Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial

Compliance with evidence-based radiographic imaging guidelines by chiropractic interns at a chiropractic training program

OBJECTIVE

Evidence-based radiographic guidelines are used to justify the need for radiographs and prevent their overuse. This study aimed to assess whether 4th-year chiropractic interns at the International Medical University plan to use x-ray imaging in their future private practice in line with the principles taught throughout their chiropractic program and the evidence-based imaging guidelines.

METHODS

A survey questionnaire was distributed to 74 final year chiropractic interns, with 62 completed responses. The questionnaire consisted of 8 case scenarios representing potential chiropractic patients. The interns were asked to decide whether to x-ray the patient or not, and which x-ray views to request if they chose to x-ray the patient.

RESULTS

Results were compared with the gold standard using percentage agreement. The findings revealed that the chiropractic students adhered to the gold standard answers for 6 out of 8 cases. However, they did not perform well in selecting the correct x-ray views for the 3 cases where radiography was indicated by the gold standard.

CONCLUSION

Results suggest that while the interns have a good understanding of when radiography is necessary, they may need additional training in selecting the appropriate x-ray views for each case.

Specific back pain - effective diagnosis and treatment from the radiologist's point of view

The diagnosis and treatment of specific back pain is important in radiology. Due to the high number of patients suffering from back pain, it is important to provide excellent diagnostic and therapeutic support.Based on a recent literature search and considering the relevant guidelines as well as expert opinions, the aspects of specific back pain important for radiologists in terms of pathogenesis, diagnosis, and treatment are presented.Clinical examination in combination with the medical history provides a valid suspected diagnosis. This should subsequently be verified radiologically. MRI is the most effective cross-sectional diagnostic method for investigating specific back pain. A conventional X-ray on two planes in a standing position can be a useful addition if postural causes are suspected. If the clinical symptoms match the morphological findings, radiological treatment can be carried out for nerve root involvement as well as for inflammatory changes of the facet joints. The improvement in symptoms after radiological therapy is considered good overall; at least a short-term improvement in symptoms can generally be achieved, but no reliable data is available regarding the long-term outcome. Using preparations containing triamcinolone, low dosages should be selected in accordance with the guidelines. Embedding in a multimodal pain therapy treatment concept should be considered.Radiology provides essential diagnostic findings regarding specific back pain. Interventional pain therapy is an effective and safe method of treating proven specific back pain. · First examine clinically, then confirm the suspected diagnosis radiologically.. · MRI is usually the method of choice.. · Interventional pain therapy should show success after a maximum of 2 interventions.. · The anti-inflammatory drug dose should be kept as low as possible.. · The individual course determines the number of interventions.. · Stueckle CA, Haage P. Specific back pain - effective diagnosis and treatment from the radiologist's point of view. Fortschr Röntgenstr 2024; DOI 10.1055/a-2371-1752.

Examination of annulus fibrosus and nucleus pulposus in cervical and lumbar intervertebral disc herniation patients by scanning acoustic microscopy, scanning electron microscopy and energy dispersive spectroscopy

Intervertebral disc herniation (IVDH) is observed in humans as a result of the alteration of annulus fibrous (AF) and nucleus pulposus (NP) tissue compositions in intervertebral discs. In this study, we studied the feasibility of scanning acoustic microscopy (SAM), scanning electron microscopy (SEM) and energy dispersive spectroscopy (EDS) in characterizing the herniated segments of AF and NP tissues from male and female patients. SAM determined the acoustic property variations in AF and NP tissues by calculating the acoustic impedance values of samples of 15 patients. SEM obtained higher resolution images and EDS made elemental analysis of the specimen. Consequently, we suggest that these techniques have the potential to be combined for the investigation and removal of the disrupted AF and NP tissues with micrometer resolution in clinics.

Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System

OBJECTIVES

Low back pain is a common clinical presentation that often results in expensive and unnecessary imaging that may lead to undue patient harm, including unnecessary procedures. We present an initiative in a safety net system to reduce imaging for low back pain.

METHODS

This quality improvement study was conducted across 70 ambulatory clinics and 11 teaching hospitals. Three electronic health record changes, using the concept of a nudge, were introduced into orders for lumbar radiography (x-ray), lumbar CT, and lumbar MRI. The primary outcome was the number of orders per 1,000 patient-days or encounters for each imaging test in the inpatient, ambulatory, and emergency department (ED) settings. Variation across facilities was assessed, along with selected indications.

RESULTS

Across all clinical environments, there were statistically significant decreases in level differences pre- and postintervention for lumbar x-ray (-52.9% for inpatient encounters, P < .001; -23.7% for ambulatory encounters, P < .001; and -17.3% for ED only encounters, P < .01). There was no decrease in ordering of lumbar CTs in the inpatient and ambulatory settings, although there was an increase in lumbar CTs in ED-only encounters. There was no difference in lumbar MRI ordering. Variation was seen across all hospitals and clinics.

DISCUSSION

Our intervention successfully decreased lumbar radiography across all clinical settings, with a reduction in lumbar CTs in the inpatient and ambulatory settings. There were no changes for lumbar MRI orders.

Diagnostic testing in children: A qualitative study of pediatricians' considerations

AIMS AND OBJECTIVES

Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation.

METHOD

We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes.

RESULTS

Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes.

CONCLUSION

We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.

Availability, Quality, and Evidence-Based Content of mHealth Apps for the Treatment of Nonspecific Low Back Pain in the German Language: Systematic Assessment

BACKGROUND

Nonspecific low back pain (NSLBP) carries significant socioeconomic relevance and leads to substantial difficulties for those who are affected by it. The effectiveness of app-based treatments has been confirmed, and clinicians are recommended to use such interventions. As 88.8% of the German population uses smartphones, apps could support therapy. The available apps in mobile app stores are poorly regulated, and their quality can vary. Overviews of the availability and quality of mobile apps for Australia, Great Britain, and Spain have been compiled, but this has not yet been done for Germany.

OBJECTIVE

We aimed to provide an overview of the availability and content-related quality of apps for the treatment of NSLBP in the German language.

METHODS

A systematic search for apps on iOS and Android was conducted on July 6, 2022, in the Apple App Store and Google Play Store. The inclusion and exclusion criteria were defined before the search. Apps in the German language that were available in both stores were eligible. To check for evidence, the apps found were assessed using checklists based on the German national guideline for NSLBP and the British equivalent of the National Institute for Health and Care Excellence. The quality of the apps was measured using the Mobile Application Rating Scale. To control potential inaccuracies, a second reviewer resurveyed the outcomes for 30% (3/8) of the apps and checked the inclusion and exclusion criteria for these apps. The outcomes, measured using the assessment tools, are presented in tables with descriptive statistics. Furthermore, the characteristics of the included apps were summarized.

RESULTS

In total, 8 apps were included for assessment. Features provided with different frequencies were exercise tracking of prefabricated or adaptable workout programs, educational aspects, artificial intelligence-based therapy or workout programs, and motion detection. All apps met some recommendations by the German national guideline and used forms of exercises as recommended by the National Institute for Health and Care Excellence guideline. The mean value of items rated as "Yes" was 5.75 (SD 2.71) out of 16. The best-rated app received an answer of "Yes" for 11 items. The mean Mobile Application Rating Scale quality score was 3.61 (SD 0.55). The highest mean score was obtained in "Section B-Functionality" (mean 3.81, SD 0.54).

CONCLUSIONS

Available apps in the German language meet guideline recommendations and are mostly of acceptable or good quality. Their use as a therapy supplement could help promote the implementation of home-based exercise protocols. A new assessment tool to obtain ratings on apps for the treatment of NSLBP, combining aspects of quality and evidence-based best practices, could be useful.

TRIAL REGISTRATION

Open Science Framework Registries sq435; https://osf.io/sq435.

[Pitfalls in communicating with patients with chronic pain in urology-from pain games to loss of authority]

Patients with chronic pain syndromes are often referred to as "difficult" patients. In addition to positive expectations of the physicians' competence, pain patients often express understandable doubts about the appropriateness and efficiency of new treatment options and are afraid of rejection and devaluation. Hope and disappointment, idealization and devaluation alternate in a characteristic way. This article demonstrates the pitfalls of communicating with patients suffering from chronic pain and provides recommendations for improving physician-patient interaction based on acceptance, honesty and empathy.

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect

INTRODUCTION

While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects.

PURPOSE

In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects.

IMPLICATIONS

This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the 'prism' of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context.

[A functional approach to disorders of the loco-motor system-a way to a better understanding?]

BACKGROUND

Disorders of the loco-motor system are frequent and expensive. The current method of diagnosing and treating these disorders does not appear to be successful.

DIAGNOSTICS

A functional approach based on the model of the functional system incorporates all aspects relevant to disorders of the loco-motor system. Most disturbances the system can compensate. If compensating mechanisms are not sufficient, the system decompensates, and symptoms develop. It is important to search not only for structural changes but also for somatic dysfunction, psychosocial factors, and changes in neuromodulation. On this basis, treatment strategies can be developed. If there are complex disturbances on different levels, a multimodal interdisciplinary treatment is indicated. The model of the functional system highlights the important role of manual medicine in the diagnostics, treatment, prevention, and rehabilitation of disorders of the loco-motor system.

An Objective Assessment of Lumbar Spine Degeneration/Ageing Seen on MRI Using An Ensemble Method-A Novel Approach to Lumbar MRI Reporting

STUDY DESIGN

Retrospective, randomized, radiographic study assessing age-related changes (ARCs) on lumbar magnetic resonance imaging (MRI) using an ensemble method.

OBJECTIVES

This study proposed to develop a novel reporting method to calculate a predicted "age estimate" for the ARC seen on lumbar MRI.

SUMMARY OF BACKGROUND DATA

Lumbar MRI reports include pathological findings but usually not the prevalence data of common findings which has been shown to decrease the need for narcotics in the management of non-specific lower back pain (NSLBP). Comparing the normal age estimation for lumbar spine degenerative changes/ARC on MRI and comparing this to the patient's real age may improve patient outcome in the management of NSLBP.

METHODS

A total of 60 lumbar MRI were taken from patients aged between 0 and 100 years. Lumbar MRI features reported as associated with age on review of the literature were measured on each MRI and statistically evaluated for correlation with age. Factors found to be associated were then entered into an ensemble model consisting of several machine learning techniques. The resulting ensemble model was then tested to predict age for a further 10 random lumbar MRI scans. One further lumbar MRI was then assessed for observer variability.

RESULTS

Features that correlated with age were disc signal intensity, the appearance of paravertebral and psoas muscle, disc height, facet joint size, ligamentum flavum thickness, Schmorl nodes, Modic changes, vertebral osteophytes, and high-intensity zones. With the ensemble model, 80% of estimated spinal age were within 11 years of the subjects' physical age.

CONCLUSION

It would appear that the intervertebral discs, and many other structures that are subjected to loading in and around the lumbar spine change their lumbar MRI appearance in a predictable way with increasing age. ARC on lumbar MRI can be assessed to predict an "expected age" for the subject.Level of Evidence: 2.

[Noninvasive Treatments for Acute and Chronic Back Pain]

Noninvasive Treatments for Acute and Chronic Back Pain Abstract. The therapy of back pain - especially the medication with opioids - can be challenging for the treating physician. Specific back pain can often be diagnosed by imaging and successfully treated by surgery or medication. In contrast, nonspecific back pain can be worsened by inappropriate imaging, questionable surgical indications and uncontrolled drug use. For the therapy of nonspecific back pain, maintaining daily activity and exercise therapy is central. Opioids are effective drugs for short-term use. However, long-term use often leads to opioid-induced hyperalgesia and hormonal dysfunction with decreased quality of life and libido. Furthermore, opioids can lead to abuse and addiction. After an ineffective treatment with non-opioids, opioids may be given for a limited time period (if possible shorter than four weeks) according to international guidelines.

What are the effects of diagnostic imaging on clinical outcomes in patients with low back pain presenting for chiropractic care: a matched observational study

Background

Evidence suggests that diagnostic imaging for low back pain does not improve care in the absence of suspicion of serious pathology. However, the effect of imaging use on clinical outcomes has not been investigated in patients presenting to chiropractors. The aim of this study was to determine if diagnostic imaging affects clinical outcomes in patients with low back pain presenting for chiropractic care.

Methods

A matched observational study using prospective longitudinal observational data with one year follow up was performed in primary care chiropractic clinics in Denmark. Data was collected from November 2016 to December 2019. Participants included low back pain patients presenting for chiropractic care, who were either referred or not referred for diagnostic imaging during their initial visit. Patients were excluded if they were less than 18 years old, had a diagnosis of underlying pathology, or had previous imaging relevant to their current clinical presentation. Coarsened exact matching was used to match participants referred for diagnostic imaging with participants not referred for diagnostic imaging on baseline variables including participant demographics, pain characteristics, and clinical history. Mixed linear and logistic regression models were used to assess the effect of imaging on back pain intensity and disability at two-weeks, three-months, and one-year, and on global perceived effect and satisfaction with care at two-weeks.

Results

2162 patients were included, with 24.1% referred for imaging. Near perfect balance between matched groups was achieved for baseline variables except age and leg pain. Participants referred for imaging had slightly higher back pain intensity at two-weeks (0.4, 95%CI: 0.1, 0.8) and one-year (0.4, 95%CI: 0.0, 0.7), and disability at two-weeks (5.7, 95%CI: 1.4, 10.0), but the changes are unlikely to be clinically meaningful. No difference between groups was found for the other outcome measures. Similar results were found when sensitivity analysis, adjusted for age and leg pain intensity, was performed.

Conclusions

Diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. These results support that current guideline recommendations against routine imaging apply equally to chiropractic practice.

Hidden consequences of patient satisfaction: A survey of pediatric surgeons

BACKGROUND

Patient satisfaction surveys are increasingly utilized to assess patients' perceptions of their health care. Recently, these scores have been linked to payment, potentially incentivizing practices to meet certain metrics. We hypothesize that increasing pressures to receive positive reviews have led physicians to alter the delivery of their care to accommodate patient expectations over standards of care.

METHODS

An 11-question REDCap™ survey was developed and emailed anonymously to all sixty-two surgeons across all surgical subspecialties at our children's hospital. Multiple-choice and open-ended questions were included. A modified Delphi method was used to acquire general consensus.

RESULTS

Survey response rate for analysis was 41/62 (66%). 23 (56%) stated that they have changed their clinical practice patterns due to concerns regarding patient dissatisfaction. Examples of such changes included: requesting imaging tests or laboratory studies, performing invasive procedures, referring for second opinions, and prescribing medications. Only 2% felt that these interventions led to any significant change in outcome of a patient's condition. Several respondents expressed concerns that factors outside their control (scheduling, parking, wait times) contributed to patient dissatisfaction and affected providers' ratings, while others expressed concerns about inherent biases driving survey participants.

CONCLUSIONS

As a result of patient satisfaction surveys, a significant number of surgeons reported altering their clinical practice beyond standard care to meet patient expectations. Some of these modifications included performing unnecessary interventions. Reliance on these surveys may be at odds with reducing health care costs and avoiding physician burnout. These and other unintended consequences of patient satisfaction surveys warrant further study before they are widely accepted as appropriate quality metrics.

LEVEL OF EVIDENCE

Level IV, questionnaire.

'Your spine is so worn out' - the influence of clinical diagnosis on beliefs in patients with non-specific chronic low back pain - a qualitative study'

BACKGROUND

Patients' beliefs have an important influence on the clinical management of low back pain and healthcare professionals should be prepared to address these beliefs. There is still a gap in the literature about the influence of patients' perceptions of their clinical diagnosis on the severity of their pain experience and disability.

OBJECTIVES

To identify the perceptions of patients with chronic non-specific low back pain regarding the influence of their clinical diagnosis on pain, beliefs, and daily life activities.

METHODS

Qualitative study of 70 individuals with chronic non-specific low back pain. A semi structured interview was conducted about patients' beliefs and perceptions regarding the influence of clinical diagnosis on their daily activities and pain intensity.

RESULTS

Most participants believed that higher number of different clinical diagnoses for the same individual may be associated with high pain intensity and disability for daily activities and that pain and injury are directly related. Patients beliefs were grouped into four main themes: (1) pain has multifactorial explanation in physical dimension; (2) improvement expectation is extremely low in patients with chronic pain; (3) clinical diagnosis influences pain and disability levels; (4) clinical diagnosis is extremely valued by patients.

CONCLUSIONS

Patients believe that there is a strong relationship between structural changes in the lower back, pain, and daily life activities; thus, providing evidence of a strong influence of the biomedical model on their beliefs.

Noninvasive multimodal fluorescence and magnetic resonance imaging of whole-organ intervertebral discs

Low back pain (LBP) is a commonly experienced symptom posing a tremendous healthcare burden to individuals and society at large. The LBP pathology is strongly linked to degeneration of the intervertebral disc (IVD), calling for development of early-stage diagnostic tools for visualizing biomolecular changes in IVD. Multimodal measurements of fluorescence molecular tomography (FMT) and magnetic resonance imaging (MRI) were performed on IVD whole organ culture model using an in-house built FMT system and a high-field MRI scanner. The resulted multimodal images were systematically validated through epifluorescence imaging of the IVD sections at a microscopic level. Multiple image contrasts were exploited, including fluorescence distribution, anatomical map associated with T1-weighted MRI contrast, and water content related with T2 relaxation time. The developed multimodality imaging approach may thus serve as a new assessment tool for early diagnosis of IVD degeneration and longitudinal monitoring of IVD organ culture status using fluorescence markers.

"I would not go to him": Focus groups exploring community responses to a public health campaign aimed at reducing unnecessary diagnostic imaging of low back pain

BACKGROUND

Community awareness of the harms of overdiagnosis remains low.

OBJECTIVE

To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain.

METHODS

We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes.

RESULTS

Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging.

CONCLUSIONS

Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully.

PATIENT OR PUBLIC CONTRIBUTION

We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation.

Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging

Background: despite the efforts of multiple stakeholders to promote appropriate care throughout the healthcare system, studies show that two out of three lower back pain (LBP) patients expect to receive imaging. We used the Choosing Wisely Canada patient-oriented framework, prioritizing patient engagement, to develop an intervention that addresses lower back pain imaging overuse. Methods: to develop this intervention, we collaborated with a multidisciplinary advisory team, including two patient partners with lower back pain, researchers, clinicians, healthcare administrators, and the Choosing Wisely Canada lead for Saskatchewan. For this qualitative study, data were collected through two advisory team meetings, two individual interviews with lower back pain patient partners, and three focus groups with lower back pain patient participants. A lower back pain prescription pad was developed as an outcome of these consultations. Results: participants reported a lack of interactive and informative communication was a significant barrier to receiving appropriate care. The most cited content information for inclusion in this intervention was treatments known to work, including physical activity, useful equipment, and reliable sources of educational material. Participants also suggested it was important that benefits and risks of imaging were explained on the pad. Three key themes derived from the data were also used to guide development of the intervention: (a) the role of imaging in LBP diagnosis; (b) the impact of the patient-physician relationship on LBP diagnosis and treatment; and (c) the lack of patient awareness of Choosing Wisely Canada and their recommendations. Conclusions: the lower back pain patient-developed prescription pad may help patients and clinicians engage in informed conversations and shared decision making that could support reduce unnecessary lower back pain imaging.

Effect of information format on intentions and beliefs regarding diagnostic imaging for non-specific low back pain: A randomised controlled trial in members of the public

OBJECTIVE

To evaluate the effects of information format on intentions to request diagnostic imaging for non-specific low back pain in members of the public.

METHODS

We performed a three arm, 1:1:1, superiority randomised trial on members of the public. Participants were randomised to one of the three groups: a Standard Care Leaflet group (standard information on low back pain), a Neutral Leaflet group (balanced information on the benefits and harms of imaging) and a Nudge Leaflet group (with behavioural cues to emphasise the harms of unnecessary imaging). Our primary outcome was intention to request imaging for low back pain.

RESULTS

418 participants were randomised. After reading the leaflet, intention to request imaging (measured on an 11-point scale (0 = definitely would not request to 10 = definitely would request) was lower in the Nudge Leaflet group (mean = 4.6, SD = 3.4) compared with the Standard Care Leaflet group (mean = 5.3, SD = 3.3) and the Neutral Leaflet group (mean = 5.3, SD = 3.0) (adjusted mean difference between Nudge and Neutral, -1.0 points, 95%CI -1.6 to -0.4).

CONCLUSION

Framing information to emphasise potential harms from overdiagnosis reduced intention to request diagnostic imaging for low back pain.

PRACTICE IMPLICATIONS

Nudge leaflets could help clinicians manage patient pressure for unnecessary tests.

Functional pain disorders - more than nociplastic pain

BACKGROUND

Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hyperalgesia and allodynia, inconsistency and reversibility, as well as dynamic cross-system interactions with biological and psychobehavioral factors. Along with this renewed understanding, functional pain disorders, also classified as chronic primary pain, are being reframed as biopsychosocial conditions that benefit from multimodal treatment.

OBJECTIVE

To summarize the current understanding of nociplastic pain and functional pain disorders, with a focus on conditions that are common in neurology practice.

METHODS

This was a narrative literature review.

RESULTS

Chronic back pain, fibromyalgia syndrome and complex regional pain syndrome are best understood within a biopsychosocial framework of pain perception that considers structural factors (predispositions and sequelae) and psychobehavioral mechanisms. Although pain is often the primary complaint, it should not be the only focus of treatment, as accompanying symptoms such as sleep or mood problems can significantly impact quality of life and offer useful leverage points for multimodal treatment. Analgesic pharmacotherapy is rarely helpful on its own, and should always be imbedded in a multidisciplinary setting.

Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: Data from the Australian Longitudinal Study on Women's Health

Objective

There are concerns that lumbar spine imaging represents low value care. Our aim was to examine the use of lumbar spine imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] over 20 years, and costs and person-level characteristics of imaging in a large cohort of Australian women.

Methods

The Australian Longitudinal Study on Women’s Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973–1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database.

Results

38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. In women with self-reported back pain, depression and poorer physical health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30–39 years were AU$51,735,649 over 2011–2015.

Conclusions

Lumbar spine imaging was common in population-based Australian women, with rates increasing over 20 years. Depression and poor physical health were associated with lumbar spine imaging. Raising awareness of this in clinicians is likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.

Psychosocial consequences of diagnosing nonspecific low-back pain radiologically: a qualitative study

BACKGROUND

Chronic low back pain (CLBP) is a complex biopsychosocial problem with financial implications for society. Most LBP is categorized as nonspecific CLBP (NS-CLBP); magnetic resonance imaging (MRI) is increasingly used in the investigation of LBP but has a high false-positive rate for NS-CLBP.

PURPOSE

To explore the psychosocial factors associated with diagnosing NS-CLBP by MRI in Saudi Arabia.

METHODS

Using a qualitative design, 11 patients with CLBP without a clear medical diagnosis who had received an MRI scan were interviewed using a semi-structured technique, and transcripts were analyzed using framework analysis.

RESULTS

Four themes of relevance to the psychosocial consequences of using MRI to diagnose CLBP were identified: 1) impact on social participation after MRI diagnosis; 2) psychological impact of MRI diagnosis; 3) conflicting advice; and 4) patient education. Although some patients expressed a sense of relief following the identification of an objective explanation of their symptoms by MRI, a number of negative consequences were also identified. In particular, fear-avoidance behavior and anxiety were apparent.

CONCLUSION

The use of MRI scanning in the diagnosis of LBP may lead to psychosocial factors influencing participation in physical and social daily activities.

Patient Preferences for Plain Radiographs in the Setting of Atraumatic Shoulder Pain: Which Factors Influence Their Decision?

INTRODUCTION

Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain, although the diagnostic utility of this imaging modality is unclear. Despite this, patients often prefer to obtain radiographs and may associate them with a more satisfactory visit.

METHODS

New patients presenting with atraumatic shoulder pain were provided with information regarding the potential advantages and disadvantages of plain radiographs as part of their visit. Patients then decided whether to receive radiographs and baseline patient demographics were collected. A detailed physical examination and history was performed by a fellowship-trained provider, and a preliminary diagnosis and tentative treatment plan was formulated. The radiographs were then reviewed to determine whether the diagnosis and treatment plan was altered by addition of the radiographs. Patients who opted for radiographs then reported whether they felt the radiographs aided in diagnosis and treatment and whether the addition of the radiograph influenced their visit satisfaction.

RESULTS

A total of 220 patients met the inclusion criteria. Overall, 121 patients (55%) requested a radiograph. The mean age was 57.1 ± 16.1 years (range, 18 to 91 years). Lack of bachelor's degree (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2 to 6.2; P = 0.01), lack of previous contralateral shoulder pain (OR, 4.0; 95% CI, 2.0 to 8.2; P = 0.0001), and lack of a previous shoulder radiograph (OR, 8.4; 95% CI, 4.1 to 16.9; P < 0.0001) or MRI within the last 6 months (OR, 6.2; 95% CI, 1.4 to 26.8; P = 0.01) were independently associated with patient preference to obtain radiographs for atraumatic shoulder pain. Of the 121 patients who requested radiographs, 117 (96.7%) felt that radiographs improved their satisfaction.

DISCUSSION

Patients who obtained radiographs overwhelmingly reported its importance in improving visit satisfaction and diagnostic accuracy. Given the increasing emphasis on shared decision making, further study of patient factors influencing the decision to obtain routine radiographs will lead to more efficient practice management and potentially improved patient satisfaction.

LEVEL OF EVIDENCE

Level II (Diagnostic).

Death of the ALARA Radiation Protection Principle as Used in the Medical Sector

ALARA is the acronym for "As Low As Reasonably Achievable." It is a radiation protection concept borne from the linear no-threshold (LNT) hypothesis. There are no valid data today supporting the use of LNT in the low-dose range, so dose as a surrogate for risk in radiological imaging is not appropriate, and therefore, the use of the ALARA concept is obsolete. Continued use of an outdated and erroneous principle unnecessarily constrains medical professionals attempting to deliver high-quality care to patients by leading to a reluctance by doctors to order images, a resistance from patients/parents to receive images, subquality images, repeated imaging, increased radiation exposures, the stifling of low-dose radiation research and treatment, and the propagation of radiophobia and continued endorsement of ALARA by regulatory bodies. All these factors result from the fear of radiogenic cancer, many years in the future, that will not occur. It has been established that the dose threshold for leukemia is higher than previously thought. A low-dose radiation exposure from medical imaging will likely upregulate the body's adaptive protection systems leading to the prevention of future cancers. The ALARA principle, as used as a radiation protection principle throughout medicine, is scientifically defunct and should be abandoned.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Early Postoperative Radiographs Have No Effect on Orthopaedic Trauma Patient's Satisfaction With Their Clinic Visit

BACKGROUND

Patient satisfaction plays a prominent role in modern orthopaedic care, reimbursement, and quality assessment, even if it runs contrary to the "standard of care." The literature shows that routine early radiographs after acute fracture care have no impact on clinical decision-making or patient outcomes, but little is known about their effect on patient satisfaction and understanding of their injuries. We hypothesized that eliminating these radiographs would negatively influence patient satisfaction scores with their clinic visit.

METHODS

One hundred patients were prospectively enrolled after acute fracture fixation. Half the patients obtained radiographs at the 2-week follow-up visit, whereas the other half did not. All patients completed a satisfaction survey about their clinic visit.

RESULTS

No difference was observed between the groups in overall satisfaction with the clinic visit (P = 0.62) or complications. However, patients with radiographs were more satisfied with the surgeon's explanations of their injury and progression (P = 0.03).

CONCLUSION

Eliminating routine early postoperative radiographs had no effect on overall patient satisfaction with the clinic visit, but it did affect satisfaction with the surgeon's explanation of their injury. This could save time, money, and radiation exposure without adversely affecting patient outcome or satisfaction, but an equivalent educational tool should be identified for clinic visits.

Multiple physical symptoms and individual characteristics - A cross-sectional study of the general population

OBJECTIVE

Multiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population.

METHODS

A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use.

RESULTS

49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20-40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication.

CONCLUSION

Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.

Explanatory multivariate modeling for disability, pain, and claims in patients with spine pain via a physical therapy direct access model of care

BACKGROUND

Direct access physical therapy (DAPT) may result in improved patient outcomes and reduced healthcare costs. Prognostic factors associated with spine-related outcomes and insurance claims with DAPT are needed.

OBJECTIVE

To identify factors that predict variations in outcomes for spine pain and insurance claims using DAPT.

METHODS

Individuals (N = 250) with spine pain were analyzed. Outcomes were classified into High, Low, or Did Not Meet minimal clinically important difference (MCID) scores. Claims were categorized into low, medium, or high tertiles. Prognostic variables were identified from patient information.

RESULTS

Females were more likely to meet High MCID (odds ratio [OR] 2.84 (95% CI = 1.32, 6.11) and Low MCID (OR 2.86, 95% CI = 1.34, 6.10). Higher initial ODI/NDI scores were associated with High MCID (OR 1.04, 95% CI = 1.07, 1.22) and Low MCID (OR 0.91, 95% CI = 0.77, 1.07). Odds of a high claim were lowered by the absence of imaging (OR 0.04, 95% CI = 0.02, 0.09) and an active versus passive treatment (OR 0.38, 95% CI = 0.18, 0.80).

CONCLUSION

Females and higher initial disability predicted favorable outcomes. The novel introduction of claims into the prognostic modeling supports that active interventions and avoiding imaging may reduce claims.

Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area

The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where SIJ is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, when the SIJ might be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the SIJ(s)-a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this Perspective article argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models with contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.

VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain

DESCRIPTION

In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP).

METHODS

The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline.

RECOMMENDATIONS

The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests

OBJECTIVES

To assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use.

DESIGN

Retrospective cohort study.

SETTING

UK primary care.

PARTICIPANTS

All patients registered to UK General Practices in the Clinical Practice Research Datalink, 2000/1 to 2015/16.

MAIN OUTCOME MEASURES

Temporal trends in test use, and crude and age and sex standardised rates of total test use and of 44 specific tests.

RESULTS

262 974 099 tests were analysed over 71 436 331 person years. Age and sex adjusted use increased by 8.5% annually (95% confidence interval 7.6% to 9.4%); from 14 869 tests per 10 000 person years in 2000/1 to 49 267 in 2015/16, a 3.3-fold increase. Patients in 2015/16 had on average five tests per year, compared with 1.5 in 2000/1. Test use also increased statistically significantly across all age groups, in both sexes, across all test types (laboratory, imaging, and miscellaneous), and 40 of the 44 tests that were studied specifically.

CONCLUSION

Total test use has increased markedly over time, in both sexes, and across all age groups, test types (laboratory, imaging, and miscellaneous) and for 40 of 44 tests specifically studied. Of the patients who underwent at least one test annually, the proportion who had more than one test increased significantly over time.

Current evidence for spinal X-ray use in the chiropractic profession: a narrative review

The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.

Informed appropriate imaging for low back pain management: A narrative review

Most patients with acute low back pain (LBP), with or without radiculopathy, have substantial improvements in pain and function in the first 4 weeks, and they do not require routine imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their LBP. It is also considered for those patients presenting with suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture and infection. In western country primary care settings, the prevalence has been suggested to be 0.7% for metastatic cancer, 0.01% for spinal infection and 0.04% for cauda equina syndrome. Of the small proportion of patients with any of these conditions, almost all have an identifiable risk factor. Osteoporotic vertebral compression fractures (4%) and inflammatory spine disease (<5%) may cause LBP, but these conditions typically carry lower diagnostic urgency. Imaging is an important driver of LBP care costs, not only because of the direct costs of the test procedures but also because of the downstream effects. Unnecessary imaging can lead to additional tests, follow-up, referrals and may result in an invasive procedure of limited or questionable benefit. Imaging should be delayed for 6 weeks in patients with nonspecific LBP without reasonable suspicion for serious disease.

The translational potential of this article: Diagnostic imaging studies should be performed only in patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition. Radiologists can play a critical role in decision support related to appropriateness of imaging requests, and accurately reporting the potential clinical significance or insignificance of imaging findings.

Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review

Main text

We aim to summarize the available evidence on the diagnostic accuracy of imaging (index test) compared to surgery (reference test) for identifying lumbar disc herniation (LDH) in adult patients.For this systematic review we searched MEDLINE, EMBASE and CINAHL (June 2017) for studies that assessed the diagnostic accuracy of imaging for LDH in adult patients with low back pain and surgery as the reference standard. Two review authors independently selected studies, extracted data and assessed risk of bias. We calculated summary estimates of sensitivity and specificity using bivariate analysis, generated linked ROC plots in case of direct comparison of diagnostic imaging tests and assessed the quality of evidence using the GRADE-approach.We found 14 studies, all but one done before 1995, including 940 patients. Nine studies investigated Computed Tomography (CT), eight myelography and six Magnetic Resonance Imaging (MRI). The prior probability of LDH varied from 48.6 to 98.7%. The summary estimates for MRI and myelography were comparable with CT (sensitivity: 81.3% (95%CI 72.3-87.7%) and specificity: 77.1% (95%CI 61.9-87.5%)). The quality of evidence was moderate to very low.

Conclusions

The diagnostic accuracy of CT, myelography and MRI of today is unknown, as we found no studies evaluating today's more advanced imaging techniques. Concerning the older techniques we found moderate diagnostic accuracy for all CT, myelography and MRI, indicating a large proportion of false positives and negatives.

Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy

The pain experience may vary greatly among individuals reporting equally high levels of pain. We sought to examine the demographic and clinical characteristics associated with pain interference in patients with high pain intensity. Among patients with chronic musculoskeletal pain who were prescribed long-term opioid therapy and who were recruited from 2 health care systems, we identified a subset who reported high pain intensity (n = 189). All individuals completed self-report assessments of clinical and demographic factors. Analyses examined characteristics associated with pain interference. Within this group of patients with high reported pain intensity, 16.4% (n = 31) had low pain interference, 39.2% (n = 74) had moderate pain interference, and 44.4% (n = 84) had high pain interference. In bivariate analyses, patients with lower pain interference had fewer symptoms of depression and anxiety, less pain catastrophizing, a better quality of life, and greater self-efficacy for managing pain. In multivariate analyses, variables most strongly associated with low pain interference, relative to high interference, were depression severity (odds ratio 0.90; 95% confidence interval 0.82-0.99) and pain self-efficacy (odds ratio 1.07; 95% confidence interval 1.02-1.12). Study results suggest that chronic pain treatments that address symptoms of depression and enhance pain self-efficacy may be prioritized, particularly among patients who are prescribed long-term opioid therapy.

PERSPECTIVE

This article describes the prevalence and correlates of pain interference categories (low, medium, and high) among patients with high pain intensity who are prescribed long-term opioid therapy. Findings reveal that 16.4% of participants with high pain intensity had low impairment. Multivariate analyses indicate that variables significantly associated with low pain interference were lower depression scores and greater pain self-efficacy.

Radiophobia: 7 Reasons Why Radiography Used in Spine and Posture Rehabilitation Should Not Be Feared or Avoided

Evidence-based contemporary spinal rehabilitation often requires radiography. Use of radiography (X-rays or computed tomography scans) should not be feared, avoided, or have their exposures lessened to decrease patient dose possibly jeopardizing image quality. This is because all fears of radiation exposures from medical diagnostic imaging are based on complete fabrication of health risks based on an outdated, invalid linear model that has simply been propagated for decades. We present 7 main arguments for continued use of radiography for routine use in spinal rehabilitation: (1) the linear no-threshold model for radiation risk estimates is invalid for low-dose exposures; (2) low-dose radiation enhances health via the body's adaptive response mechanisms (ie, radiation hormesis); (3) an X-ray with low-dose radiation only induces 1 one-millionth the amount of cellular damage as compared to breathing air for a day; (4) radiography is below inescapable natural annual background radiation levels; (5) radiophobia stems from unwarranted fears and false beliefs; (6) radiography use leads to better patient outcomes; (7) the risk to benefit ratio is always beneficial for routine radiography. Radiography is a safe imaging method for routine use in patient assessment, screening, diagnosis, and biomechanical analysis and for monitoring treatment progress in daily clinical practice.

Non-Specific Low Back Pain

BACKGROUND

For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition.

METHODS

The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process.

RESULTS

If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible.

CONCLUSION

A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Addressing overuse in emergency medicine: evidence of a role for greater patient engagement

Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.

The reassuring potential of spinal imaging results: development and testing of a brief, psycho-education intervention for patients attending secondary care

PURPOSE

To develop and test a standardised method of interpreting spinal imaging findings in a manner designed to reassure patients with low back pain and promote engagement in an active recovery.

METHODS

A five-phase development and testing process involved collaborative working party contributions, informal and formal appraisal of the intervention content by clinicians and consumers, a two-stage online evaluation of the take-home patient resource, and onsite testing.

RESULTS

A total of 12 health professionals and 77 consumers were included in formal evaluative processes at various stages of the development and testing process. Consumers assessed the revised iteration of the take-home resource to be clearer and easier to understand than the original version. We integrated all feedback and evaluation outcomes to develop the final intervention content, which was approved by experienced clinicians and considered safe. We devised a framework to guide delivery of the low-cost clinical intervention and a 10-15-min timeframe was demonstrated to be realistic.

CONCLUSIONS

We have developed, modified, and tested a pragmatic framework for a brief, psychoeducational intervention. We have established face validity and acceptability from key stakeholders and engaged clinicians and are ready to proceed with a pilot feasibility trial.

Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?

BACKGROUND

Low back pain (LBP) has a prevalence of 84% in Africa. The commonest form of imaging is plain lumbar spine x-ray. It gives a radiation dose equivalent to 65 times a chest x-ray dose and sends one of the highest doses to the human reproductive organs. The commonest cause of LBP in Africa is degenerative disease. X-ray findings do not change mode of treatment yet most physicians still routinely request for x-rays.

METHODS

This is a systematic review of databases including The Cochrane, CINAHL plus, AMED, and MEDLINE. Key evidence was clinical guidelines on x-ray use for low back pain. Key search terms included low back pain, x-rays, guidelines, Ghana.

RESULTS

Four clinical guidelines on LBP emerged from two Systematic Reviews rated excellent and four good Randomized Controlled Trials: The European guidelines for acute and sub-acute non-specific Low Back Pain, The American College of Physicians and the American Pain Society guideline for diagnostic imaging for Low Back Pain, The NICE guidelines for persistent non-specific Low Back Pain and the Ghana Standard Treatment Guidelines (GSTG). All the guidelines agree that a good history and clinical examination for all LBP patients helps in diagnosing. Only GSTG recommends routine plain spinal x-rays.

CONCLUSION

There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.

FUNDING

None declared.

Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms

Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.

DIAGNOSIS

Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.

CONCLUSIONS

This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.

Effect on healthcare utilization and costs of spinal manual therapy for acute low back pain in routine care: A propensity score matched cohort study

Spinal manual therapy (SMT) is a popular treatment option for low back pain (LBP). The aim of our analysis was to evaluate the effects of manual therapy delivered by general practitioners and ambulatory orthopedic surgeons in routine care on follow up consultations, sick leave, health service utilization and costs for acute LBP compared to matched patients not receiving manual therapy. This is a propensity score matched cohort study based on health claims data. We identified a total of 113.652 adult patients with acute LBP and no coded red flags of whom 21.021 (18%) received SMT by physicians. In the final analysis 17.965 patients in each group could be matched. Balance on patients’ coded characteristics, comorbidity and prior health service utilization was achieved. The provision of SMT for acute LBP had no relevant impact on follow up visits and days of sick leave for LBP in the index billing period and the following year. SMT was associated with a higher proportion of imaging studies for LBP (30.6% vs. 23%, SMD: 0.164 [95% CI 0.143–0.185]). SMT did not lead to meaningful savings by replacing other health services for LBP. SMT for acute non-specific LBP in routine care was not clinically meaningful effective to reduce sick leave and reconsultation rates compared to no SMT and did not lead to meaningful savings by replacing other health services from the perspective of health insurance. This does not imply that SMT is ineffective but might reflect a problem with selection of suitable patients and the quality and quantity of SMT in routine care. National Manual Medicine societies should state clearly that imaging is not routinely needed prior to SMT in patients with low suspicion of presence of red flags and monitor the quality of provided services.