responding affirmatively to the questions: ‘Have you had any problems with your feet over the last year?’ or ‘Have you had pain in the last year in and around the foot?’. The main outcome measure was a record of a musculoskeletal foot-related consultation within 18 months following the survey.

Results. Of the 3858 participants with foot problems who had not consulted before the survey, 350 (9.1%) consulted in the 18 months following the survey. Age, sex, education, general health and pain in other regions were not associated with future consultation. However, those who consulted were more likely to have reported foot pain [adjusted odds ratio (OR) 2.04; 95% CI 1.22, 3.42) and to consider treatments to be effective in controlling disease (OR 1.54; 95% CI 1.07, 2.21) in the baseline survey, and to have been a frequent consulter in the 18 months before the survey (OR 1.65; 95% CI 1.30, 2.09).

Conclusions. Only a minority of older people with musculoskeletal foot problems consult their general practitioner about them. Foot pain, frequent consultation for other problems and positive perceptions of treatment efficacy appear to be the strongest factors influencing future consultation.

How important are back pain beliefs and expectations for satisfactory recovery from back pain?

In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional processes in the interpretation of pain signals, giving meaning to pain and shaping our response to it. We highlight three types of beliefs that have a particularly strong influence: fear-avoidance beliefs, pain self-efficacy beliefs and catastrophising. We examine the influence of beliefs, preferences and expectations on seeking consultation, interventions and treatment outcome from the perspective both of the patient and the health-care practitioner. We then adopt a broader societal perspective, considering secondary prevention and campaigns, which have attempted to change beliefs at a population level. The article concludes with a summary of the key messages for clinical management of patients presenting with painful conditions and suggestions for further research.

Factors defining care-seeking in low back pain--a meta-analysis of population based surveys

Little is known about factors determining health care-seeking behavior in low back pain. While a number of studies have described general characteristics of health care utilization, only a few have aimed at appropriately assessing determinants of care-seeking in back pain, by comparing seekers and non-seekers. The objective of this systematic review was to identify determinants of health care-seeking in studies with well-defined groups of care-seekers and non-seekers with non-specific low back pain. A search was conducted in Medline, AMED, Cinahl, Web of Science, PsycINFO, National Research Register, Cochrane Library and LILACS looking for population- based surveys of non-specific low back pain patients older than 18 years, published since 1966. To be included in the review, studies needed to report on characteristics of well-defined groups of care-seekers and non-seekers. Methodological quality was assessed using a criteria list based on sampling, response rate, data reproducibility, power calculation and external validity. Risk estimates were expressed as odd ratios (95% confidence intervals). When possible, meta-analyses were performed, using a random effects model. Eleven studies were included in the review. Pooled results show that women are slightly more likely to seek care for their back pain as are patients with a previous history of back pain. Pain intensity was only slightly associated with care-seeking, whereas patients with high levels of disability were nearly eight times more likely to seek care than patients with lower levels of disability.

Systematic review: frequency and reasons for consultation for gastro-oesophageal reflux disease and dyspepsia

BACKGROUND

Upper gastrointestinal symptoms impose a substantial illness burden and management costs. Understanding perceptions and reasons for seeking healthcare is a prerequisite for meeting patients' needs effectively.

AIM

To review systematically findings on consultation frequencies for gastro-oesophageal reflux disease (GERD) and dyspepsia and patients' reasons for consultation.

METHODS

Systematic literature searches.

RESULTS

Reported consultation rates ranged from 5.4% to 56% for GERD and from 26% to 70% for dyspepsia. Consultation for GERD was associated with increased symptom severity and frequency, interference with social activities, sleep disturbance, lack of timetabled work, higher levels of comorbidity, depression, anxiety, phobia, somatization and obsessionality. Some consulted because of fears that their symptoms represented serious disease; others avoided consultation because of this. Inconsistent associations were seen with medication use. Patients were less likely to consult if they felt that their doctor would trivialize their symptoms. Few factors were consistently associated with dyspepsia consultation. However, lower socio-economic status and Helicobacter pylori infection were associated with increased consultation.

CONCLUSION

Patients' perceptions of their condition, comorbid factors and external reasons such as work and social factors are related to consultation rates for GERD. Awareness of these factors can guide the clinician towards a more effective strategy than one based on drug therapy alone.

Utilization of health resources due to low back pain: survey and registered data compared

STUDY DESIGN

Cross-sectional population-based survey and registration of general practice (GP).

OBJECTIVE

To describe the utilization of health care services among persons with low back pain on the basis of different databases, i.e., surveys and registrations. Special attention will be paid to utilization of GPs, specific medical specialists, and physiotherapists.

SUMMARY OF BACKGROUND DATA

Both surveys and health care registrations can provide data on utilization of health care services due to low back pain. It is unclear as to how the utilization figures from different data sources can be compared.

METHODS

Survey data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort study, a postal health survey among Dutch inhabitants aged 25 years or older (n = 3664) in 1998, and registered data from the second Dutch National Survey of General Practice, which represents 2 years (2000-2001) of GP-registration data for 293,636 persons aged 25 years or older.

RESULTS

The size of the population that in 1 year had GP-contact due to low back pain was estimated as 13.0% (survey) and 8.9% (registration data). Less than one-third of those with low back pain consult their GP due to low back pain in the past year. Survey data show that 33.2% of those with low back pain have had contact with the physiotherapist. Of those contacts, 76% were explicitly due to low back pain. Based on the registration data, these percentages were slightly different: 25.9% and 83.8%, respectively. Large differences between survey and registration data were found for the contact with a medical specialist.

CONCLUSION

Large health care resources are used for low back pain although the majority of low back pain sufferers do not have contact with health care. Survey data show slightly higher consultation figures than registration-based figures probably mainly due to response and recall bias, and registration thresholds.

Chronic non-specific low back pain - sub-groups or a single mechanism?

BACKGROUND

Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.

DISCUSSION

Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.

SUMMARY

The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.

Psychosocial factors and their predictive value in chiropractic patients with low back pain: a prospective inception cohort study

BACKGROUND

Being able to estimate the likelihood of poor recovery from episodes of back pain is important for care. Studies of psychosocial factors in inception cohorts in general practice and occupational populations have begun to make inroads to these problems. However, no studies have yet investigated this in chiropractic patients.

METHODS

A prospective inception cohort study of patients presenting to a UK chiropractic practice for new episodes of non-specific low back pain (LBP) was conducted. Baseline questionnaires asked about age, gender, occupation, work status, duration of current episode, chronicity, aggravating features and bothersomeness using Deyo's 'Core Set'. Psychological factors (fear-avoidance beliefs, inevitability, anxiety/distress and coping, and co-morbidity were also assessed at baseline. Satisfaction with care, number of attendances and pain impact were determined at 6 weeks. Predictors of poor outcome were sought by the calculation of relative risk ratios.

RESULTS

Most patients presented within 4 weeks of onset. Of 158 eligible and willing patients, 130 completed both baseline and 6-week follow-up questionnaires. Greatest improvements at 6 weeks were in interference with normal work (ES 1.12) and LBP bothersomeness (ES 1.37). Although most patients began with moderate-high back pain bothersomeness scores, few had high psychometric ones. Co-morbidity was a risk for high-moderate interference with normal work at 6 weeks (RR 2.37; 95% C.I. 1.15-4.74). An episode duration of >4 weeks was associated with moderate to high bothersomeness at 6 weeks (RR 2.07; 95% C.I. 1.19-3.38) and negative outlook (inevitability) with moderate to high interference with normal work (RR 2.56; 95% C.I. 1.08-5.08).

CONCLUSION

Patients attending a private UK chiropractic clinic for new episodes of non-specific LBP exhibited few psychosocial predictors of poor outcome, unlike other patient populations that have been studied. Despite considerable bothersomeness at baseline, scores were low at follow-up. In this independent health sector back pain population, general health and duration of episode before consulting appeared more important to outcome than psychosocial factors.

A correlation between low back pain and associated factors: a study involving 772 patients who had undergone general physical examination

Many factors are associated with the development of low back pain. Among them, exercise, obesity, smoking, age, educational level and stress are the most common. This study examined the association of these factors with low back pain. An additional aim was to determine a procedure for preventing low back pain. This study analyzed the responses to a questionnaire sent to 772 individuals who had undergone a medical examination at this hospital in 2003 and excluded the individuals who had shown symptoms or their test results indicated a particular disease. Assuming that there were no variables, individuals who exercised regularly 3-4 times per week would have a lower chance of having low back pain than those who did not exercise regularly. The analysis revealed that individuals with a college degree or higher education have a lower chance of experiencing low back pain than those with only a high school education or even college drop-outs. When the other variables were constant, age, extent of obesity (body mass index), smoking and level of stress were not found to affect the development of low back pain. The level of education was associated with the development of low back pain. However, regular exercise 3-4 times per week or more would be most effective in reducing the incidence and duration of low back pain.

Musculoskeletal disorders in shipyard industry: prevalence, health care use, and absenteeism

Background

It is unclear whether the well-known risk factors for the occurrence of musculoskeletal disorders (MSD) also play an important role in the determining consequences of MSD in terms of sickness absence and health care use.

Methods

A cross-sectional study was conducted among 853 shipyard employees. Data were collected by questionnaire on physical and psychosocial workload, need for recovery, perceived general health, occurrence of musculoskeletal complaints, and health care use during the past year. Retrospective data on absenteeism were also available from the company register.

Results

In total, 37%, 22%, and 15% of employees reported complaints of low back, shoulder/neck, and hand/wrist during the past 12 months, respectively. Among all employees with at least one MSD, 27% visited a physician at least once and 20% took at least one period of sick leave. Various individual and work-related factors were associated with the occurrence of MSD. Health care use and absenteeism were strongest influenced by chronicity of musculoskeletal complaints and comorbidity with other musculoskeletal complaints and, to a lesser extent, by work-related factors.

Conclusion

In programmes aimed at preventing the unfavourable consequences of MSD in terms of sickness absence and health care use it is important to identify the (individual) factors that determine the development of chronicity of complaints. These factors may differ from the well-know risk factors for the occurrence of MSD that are targeted in primary prevention.

Minor psychiatric disorders among Brazilian ragpickers: a cross-sectional study

BACKGROUND

Ragpickers are informal workers who collect recyclable materials to earn a small wage. Their life and working conditions are extremely difficult. We examined minor psychiatric disorders (MPD) among a cohort of ragpickers in Pelotas, a city in southern Brazil.

METHODS

Ragpickers were matched by sex, age, and years of schooling with a sample of non-ragpickers from the same poor neighborhoods. The cross-sectional study gathered data by interview on 990 individuals in 2004. MPD were assessed using a standard self-reporting questionnaire, the SRQ-20.

RESULTS

The prevalence of MPD among ragpickers was 44.7%, higher than reported by neighborhood controls (33.6%; p < 0.001). MPD were more common among females, those of lower economic level, smokers and alcoholics. Among occupational characteristics, MPD prevalence was associated with frequent static postures, low job satisfaction and recent work accidents.

CONCLUSION

Ragpickers more frequently report MPD than other poor workers living in the same neighborhoods, with many of the same life conditions. Improving the work lives of these precarious workers should address not only the physical hazards of their jobs but their mental and emotional health as well.

A comparative analysis on musculoskeletal disorders between Greek and Dutch nursing personnel

OBJECTIVE

To analyse cross-cultural differences between Greek and Dutch nursing personnel in association with the risk factors and occurrence and consequences (absenteeism and medical care seeking) of musculoskeletal disorders.

METHODS

This study was based on questionnaire surveys among 393 nurses and caregivers in nursing homes and homes for the elderly in The Netherlands and among 351 nurses in general hospitals in Athens, Greece. Logistic regression analysis was used to analyse associations between physical and psychosocial workload, need for recovery, perceived general health and (1) the occurrence of musculoskeletal complaints in the past 12 months, (2) chronic complaints during at least 3 months, and (3) complaints which led to sickness absence and medical care seeking.

RESULTS

Greek nurses reported significantly more back complaints in the past 12 months (75 vs. 62%) than the Dutch workers, but chronicity (11 vs. 12%) and sickness absence (17 vs. 15%) of these complaints did not differ. Similar differences were observed for neck complaints but not for shoulder complaints. Most Greek nurses with back complaints visited a medical specialist (40%) while Dutch nurses and caregivers sought care through a general practitioner (33%). Multivariate analyses showed that in both countries strenuous back postures (ORs 1.9 and 1.9) and especially a moderate general health (ORs 4.3 and 2.9) were the significant risk factors for back pain.

CONCLUSIONS

In both countries similar risk factors were associated with the occurrence of low-back pain. Cross-national differences were less important for the risk factors and musculoskeletal complaints than for the consequences of these complaints and for medical care seeking.

Prevalence of low back pain in a developing urban setting

STUDY DESIGN

A cross-sectional survey was conducted using face-to-face interviews.

OBJECTIVES

To estimate the prevalence of low back pain (LBP) in an urban population of Turkey and to determine the factors associated with occurrence of LBP.

SUMMARY OF BACKGROUND DATA

Little information exists in the literature regarding the epidemiology of LBP in developing countries. A few data from previous studies suggest that the prevalence of LBP is rather lower in developing countries compared with developed countries.

METHODS

A total of 100 clusters of households (3,215 residents aged 16 years or older) in municipality area of Antalya was selected by systematic sampling. Of these, 3,173 study participants agreed to interview. The response rate was 98.7%.

RESULTS

The crude lifetime, 12-month, and point prevalences of LBP were 46.6% (95% confidence interval [CI], 44.9-48.3), 35.9% (95% CI, 34.2-37.6), and 20.1% (95% CI, 18.7-21.5), respectively. In logistic regression analysis, age of 36 years or older, female sex, multiparity, being a housewife, being from East Turkey, and smoking showed independent associations with having current LBP. Being religious, heavy smoking, and age 26 to 45 years were associated with having restricted activity related to LBP.

CONCLUSIONS

In comparison with other developing countries, point prevalence of LBP is higher in Turkey and approximates to prevalence estimates of LBP in developed countries. Smoking may be associated with both occurrence and severity of LBP. Although piety is not associated with having LBP, religious people are more likely to have restricted activity related to LBP.

Low back pain in a representative sample of Greek population: analysis according to personal and socioeconomic characteristics

STUDY DESIGN

A cross-sectional study of low back pain and its related aspects in a representative sample of Greek population.

OBJECTIVES

To estimate the prevalence of low back pain in the Greek population and to study the association of low back pain frequency and severity with socioeconomic and demographic characteristics.

SUMMARY OF BACKGROUND DATA

Several prevalence studies carried out in different populations suggest a high frequency of this condition in the general population. Socioeconomic and demographic factors are likely to influence frequency and severity of low back pain. In Greece, there have been no previous studies investigating low back pain frequency and severity and its related aspects in the general population. Studies carried out in selected Greek populations suggest a 3-month prevalence of about 50%.

METHODS

A 2000-person sample of the Greek population older than 15 years was selected by multiple-stage sampling, with definition of sample quotas based on demographic characteristics. Information about low back pain and its related aspects, as well as about socioeconomic and demographic characteristics, was collected by personal interviews. The study was carried out between March 10 and April 12, 2000.

RESULTS

A total of 635 persons (31.7%) reported low back pain the last month. Among them 126 (19.9%) stayed in bed for some time, with a mean duration of staying in bed of 5.5 days. Work absenteeism represented a 19.1% of people younger than 65 years (54 persons) with a mean duration of 4.52 days. Low back pain frequency and severity were related to several socio-demographic factors at a statistically significant level. Sex, age, and kind of job presented a significant association with risk of low back pain independently from other socioeconomic factors.

CONCLUSIONS

According to the results of the study, low back pain is a frequent symptom in the general Greek population. Low back pain frequency and severity are associated with several socio-demographic factors, especially with age, sex, and kind of job.

Patterns of care for low back pain in a working population

STUDY DESIGN

A prospective longitudinal study with 1-year follow-up.

SUMMARY OF BACKGROUND DATA

Little is known about the consequences of having back pain and the patterns underlying the decisions to use medical care.

OBJECTIVES

The aim of this study is to describe care utilization for low back pain (LBP) and to investigate which factors determine use of care for LBP.

METHODS

We used a self-administered questionnaire to collect data on individual, health-related, and work-related factors and the type of medical care sought among 529 employees of nursing homes and homes for the elderly in the Netherlands. Logistic regression models were used to present associations between aforementioned factors and care utilization for LBP.

RESULTS

A large proportion of the working population was afflicted with LBP, and only one third sought care. Individuals who use care had more intense pain, chronic pain, and functional limitations. Patients' characteristics varied among the different type of health care providers. Well-known work-related risk factors for the occurrence of LBP did not determine use of care for workers with LBP.

CONCLUSIONS

Care utilization due to LBP was associated with severity and nature of back pain. Patients' characteristics vary among the different type of health care providers, but work-relatedness of LBP seems similar across all providers.

Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study

OBJECTIVE

To investigate the respective contribution of various biologic and psychosocial factors, especially initial health-related quality of life (HRQOL), in the natural history of acute low back pain (LBP) and to evaluate the impact of this condition on HRQOL.

METHODS

For 3 months, we assessed 113 patients consulting for nonspecific acute LBP of <72 hours duration at inclusion and treated with acetaminophen. Endpoints included pain, disability assessed by the Roland Disability Questionnaire, and HRQOL assessed by the Short Form 36 health survey (SF-36).

RESULTS

Seventy-three percent of patients recovered within 2 weeks and 5% of patients developed chronic LBP. Prior low back surgery, higher initial disability questionnaire score, lower SF-36 score, and temporary compensation status were independently associated with delayed recovery. The impact of the acute LBP episode on HRQOL was brief and moderate, except for patients with comorbidity, psychiatric disorders, those of foreign origin, unemployed, or with job dissatisfaction. The impact of compensation status, sick leave, and bed rest was more profound and lasting.

CONCLUSIONS

This study highlights the large contribution of work-related factors, but also initial HRQOL, to the prognosis of LBP. It also suggests that LBP impairs HRQOL mainly through compensation and inappropriate medical care, and that, in turn, impaired HRQOL favors the condition becoming chronic. These findings have implications for future research into the management of LBP.

Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors

Psychosocial factors are known to act as obstacles to recovery from low back pain, but predictors of longer-term outcomes are not established. An average 4-year follow-up of a cohort of 252 low back pain patients attending for manipulative care was conducted to describe the longer-term course of low back pain, and to identify predictors of outcomes. Clinical and psychosocial data were obtained at baseline. Mailed questionnaires collected self-reported outcomes (pain, disability, recurrence and care seeking). Among the 60% who responded, the statistically significant reduction in mean Roland Disability Questionnaire score seen at 1 year did not improve further during follow-up. At the 4-year point, 49% of respondents reported residual disability, and 59% reported at least 'mild' pain. Symptom recurrence beyond the 1-year point was reported by 78% of respondents, with half of them seeking further care. Recurrence and care seeking were related to fear avoidance beliefs and duration of presenting symptoms. The disability score at 4-years was statistically significantly related to baseline depressive symptoms and higher pain intensity. Low back pain presenting for manipulative care is characterized by high levels of recurrence and care seeking over at least 4-years for many patients. Because psychosocial factors at presentation exert a long-term influence, they need to be considered by manual therapists.