Low back pain in primary care: a description of 1250 patients with low back pain in danish general and chiropractic practice

Diagnostic imaging in the management of older adults with low back pain: analysis from the BAck Complaints in Elders: Chiropractic - Australia cohort study

BACKGROUND

Diagnostic imaging is commonly used in the management of low back pain (LBP), with approximately one-quarter of those who present to primary care referred for imaging. Current estimates of imaging frequency commonly exclude older adults; however, pathology detected with imaging (e.g., osteoporosis, cancer) may occur more frequently in older populations. The aims of this study were to: (i) determine the frequency and forms of diagnostic imaging use in older adults presenting for chiropractic care for LBP in Australia; (ii) describe participant characteristics associated with imaging use; and (iii) describe the types of radiographic findings.

METHODS

Data were collected from the BAck Complaints in Elders: Chiropractic-Australia (BACE: C-A) study, a 12-month, prospective cohort study of adults aged ≥ 55 years with a new episode of LBP. Self-reported frequency of imaging use (baseline, 2 and 6 weeks, 3, 6, 9, and 12 months) was reported descriptively by imaging modality. Imaging reports were obtained, and imaging findings were independently extracted and categorised. Baseline characteristics were assessed for differences in those who received imaging compared to those who did not. Proportions of imaging use and imaging findings were presented descriptively with 95% confidence intervals.

RESULTS

The BACE: C-A cohort comprised 217 participants of whom 60.8% reported receiving diagnostic imaging for their current episode of LBP. X-ray was performed most (44.7%), followed by computed tomography (CT) (30.8%). Participants receiving imaging reported higher low back disability, more healthcare use for LBP, more frequent leg pain, more suspected serious pathology, and stronger beliefs that imaging was important. Degenerative changes were the most common imaging finding (96.6%). Pathology of possible clinical significance, including compression fracture or suspected osteoporosis, was present in 15.5% of participants.

CONCLUSION

Three out of five older adults with LBP who sought chiropractic care received imaging over one-year. Participants receiving imaging tended to have more complex presentations (e.g., more disability, suspected underlying pathology) or stronger beliefs that imaging was necessary for the management of LBP. Degenerative changes were the most common imaging finding. Pathology of potential clinical relevance was present on approximately 15% of imaging reports received. No conditions requiring immediate medical attention were reported.

The chiropractors' dilemma in caring for older patients with musculoskeletal complaints: Collaborate, integrate, coexist, or separate?

The world's elderly population is growing at a rapid pace. This has led to an increase in demand on the health and welfare systems due to age-related disorders, with musculoskeletal complaints driving the need for rehabilitation services. However, there are concerns about health services' ability to meet this demand. While chiropractic care is gaining recognition for its benefits in treating older adults with musculoskeletal disorders, there is limited scientific literature on chiropractors' role and experiences in this area. To bridge this gap, we interviewed 21 chiropractors in Great Britain, the Netherlands, Norway, and Sweden. Inductive qualitative content analysis was used to analyse the interviews, and despite differences in integration and regulation between the countries, several common facilitators and barriers in caring for and managing older patients with musculoskeletal complaints emerged. While participants expressed optimism about future collaborations with other healthcare professionals and the integration of chiropractic into national healthcare systems, they also highlighted significant concerns regarding the existing healthcare infrastructure. The participants also felt that chiropractors, with their non-surgical and holistic approach, were well-positioned to be the primary point of contact for older patients. However, there were some common barriers, such as the affordability of care, limited integration of chiropractic, and the need to prioritise musculoskeletal complaints within public healthcare. Our findings suggest that chiropractors experience their clinical competencies as an underutilised resource in the available healthcare systems and that they could contribute to and potentially reduce the escalating burden of musculoskeletal complaints and associated costs among older patients. Additionally, our findings highlight the desire among the participants to foster collaboration among healthcare professionals and integrate chiropractic into the national public healthcare system. Integrating chiropractors as allied health professionals was also perceived to improve coordinated, patient-centred healthcare for older adults.

Swiss chiropractic cohort (Swiss ChiCo) pilot study: feasibility for a musculoskeletal cohort study conducted within a nationwide practice-based research network

PURPOSE

Practice-based research networks are collaborations between clinicians and researchers to advance primary care research. This study aims to assess the feasibility for longitudinal data collection within a newly established chiropractic PBRN in Switzerland.

METHODS

A prospective observational cohort feasibility study was performed. PBRN participating chiropractors were asked to recruit patients seeking new conservative health care for musculoskeletal pain from March 28, 2022, to September 28, 2022. Participants completed clinically oriented survey questions and patient-reported outcome measures before the initial chiropractic assessment as well as 1 h, 2 weeks, 6 weeks, and 12 weeks thereafter. Feasibility was assessed through a variety of process, resource, and management metrics. Patient clinical outcomes were also assessed.

RESULTS

A total of 76 clinicians from 35 unique primary care chiropractic clinics across Switzerland participated. A total of 1431 patients were invited to participate, of which 573 (mean age 47 years, 51% female) were enrolled. Patient survey response proportions were 76%, 64%, 61%, and 56%, at the 1-h, 2-, 6-, and 12-week survey follow-ups, respectively. Evidence of an association was found between increased patient age (OR = 1.03, 95%CI 1.01-1.04), patient from a German-speaking region (OR = 1.81, 95%CI 1.17-2.86), non-smokers (OR = 1.89, 95%CI 1.13-3.17), and increased pain impact score at baseline (OR = 1.18, 95%CI 1.01-1.38) and response to all surveys.

CONCLUSION

The Swiss ChiCo pilot study exceeded its prespecified feasibility objectives. Nationwide longitudinal data capture was highly feasible. Similar to other practice-based cohorts, participant retention remains a challenge. Trial registration Swiss chiropractic cohort (Swiss ChiCo) pilot study (ClinicalTrials.gov identifier: NCT05116020).

Identifying latent subgroups in the older population seeking primary health care for a new episode of back pain - findings from the BACE-N cohort

BACKGROUND

Back pain is the number one condition contributing to years lived with disability worldwide, and one of the most common reasons for seeking primary care. Research on this condition in the ageing population is sparse. Further, the heterogeneity of patients with back pain complicates the management in clinical care. It is possible that subgrouping people with similar characteristics would improve management. This paper aimed to identify latent classes based on demographics, pain characteristics, psychosocial behavior, and beliefs and attitudes about back pain, among older patients seeking primary care with a new episode of back pain, and to examine if there were differences regarding the classes' first point-of-contact.

METHODS

The study was part of the international BACE (Back complaints in elders) consortium and included 435 patients aged ≥ 55 years seeking primary care (general practitioners, physiotherapists, and chiropractors) in Norway from April 2015 to March 2020. A latent class analysis was performed to identify latent classes. The classes were described in terms of baseline characteristics and first point-of-contact in primary care.

RESULTS

Four latent classes were identified. The mean age was similar across groups, as were high expectations towards improvement. Class 1 (n = 169, 39%), the "positive" class, had more positive attitudes and beliefs, less pain catastrophizing and shorter duration of current pain episode. Class 2 (n = 31, 7%), the "fearful" class, exhibited the most fear avoidance behavior, and had higher mean pain intensity. Class 3 (n = 33, 8%), the "distressed" class, had the highest scores on depression, disability, and catastrophizing. Finally, class 4 (n = 202, 46%), the "hopeful" class, showed the highest expectations for recovery, although having high pain intensity. The identified four classes showed high internal homogeneity, sufficient between-group heterogeneity and were considered clinically meaningful. The distribution of first point-of-contact was similar across classes, except for the positive class where significantly more patients visited chiropractors compared to general practitioners and physiotherapists.

CONCLUSIONS

The identified classes may contribute to targeting clinical management of these patients. Longitudinal research on these latent classes is needed to explore whether the latent classes have prognostic value. Validation studies are needed to evaluate external validity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04261309.

Is the use of diagnostic imaging and the self-reported clinical management of low back pain patients influenced by the attitudes and beliefs of chiropractors? A survey of chiropractors in the Netherlands and Belgium

BACKGROUND

No previous studies have examined the association between attitudes and beliefs of chiropractors and their adherence to low back pain (LBP) guidelines. The aim of this study is: (1) to assess the attitudes and beliefs towards the management of LBP of Dutch and Belgian chiropractors; and (2) to investigate the association of these attitudes and beliefs on the use of diagnostic imaging and on the adherence to diagnostic guidelines and guidelines in the management of patients with LBP.

METHODS

STUDY DESIGN: Cross-sectional study using a web-based questionnaire in chiropractic private practices in the Netherlands and Belgium. The survey included sociodemographic characteristics, use of diagnostic imaging, the Pain Attitude and Beliefs Scale-Physiotherapists (PABS.PT) and 6 vignettes (3 acute and 3 chronic LBP patients). We used Latent Profile Analysis (LPA) to categorise the chiropractors into clusters depending on their PABS.PT outcome, whereby the classes differed primarily on the biomedical score. We used linear, logistic, and mixed models to examine the associations between these clusters, and adherence to the recommendations of guidelines on: (1) diagnostic imaging use, and (2) management of LBP (i.e. advice on activity, treatment, return-to-work, and bedrest).

RESULTS

The response rate of the Dutch and Belgian chiropractors was 61% (n = 149/245) and 57% (n = 54/95), respectively. The majority of chiropractors scored midrange of the biomedical scale of the PABS.PT. Three clusters were identified using LPA: (1) high biomedical class (n = 18), (2) mid biomedical class (n = 117) and (3) low biomedical class (n = 23). Results from the vignettes suggest that chiropractors in the high biomedical class better adhere to diagnostic imaging guidelines and to LBP guidelines when it concerns advice on return-to-work and activity compared to the other two classes. However, no differences were identified between the classes for treatment of LBP. All chiropractors adhered to the guidelines' recommendation on bedrest.

CONCLUSION

The high biomedical class demonstrated better overall adherence to the practice guidelines for the management of LBP and diagnostic imaging than the other classes. Due to the small numbers for the high and low biomedical classes, these results should be interpreted with caution.

Demographic and clinical characteristics of patients with low back pain in primary and secondary care settings in Southern Denmark

Objective: To describe and compare the demographic and clinical characteristics of patients with acute or chronic low back pain across all health care settings treating this condition.Design and setting: Concurrent prospective survey registration of all consecutive consultations regarding low back pain at general practitioners, chiropractors, physiotherapists, and the secondary care spine centre in Southern Denmark.Subjects: Patients ≥16 years of age with low back pain.Main outcome measure: Demographic characteristics, symptoms, and clinical findings were registered and descriptively analysed. Pearson's chi-square tested differences between the populations in the four settings. Multiple logistic regression assessed the odds of consulting specific settings, and t-test assessed differences between patients attending for a first and later consultation.Results: Thirty-six general practitioners, 44 chiropractors, 74 physiotherapists, and 35 secondary care Spine Centre personnel provided information on 5645 consultations, including 1462 first-visit consultations. The patients differed significantly across the settings. Patients at the Spine Centre had the most severe symptoms and signs and were most often on sick leave. Compared to the other populations, the chiropractor population was younger, whereas the physiotherapist population was older, more often females, and had prolonged symptoms. In general practice, first-time consultations were with milder cases while patients who attended for a second or later consultation had the worst symptoms, findings, and risk of sick leave compared to the other primary care settings.Conclusion: The demographic and clinical characteristics of patients with low back pain differ considerably across the health care settings treating them.KEY POINTSThe study describes the symptoms and clinical findings of patients with low back pain consulting the Danish health care system in all its settings.Patients with chiropractors were youngest, while those with physiotherapists were the oldest and most frequently female.First consultations in general practice were generally with the least symptomatic patients while those returning for a subsequent consultation had more severe disease including more sick leave compared to patients in the other primary care settings.Our findings call for caution when generalizing between health care settings for patients with low back pain.

Multimorbidity in patients with low back pain in Danish chiropractic practice: a cohort study

BACKGROUND

People with multimorbidity, defined as the co-existence of two or more chronic conditions in an individual, often suffer from pain and functional limitations caused by musculoskeletal disorders and the chronic conditions. In chiropractic practice, two thirds of patients are treated for low back pain (LBP). It is unknown to what extent LBP is accompanied with chronic conditions in chiropractic practice. The objective was to determine the prevalence of multimorbidity among patients with LBP in chiropractric practice and to investigate if multimorbidity affects pain intensity, self-rated health, physical and mental health. Finally, to explore if individuals with multimorbidity have a different recovery for the LBP.

METHODS

Patients presenting with a new episode of LBP were recruited from 10 chiropractic clinics in 2016-2018. Patient-reported data concerning socio-demographics, self-rated health, pain intensity, history of LBP, mental health and chronic conditions were collected at baseline. The prevalence of multimorbidity was determined. To evaluate differences in recovery from the LBP, we estimated changes in the Roland Morris Disability Questionnaire (RMDQ) score and use of pain medication at baseline, 2 weeks, 3 months and 12 months. The analyses were adjusted using regression models.

RESULTS

2083 patients were included at baseline and 71%, 68% and 64% responded to follow-up questionnaires at 2 weeks, 3 and 12 months. 1024 (49%) participants reported to have at least one chronic condition and 421 (20%) had multimorbidity (≥ 2 chronic conditions). The presence of multimorbidity was associated with increased odds of poor self-rated health (OR 2.13), physical fitness (OR 1.79), poor muscular strength (OR 1.52), poor endurance (OR 1.51), and poor balance (OR 1.33). Patients with high LBP intensity combined with multimorbidity showed a poorer recovery than patients without chronic diseases (mean difference in RMDQ score 3.53 at 12 months follow-up). More patients with multimorbidity used pain medication for LBP at 12 months follow-up compared to those without chronic disease (OR 2.36).

CONCLUSIONS

Chiropractors should be aware that patients with LBP may suffer from multimorbidity with poor general health. Patients with multimorbidity also have poorer recovery from LBP than people without chronic disease and clinical follow-up may be indicated.

Swiss chiropractic practice-based research network and musculoskeletal pain cohort pilot study: protocol of a nationwide resource to advance musculoskeletal health services research

INTRODUCTION

Musculoskeletal (MSK) pain conditions, a leading cause of global disability, are usually first managed in primary care settings such as medical, physiotherapy, and chiropractic community-based practices. While chiropractors often treat MSK conditions, there is limited real-world evidence on the topic of health service outcomes among patients receiving this type of care. A nationwide Swiss chiropractic practice-based research network (PBRN) and MSK pain patient cohort study will have potential to monitor the epidemiological trends of MSK pain conditions and contribute to healthcare quality improvement. The primary aims of this protocol are to (1) describe the development of an MSK-focused PBRN within the Swiss chiropractic setting, and (2) describe the methodology of the first nested study to be conducted within the PBRN-an observational prospective patient cohort pilot study.

METHODS AND ANALYSIS

This initiative is conceptualised with two distinct phases. Phase I focuses on the development of the Swiss chiropractic PBRN, and will use a cross-sectional design to collect information from chiropractic clinicians nationwide. Phase II will recruit consecutive patients aged 18 years or older with MSK pain from community-based chiropractic practices participating in the PBRN into a prospective chiropractic cohort pilot study. All data collection will occur through electronic surveys offered in the three Swiss official languages (German, French, Italian) and English. Surveys will be provided to patients prior to their initial consultation in clinics, 1 hour after initial consultation, and at 2, 6 and 12 weeks after initial consultation.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the independent research ethics committee of Canton Zurich (BASEC-Nr: 2021-01479). Informed consent will be obtained electronically from all participants. Findings will be reported to stakeholders after each study phase, presented at local and international conferences, and disseminated through peer-reviewed publications.

STUDY PRE-REGISTRATION

Phase I-Swiss chiropractic PBRN (ClinicalTrials.gov identifier: NCT05046249); Phase 2-Swiss chiropractic cohort (Swiss ChiCo) pilot study (ClinicalTrials.gov identifier: NCT05116020).

Management of people with low back pain: a survey of opinions and beliefs of Dutch and Belgian chiropractors

BACKGROUND

Chiropractors commonly provide care to people with low-back pain (LBP). The aim of this survey was to determine the opinions and beliefs of chiropractors regarding the support and management of LBP. We also investigated whether their management is in accordance with the three most commonly recommended approaches to LBP based upon international guidelines (i.e. advice regarding return-to-work, limit bedrest, and stay active).

METHODS

A web-based survey was sent out in 2013 to collect data from registered Dutch and Belgian chiropractors. In addition to providing a description of their sociodemographic and practice characteristics, chiropractors were asked to complete six patient vignettes representing people with LBP who typically present to a chiropractor. The respondents indicated which intervention(s) they would recommend or undertake. Based upon these vignettes, we were able to determine whether their management approach adhered to clinical guidelines. Generalized mixed models were used to explore guidelines adherence and their relationship to chiropractors' characteristics.

RESULTS

In total, 60% (n = 203/340) of the chiropractors who were invited, chose to participate. Chiropractors reported applying a chiropractic adjustment in 90% of all vignettes, while the advice to exercise varied from one-third in the chronic cases to approximately half of those with acute LBP. More than 75% of the chiropractors would initially treat LBP 1-2 times a week. More than 90% of the chiropractors advised against bedrest. Overall, self-reported adherence to clinical guidelines for all six vignettes was [64.5% (CI 58.7-70.0)]. Adherence in the chronic vignettes [73.4% (CI 66.7-79.2)] was better than in the acute vignettes [55.9% (CI 50.5-61.1)]. Importantly, regarding recommended approaches to LBP, chiropractors more consistently followed guidelines regarding advice to limit bedrest [98.5% (CI 97.3-99.1)] than advice to stay active [77.5% (CI 72.3-81.9)] or return-to-work [59.4% (CI 55.2-63.4)]. Finally, Dutch chiropractors were more likely to adhere to the guidelines than Belgian chiropractors.

CONCLUSIONS

Chiropractic adjustments were the most common self-reported treatment modalities supplemented by exercise in the management of LBP patients. Two-thirds of the chiropractors reported adhering to the guidelines regarding management and advice for LBP patients. Practitioners should improve guideline adherence, particularly for acute LBP cases, and when advising on return-to-work.

Beliefs about back pain and associations with clinical outcomes: a primary care cohort study

OBJECTIVE

To investigate associations between beliefs about low back pain (LBP) at baseline and pain intensity and disability at 2-week, 13-week and 52-week follow-up.

DESIGN

Observational cohort study.

SETTING

Primary care private chiropractic clinics in Denmark.

PARTICIPANTS

A total of 2734 adults consulting a chiropractor for a new episode of LBP, with follow-up data available from 71%, 61% and 52% of the participants at 2, 13 and 52 weeks, respectively.

OUTCOME MEASURES

Beliefs about LBP were measured by the Back Belief Questionnaire (BBQ) before consulting the chiropractor. Pain (Numerical Rating Scale 0-10) and disability (the Roland-Morris Disability Questionnaire) were measured at baseline and after 2, 13 and 52 weeks. Associations were explored using longitudinal linear mixed models estimating interactions between BBQ and time, and by estimating associations between single items of BBQ and 13-week outcomes.

RESULTS

More positive beliefs about LBP were weakly associated with a reduction in pain at 2 weeks (β interaction BBQ#Time=-0.02 (95% CI -0.04 to -0.001)), at 13 weeks (-0.03 (95% CI -0.05 to -0.01)) and at 52 weeks of follow-up (-0.03 (95% CI -0.05 to -0.01); p=0.003). For disability, the association was uncertain (p=0.7). The item 'Back trouble means periods of pain for the rest of one's life' had the strongest association with both reduction in pain (-0.29, 95% CI -0.4 to -0.19, p<0.001) and disability (-2.42, 95% CI -3.52 to -1.33, p<0.001) at 13-week follow-up.

CONCLUSION

Positive beliefs regarding LBP, measured by the BBQ, were associated with a reduction in pain intensity at both short-term and long-term follow-up. However, the association was weak, and the clinical relevance is therefore questionable. No clear association was demonstrated between beliefs and disability. This study did not show promise that back beliefs as measured by the BBQ were helpful for predicting or explaining the course of LBP in this setting.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study

OBJECTIVES

To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor).

DESIGN

Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study.

SETTING

Norwegian GP, PT and chiropractic primary care centres.

PARTICIPANTS

Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses.

RESULTS

Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05).

CONCLUSION

Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations.

TRIAL REGISTRATION NUMBER

NCT04261309.

How Does the Measurement of Disability in Low Back Pain Map Unto the International Classification of Functioning, Disability and Health?: A Scoping Review of the Manual Medicine Literature

ABSTRACT

The objective of this study was to catalog items from instruments used to measure functioning, disability, and contextual factors in patients with low back pain treated with manual medicine (manipulation and mobilization) according to the International Classification of Functioning, Disability and Health. This catalog will be used to inform the development of an International Classification of Functioning, Disability and Health-based assessment schedule for low back pain patients treated with manual medicine. In this scoping review, we systematically searched MEDLINE, Embase, PsycINFO, and CINAHL. We identified instruments (questionnaires, clinical tests, single questions) used to measure functioning, disability, and contextual factors, extracted the relevant items, and then linked these items to the International Classification of Functioning, Disability and Health. We included 95 articles and identified 1510 meaningful concepts. All but 70 items were linked to the International Classification of Functioning, Disability and Health. Of the concepts linked to the International Classification of Functioning, Disability and Health, body functions accounted for 34.7%, body structures accounted for 0%, activities and participation accounted for 41%, environmental factors accounted for 3.6%, and personal factors accounted for 16%. Most items used to measure functioning and disability in low back pain patient treated with manual medicine focus on body functions, as well as activities and participation. The lack of measures that address environmental factors warrants further investigation.

The Danish Chiropractic Low Back Pain Cohort (ChiCo): Description and Summary of an Available Data Source for Research Collaborations

BACKGROUND

Back pain is among the most frequent reasons for care seeking globally. Observational clinical cohorts are useful for understanding why people seek care, the content of that care, and factors related to prognosis. This paper describes the Danish Chiropractic low back pain Cohort (ChiCo) and summarizes the primary characteristics of the population to inform the scientific community of the availability of these data as a resource for collaborative research projects.

METHODS

Adults seeking chiropractic care for a new episode of non-specific back pain were enrolled at the initial visit and followed up after 2, 13, and 52 weeks, with a subpopulation having weekly follow-ups for 1 year. Patient-reported and clinical-reported data were collected in an electronic database using the REDCap software (REDCap Consortium, projectredcap.org). Variables were chosen to measure pre-defined research domains and questions and to capture information across health constructs deemed relevant for additional research. Non-responders at 13 and 52 weeks were contacted by phone to maximize follow-up data and explore differences on core outcomes between responders and non-responders.

RESULTS

A total of 2848 patients (mean age 45 years, 59% men) were included from 10 clinics with 71%, 68% and 64% responding to follow-ups at 2, 13 and 52 weeks, respectively. Most participants (82%) were employed, nearly half reported current LBP for 1-7 days, and 83% had experienced LBP episodes previously. We did not identify indications of serious attrition bias.

CONCLUSION

We have described the aims and procedures for establishing the ChiCo cohort, characteristics of the cohort, and available information about attrition bias. These data have the potential to be linked, at an individual participant level, to the extensive Danish population-based registries that measure diverse health and social characteristics.

Baseline Characteristics May Help Indicate the Best Choice of Health Care Provider for Back Pain Patients in Primary Care: Results From a Prospective Cohort Study

OBJECTIVE

Baseline characteristics of patients low back pain differ substantially between care settings, but it is largely unknown whether predictors are of equal importance across settings. The aim of this study was to investigate whether 8 known predictors relate differently to outcomes in chiropractic practice and in general practice and to which degree these factors may be helpful in selecting patients benefiting more from one setting or the other.

METHODS

Patient characteristics were collected at baseline, and outcomes of pain intensity (numeric rating scale 0-10) and activity limitation (Roland-Morris Disability Questionnaire 0-100) after 2, 12, and 52 weeks. Differences in the prognostic strength between settings were investigated for each prognostic factor separately by estimating the interaction between setting and the prognostic factor using regression models. Between-setting differences in outcome in high-risk and low-risk subgroups, formed by single prognostic factors, were assessed in similar models adjusted for a propensity score to take baseline differences between settings into account.

RESULTS

Prognostic factors were generally associated more strongly with outcomes in general practice compared with chiropractic practice. The difference was statistically significant for general health, duration of pain, and musculoskeletal comorbidity. After propensity score adjustment, differences in outcomes between settings were insignificant, but negative prognostic factors tended to be less influential in chiropractic practice except for leg pain and depression, which tended to have less negative impact in general practice.

CONCLUSION

Known prognostic factors related differently to outcomes in the 2 settings, suggesting that some subgroups of patients might benefit more from one setting than the other.

An App-Delivered Self-Management Program for People With Low Back Pain: Protocol for the selfBACK Randomized Controlled Trial

BACKGROUND

Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP.

OBJECTIVE

The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP.

METHODS

This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months.

RESULTS

The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020.

CONCLUSIONS

This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14720.

Back beliefs in patients with low back pain: a primary care cohort study

Background

The Back Belief Questionnaire (BBQ) measures beliefs about negative consequences of back pain. The aim of this study was to describe the back beliefs of a large clinical population with low back pain (LBP), to investigate the associations between back beliefs and patient characteristics when care-seeking, and between on-going pain and back beliefs at follow up.

Methods

Patients aged over 18, consulting with LBP with or without radicular pain of all symptom durations, were recruited from chiropractic clinics. The BBQ was completed on the first visit and at 3- and 12-month follow-ups. Sociodemographic- and symptom-related questions were answered at baseline. A BBQ sum score was calculated at all three time points, and linear regression was used to analyse the cross-sectional association between baseline patient characteristics and BBQ scores. Wilcoxon signed-rank test was used to test differences in BBQ scores for patients with and without on-going LBP at 3- and 12-months follow up.

Results

The baseline population consisted of 2295 participants. The median BBQ sum scores at baseline, 3 and 12 months had interquartile ranges of 33 [29–36], 33 [29–37], and 31 [27–35] respectively. Patient characteristics and symptoms were associated with baseline BBQ scores (p < 0.05), but most association were weak. The strongest association was with severe disability (4.0 points (95% CI 3.3–4.6) lower BBQ than no disability). Negative beliefs were related to more severe LBP at baseline and with on-going pain at follow up.

Conclusion

At a population level, back beliefs were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common. Studies exploring individual patterns of back beliefs and associations with clinical outcomes over time are recommended.

Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks

STUDY DESIGN

A prospective observational study.

OBJECTIVE

To externally validate the prediction model developed by Schellingerhout and colleagues predicting global perceived effect at 12 weeks in patients with neck pain and to update and internally validate the updated model.

SUMMARY OF BACKGROUND DATA

Only one prediction model for neck pain has undergone some external validation with good promise. However, the model needs testing in other populations before implementation in clinical practice.

METHODS

Patients with neck pain (n = 773) consulting Norwegian chiropractors were followed for 12 weeks. Parameters from the original prediction model were applied to this sample for external validation. Subsequently, two random samples were drawn from the full study sample. One sample (n = 436) was used to update the model; by recalibration, removing noninformative covariates, and adding new possible predictors. The updated model was tested in the other sample (n = 303) using stepwise logistic regression analysis. Main outcomes for performance of models were discrimination and calibration plots.

RESULTS

Three hundred seventy patients (47%) in the full study sample reported persistent pain at 12 weeks. The performance of the original model was poor, area under the receiver operating characteristics curve was 0.55 with a Confidence Interval of 0.51-0.59. The updated model included Radiating pain to shoulder and/or elbow, education level, physical activity, consultation-type (first- time, follow-up or maintenance consultation), expected course of neck pain, previous course of neck pain, number of pain sites, and the interaction term Physical activity##Number of pain sites. The area under the receiver operating characteristics curve was 0.65 with a 95% Confidence Interval of 0.58-0.71 for the updated model.

CONCLUSION

The predictive accuracy of the original model performed insufficiently in the sample of patients from Norwegian chiropractors and the model is therefore not recommended for that setting. Only one predictor from the original model was retained in the updated model, which demonstrated reasonable good performance predicting outcome at 12 weeks. Before considering clinical use, a new external validation is required.

LEVEL OF EVIDENCE

3.

Contrasting real time quantitative measures (weekly SMS) to patients' retrospective appraisal of their one-year's course of low back pain; a probing mixed-methods study

Background

Due to the recurrent nature of low back pain (LBP), the traditional concepts of cure and recovery are challenged, and investigating the course rather than status at fixed time-points may help us understand prognosis as well as treatment effect. However, methods of frequent measuring still need development and validation. Therefore, this study aims to evaluate the agreement between continuous, quantitative self-assessment (weekly SMS) of the course of LBP over a one-year period and qualitatively derived retrospective patient self-appraisal of the same time-period.

Methods

Participants were 32 subjects with LBP from primary care. The quantitative measures consisted of weekly SMS questions for one-year about pain intensity, days with LBP, and activity limitations for that week. For each subject, the weekly responses were graphed and categorized into categories based on intensity, variation and overall change patterns. Qualitative measures were based on semi-structured telephone interviews one-year after a consultation for LBP, where two coders independently categorized the self-appraisal of LBP course into the same predefined categories as the SMS-based trajectories. Furthermore, patients' perceived overall recovery was related to variation patterns from SMS track.

Results

There was perfect agreement for 48% in the pain intensity domain, 53% in the variation domain and 63% in the change pattern domain. Most of the discordant cases were classified in neighboring categories with the majority relating to fluctuating patterns. The self-perceived overall recovery status seemed to be reflected quite well by the quantitative measures of pain intensity and days with pain in this study.

Conclusion

This study shows that a real time quantitative measure (weekly SMS) and the patient's retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient's ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.

Are frequent measurements in back pain research harmful? Two comparisons of back pain in groups with or without frequent follow-up

Background

Frequent measures are becoming increasingly used to evaluate the course of spinal pain. However, it is not known whether this type of continuous follow-up in itself has implications for people’s experience of pain. Therefore this article examines a potential impact of frequent follow-up using SMS reporting on the report of pain, based on results from two previous studies of spinal pain.

Methods

We examined two sets of cohorts, where each set was comparable in all other aspects, but one cohort in each set had been followed with weekly SMS-questions about the presence of spinal pain for 6 years and 1 year, respectively, whereas the other cohort had not answered any questions for research purposes before. At the end of the follow-up period, two cohorts, consisting of pupils from 5th and 6th grade, completed the Young Spine Questionnaire about spinal pain, one cohort in 2010 and the other in 2014. The other set of cohorts, consisting of low back pain patients in primary care, completed an extensive questionnaire about their back pain (2011 to 2013).

Results

In both sets of cohorts there was a statistically significant difference in pain intensity with the pupils/patients who had been subject to frequent follow-up over long periods of time reporting lower intensity of pain. Other differences were small and not statistically significant.

Conclusion

Since the data were not optimally suited for the purpose of these analyses, the results should obviously be interpreted with caution, but they do not support a theory about increased attention leading to increased awareness, which in turn will lead to increased pain. On the contrary, participants reported lower levels of pain when belonging to the samples that had been subject to frequent follow-up by SMS-track over long periods of time.

Does a Diagnostic Classification Algorithm Help to Predict the Course of Low Back Pain? A Study of Danish Chiropractic Patients With 1-Year Follow-up

BACKGROUND

A diagnostic classification algorithm, "the Petersen classification," consisting of 12 categories based on a standardized examination protocol, was developed for the primary purpose of identifying clinically homogeneous subgroups of individuals with low back pain (LBP).

OBJECTIVES

To investigate whether a diagnostic classification algorithm is associated with activity limitation and LBP intensity at follow-up assessments of 2 weeks, 3 months, and 1 year, and whether the algorithm improves outcome prediction when added to a set of known predictors.

METHODS

This was a prospective observational study of 934 consecutive adult patients with new episodes of LBP who were visiting chiropractic practices in primary care and categorized according to the Petersen classification. Outcomes were disability and pain intensity measured with questionnaires at 2 weeks and 3 months, and 1-year trajectories of LBP based on weekly responses to text messages. Associations were analyzed with linear and logistic regression models. In a subgroup of patients, the numbers of visits to primary and secondary care were described.

RESULTS

The Petersen classification was statistically significantly associated with all outcomes (P<.001) but explained very little of the variance (R² = 0.00-0.05). Patients in the nerve root involvement category had the most pain and activity limitation and the most visits to primary and secondary care. Patients in the myofascial pain category were the least affected.

CONCLUSION

The Petersen classification was not helpful in determining individual prognosis in patients with LBP receiving usual care in chiropractic practice. However, patients should be examined for potential nerve root involvement to improve prediction of likely outcomes.

LEVEL OF EVIDENCE

Prognosis, level 1b. J Orthop Sports Phys Ther 2018;48(11):837-846. Epub 8 May 2018. doi:10.2519/jospt.2018.8083.

Predicting pain recovery in patients with acute low back pain: Updating and validation of a clinical prediction model

BACKGROUND

The prognosis of acute low back pain (LBP) is typically good; however, there is substantial variation in individual patient's outcomes. We recently developed a prediction model that was able to predict the likelihood of pain recovery in patients with acute LBP who continue to have pain approximately 1 week after initially seeking care. The aims of the current study were to (a) re-categorize the variables in the developmental dataset to be able to validate the model in the validation dataset; (b) refit the existing model in the developmental dataset; and (c) validate the model in the validation dataset.

METHODS

The validation study sample comprised 737 patients with acute LBP, with a pain score of ≥2/10, 1 week after initially seeking care and with duration of current episode of ≤4 weeks. The primary outcome measure was days to pain recovery. Some of the variables from the development dataset were re-categorized prior to refitting the existing model in the developmental dataset using Cox regression. The performance (calibration and discrimination) of the prediction model was then tested in the validation dataset.

RESULTS

Three variables of the development dataset were re-categorized. The performance of the prediction model with re-categorized variables in the development dataset was good (C-statistic = 0.76, 95% CI 0.70-0.82). The discrimination of the model using the validation dataset resulted in a C-statistic of 0.71 (95% CI 0.63-0.78). The calibration for the validation sample was acceptable at 1 month. However, at 1 week the predicted proportions within quintiles tended to overestimate the observed recovery proportions, and at 3 months, the predicted proportions tended to underestimate the observed recovery proportions.

CONCLUSIONS

The updated prediction model demonstrated reasonably good external validity and may be useful in practice, but further validation and impact studies in relevant populations should be conducted.

SIGNIFICANCE

A clinical prediction model based on five easily collected variables demonstrated reasonable external validity. The prediction model has the potential to inform patients and clinicians of the likely prognosis of individuals with acute LBP but requires impact studies to assess its clinical usefulness.

The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided

Background

Previous research has investigated utilization rates, who sees chiropractors, for what reasons, and the type of care that chiropractors provide. However, these studies have not been comprehensively synthesized. We aimed to give a global overview by summarizing the current literature on the utilization of chiropractic services, reasons for seeking care, patient profiles, and assessment and treatment provided.

Methods

Systematic searches were conducted in MEDLINE, CINAHL, and Index to Chiropractic Literature using keywords and subject headings (MeSH or ChiroSH terms) from database inception to January 2016. Eligible studies: 1) were published in English or French; 2) were case series, descriptive, cross-sectional, or cohort studies; 3) described patients receiving chiropractic services; and 4) reported on the following theme(s): utilization rates of chiropractic services; reasons for attending chiropractic care; profiles of chiropractic patients; or, types of chiropractic services provided. Paired reviewers independently screened all citations and data were extracted from eligible studies. We provided descriptive numerical analysis, e.g. identifying the median rate and interquartile range (e.g., chiropractic utilization rate) stratified by study population or condition.

Results

The literature search retrieved 14,149 articles; 328 studies (reported in 337 articles) were relevant and reported on chiropractic utilization (245 studies), reason for attending chiropractic care (85 studies), patient demographics (130 studies), and assessment and treatment provided (34 studies). Globally, the median 12-month utilization of chiropractic services was 9.1% (interquartile range (IQR): 6.7%-13.1%) and remained stable between 1980 and 2015. Most patients consulting chiropractors were female (57.0%, IQR: 53.2%-60.0%) with a median age of 43.4 years (IQR: 39.6-48.0), and were employed (median: 77.3%, IQR: 70.3%-85.0%). The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7%, IQR: 43.0%-60.2%), neck pain (22.5%, IQR: 16.3%-24.5%), and extremity problems (10.0%, IQR: 4.3%-22.0%). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3%, IQR: 55.4%-91.3%), soft-tissue therapy (35.1%, IQR: 16.5%-52.0%), and formal patient education (31.3%, IQR: 22.6%-65.0%).

Conclusions

This comprehensive overview on the world-wide state of the chiropractic profession documented trends in the literature over the last four decades. The findings support the diverse nature of chiropractic practice, although common trends emerged.

Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain

Objective To compare the duration of financial compensation and the occurrence of a second episode of compensation of workers with occupational back pain who first sought three types of healthcare providers. Methods We analyzed data from a cohort of 5511 workers who received compensation from the Workplace Safety and Insurance Board for back pain in 2005. Multivariable Cox models controlling for relevant covariables were performed to compare the duration of financial compensation for the patients of each of the three types of first healthcare providers. Logistic regression was used to compare the occurrence of a second episode of compensation over the 2-year follow-up period. Results Compared with the workers who first saw a physician (reference), those who first saw a chiropractor experienced shorter first episodes of 100 % wage compensation (adjusted hazard ratio [HR] = 1.20 [1.10-1.31], P value < 0.001), and the workers who first saw a physiotherapist experienced a longer episode of 100 % compensation (adjusted HR = 0.84 [0.71-0.98], P value = 0.028) during the first 149 days of compensation. The odds of having a second episode of financial compensation were higher among the workers who first consulted a physiotherapist (OR = 1.49 [1.02-2.19], P value = 0.040) rather than a physician (reference). Conclusion The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.

Latent class analysis derived subgroups of low back pain patients - do they have prognostic capacity?

BACKGROUND

Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the 'comparator variables').

METHODS

This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above.

RESULTS

The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants' recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%-6.9% for pain intensity and from 6.8%-20.3% for disability, and highest at the 2 weeks follow-up.

CONCLUSIONS

Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

How can latent trajectories of back pain be translated into defined subgroups?

Background

Similar types of trajectory patterns have been identified by Latent Class Analyses (LCA) across multiple low back pain (LBP) cohorts, but these patterns are impractical to apply to new cohorts or individual patients. It would be useful to be able to identify trajectory subgroups from descriptive definitions, as a way to apply the same definitions of mutually exclusive subgroups across populations. In this study, we investigated if the course trajectories of two LBP cohorts fitted with previously suggested trajectory subgroup definitions, how distinctly different these subgroups were, and if the subgroup definitions matched with LCA-derived patterns.

Methods

Weekly measures of LBP intensity and frequency during 1 year were available from two clinical cohorts. We applied definitions of 16 possible trajectory subgroups to these observations and calculated the prevalence of the subgroups. The probability of belonging to each of eight LCA-derived patterns was determined within each subgroup. LBP intensity and frequency were described within subgroups and the subgroups of ‘fluctuating’ and ‘episodic’ LBP were compared on clinical characteristics.

Results

All of 1077 observed trajectories fitted with the defined subgroups. ‘Severe episodic LBP’ was the most frequent pattern in both cohorts and ‘ongoing LBP’ was almost non-existing. There was a clear relationship between the defined trajectory subgroups and LCA-derived trajectory patterns, as in most subgroups, all patients had high probabilities of belonging to only one or two of the LCA patterns. The characteristics of the six defined subgroups with minor LBP were very similar. ‘Fluctuating LBP’ subgroups were significantly more distressed, had more intense leg pain, higher levels of activity limitation, and more negative expectations about future LBP than ‘episodic LBP’ subgroups.

Conclusion

Previously suggested definitions of LBP trajectory subgroups could be readily applied to patients’ observed data resulting in subgroups that matched well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with minor LBP. Stable levels of LBP were almost not observed and we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.

Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain

Background

Low back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.

Method

Adult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.

Results

The study comprised 1271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.

Conclusion

The QTFC identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals’ outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1495-3) contains supplementary material, which is available to authorized users.

Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain

Background

Heterogeneity in patients with low back pain (LBP) is well recognised and different approaches to subgrouping have been proposed. Latent Class Analysis (LCA) is a statistical technique that is increasingly being used to identify subgroups based on patient characteristics. However, as LBP is a complex multi-domain condition, the optimal approach when using LCA is unknown. Therefore, this paper describes the exploration of two approaches to LCA that may help improve the identification of clinically relevant and interpretable LBP subgroups.

Methods

From 928 LBP patients consulting a chiropractor, baseline data were used as input to the statistical subgrouping. In a single-stage LCA, all variables were modelled simultaneously to identify patient subgroups. In a two-stage LCA, we used the latent class membership from our previously published LCA within each of six domains of health (activity, contextual factors, pain, participation, physical impairment and psychology) (first stage) as the variables entered into the second stage of the two-stage LCA to identify patient subgroups. The description of the results of the single-stage and two-stage LCA was based on a combination of statistical performance measures, qualitative evaluation of clinical interpretability (face validity) and a subgroup membership comparison.

Results

For the single-stage LCA, a model solution with seven patient subgroups was preferred, and for the two-stage LCA, a nine patient subgroup model. Both approaches identified similar, but not identical, patient subgroups characterised by (i) mild intermittent LBP, (ii) recent severe LBP and activity limitations, (iii) very recent severe LBP with both activity and participation limitations, (iv) work-related LBP, (v) LBP and several negative consequences and (vi) LBP with nerve root involvement.

Conclusions

Both approaches identified clinically interpretable patient subgroups. The potential importance of these subgroups needs to be investigated by exploring whether they can be identified in other cohorts and by examining their possible association with patient outcomes. This may inform the selection of a preferred LCA approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1411-x) contains supplementary material, which is available to authorized users.

Workers' characteristics associated with the type of healthcare provider first seen for occupational back pain

BACKGROUND

Few studies have compared the factors that drive patients' decision to choose a chiropractor, physician or physiotherapist as their first healthcare provider for occupational back pain. The purpose of this study is to identify characteristics associated with the choice of first healthcare provider seen for acute uncomplicated occupational back pain.

METHODS

We analyzed data collected by the Workplace Safety and Insurance Board from a cohort of workers with compensated back pain in 2005 in Ontario (Canada). Multivariable logistic regression models were created to identify factors associated with the type of first healthcare provider seen (chiropractor, physician, or physiotherapist). Adjustments to the final models were evaluated using the area under the receiver-operating characteristics curve (ROC).

RESULTS

According to the 5520 analyzed claims, 85.3 % of the patients saw a physician, 11.4 % saw a chiropractor, and 3.2 % saw a physiotherapist. Longer job tenure (odds ratio (OR) = 1.02, P = 0.004), higher gross personal income (OR = 1.06, P = 0.018), mixed-manual job (OR = 1.35, P = 0.004) and previous similar injury (OR = 1.60, P < 0.001) increased the odds of seeing a chiropractor rather than a physician, while the size of the community (>500,000 inhabitants) and the availability of an early return to work program in the workplace (OR = 0.77, P = 0.035) decreased it. The odds of seeing a physiotherapist rather than a physician increased with increasing age (OR = 1.19, P = 0.019), previous similar injury (OR = 1.71, P < 0.001) and severity of injury (OR = 2.03, P = 0.010). Increased age (OR = 1.28, P = 0.008) and size of community (>1,500,000 inhabitants; OR = 2.58, P = 0.002) increased the odds of seeing a physiotherapist rather than a chiropractor, while holding a mixed-manual job significantly decreased those odds (OR = 0.63, P = 0.044). The area under the ROC curve of our multivariable models varied from 0.62 to 0.64.

CONCLUSION

The type of first healthcare provider sought for occupational back pain is influenced by injury-and work-related factors and by the worker's age, income and community size. Contrary to previous studies, the workers who first sought a physician did not have higher odds of having a severe injury.

Severity of back pain may influence choice and order of practitioner consultations across conventional, allied and complementary health care: a cross-sectional study of 1851 mid-age Australian women

BACKGROUND

Back pain is a common, disabling and costly disorder for which patients often consult with a wide range of health practitioners. Unfortunately, no research to date has directly examined the association between the severity of back pain and back pain sufferers' choice of whom and in what order to consult different health practitioners.

METHODS

This is a sub-study of the large nationally representative Australian Longitudinal Study on Women's Health (ALSWH). The mid-age cohort women (born 1946-51, n = 13,715) of the ALSWH were recruited from the Australian national Medicare database in 1996. These women have been surveyed six time, with survey 6 being conducted in 2010 (n = 10,011). Mid-age women (n = 1851) who in 2010 had sought help from a health care practitioner for their back pain were mailed a self-report questionnaire targeting their previous 12 months of health services utilisation, health status and their levels of back pain intensity.

RESULTS

A total of 1620 women were deemed eligible and 1310 (80.9 %) returned completed questionnaires. Mid-age women with back pain visited various conventional, allied health and CAM practitioners for care: 75.6 % consulted a CAM practitioner; 58.4 % consulted a medical doctor; and 54.2 % consulted an allied health practitioner. Women with the most severe back pain sought conventional care from a general practitioner, and those who consulted a general practitioner first had more severe back pain than those who consulted another practitioner first. Following the general practitioner visit, the women with more severe back pain were more likely to be referred to a conventional specialist, and those with less severe back pain were more likely to be referred to a physiotherapist.

CONCLUSIONS

Our findings suggest that women with more severe back pain are likely to visit a conventional practitioner first, whereas women with less severe back pain are likely to explore a range of treatment options including CAM practitioners. The improvement of back pain over time following the various possible sequencing of consultations with different types of health practitioners is a topic with implications for ensuring safe and effective back pain care and worthy of further detailed investigation.

Using existing questionnaires in latent class analysis: should we use summary scores or single items as input? A methodological study using a cohort of patients with low back pain

Background

Latent class analysis (LCA) is increasingly being used in health research, but optimal approaches to handling complex clinical data are unclear. One issue is that commonly used questionnaires are multidimensional, but expressed as summary scores. Using the example of low back pain (LBP), the aim of this study was to explore and descriptively compare the application of LCA when using questionnaire summary scores and when using single items to subgrouping of patients based on multidimensional data.

Materials and methods

Baseline data from 928 LBP patients in an observational study were classified into four health domains (psychology, pain, activity, and participation) using the World Health Organization’s International Classification of Functioning, Disability, and Health framework. LCA was performed within each health domain using the strategies of summary-score and single-item analyses. The resulting subgroups were descriptively compared using statistical measures and clinical interpretability.

Results

For each health domain, the preferred model solution ranged from five to seven subgroups for the summary-score strategy and seven to eight subgroups for the single-item strategy. There was considerable overlap between the results of the two strategies, indicating that they were reflecting the same underlying data structure. However, in three of the four health domains, the single-item strategy resulted in a more nuanced description, in terms of more subgroups and more distinct clinical characteristics.

Conclusion

In these data, application of both the summary-score strategy and the single-item strategy in the LCA subgrouping resulted in clinically interpretable subgroups, but the single-item strategy generally revealed more distinguishing characteristics. These results 1) warrant further analyses in other data sets to determine the consistency of this finding, and 2) warrant investigation in longitudinal data to test whether the finer detail provided by the single-item strategy results in improved prediction of outcomes and treatment response.

Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs

RATIONALE, AIMS AND OBJECTIVE

Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs.

METHODS

A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting.

RESULTS

747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs (OR = 3.46, P = 0.001), advanced imaging (OR = 3.38, P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR = 4.76, P = 0.012) and LBP-related costs (standardized Β = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging (OR = 0.21, P = 0.001) or a surgeon visit (OR = 0.13, P = 0.005) and increased episode of care duration (standardized Β = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs (OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery.

CONCLUSIONS

Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.

Cognitive representations in low back pain in patients receiving chiropractic versus physiotherapy treatment

This study focused on cognitive representations of low back pain patients receiving chiropractic ( n = 213) versus physiotherapy treatment ( n = 125). Variables assessed included satisfaction with care, illness perceptions, beliefs about pain and medicines, attitudes towards doctors and medicine, suffering, adherence and functional incapacity. In the chiropractic treatment, functional incapacity was predicted by painful symptoms, suffering and personal control, and in the physiotherapy treatment by age, pain intensity, positive suffering, care satisfaction, illness identity and medication adherence. The groups differed on all cognitive variables assessed. Interventions should take into consideration cognitive dimensions, across treatment modalities.

Low back pain patients in Sweden, Denmark and the UK share similar characteristics and outcomes: a cross-national comparison of prospective cohort studies

BACKGROUND

Low back pain (LBP) is the world's leading cause of disability and yet poorly understood. Cross-national comparisons may motivate hypotheses about outcomes being condition-specific or related to cultural differences and can inform whether observations from one country may be generalised to another. This analysis of data from three cohort studies explored whether characteristics and outcomes differed between LBP patients visiting chiropractors in Sweden, Denmark and the UK.

METHODS

LBP patients completed a baseline questionnaire and were followed up after 3, 5, 12 and 26 weeks. Outcomes were LBP intensity (0-10 scales) and LBP frequency (0-7 days the previous week). Cohort differences were tested in mixed models accounting for repeated measures. It was investigated if any differences were explained by different baseline characteristics, and interaction terms between baseline factors and nations tested if strength of prognostic factors differed across countries.

RESULTS

The study sample consisted of 262, 947 and 453 patients from Sweden, Denmark and the UK respectively. Patient characteristics were largely similar across cohorts although some statistically significant differences were observed. The clinical course followed almost identical patterns across nations and small observed differences were not present after adjusting for baseline factors. The associations of LBP intensity and episode duration with outcome differed in strength between countries.

CONCLUSIONS

Chiropractic patients with low back pain had similar characteristics and clinical course across three Northern European countries. It is unlikely that culture have substantially different impacts on the course of LBP in these countries and the results support knowledge transfer between the investigated countries.

Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients

Background

Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics.

Methods

In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed).

Results

The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D.

Conclusions

The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different.

Trial registration

Sample A comes from an ongoing trial registered at clinical trials.gov; NCT01539863, February 22, 2012.

Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain. A latent class analysis of longitudinal data

BACKGROUND CONTEXT

The clinical presentation and outcome of patients with nonspecific low back pain (LBP) are very heterogeneous and may be better understood by the recognition of reproducible subgroups. One approach to subgrouping is the identification of clinical course patterns (trajectories). However, it has been unclear how dependent these trajectories are on the analytical model used and the pain characteristics included.

PURPOSE

To identify LBP trajectories using LBP intensity and frequency measured once a week over 1 year and compare the results obtained using different analytical approaches.

STUDY DESIGN

A prospective observational cohort study.

PATIENT SAMPLE

Patients presenting with nonspecific LBP to general practitioners and chiropractors.

OUTCOME MEASURES

Weekly self-report of LBP intensity (0-10) and the number of LBP days measured by short message service cell phone questions over a 1-year follow-up period.

METHODS

Latent class analysis was used to identify the trajectories of LBP and 12 different analytical models were compared. The study was a component of a broader study funded by an unrestricted grant from the Danish Chiropractors' Foundation (USD 370,000).

RESULTS

The study included 1,082 patients. The 12 models resulted in 5 to 12 subgroups, with a number of trajectories stable across models that differed on pain intensity, number of LBP days, and shape of trajectory.

CONCLUSIONS

The clinical course of LBP is complex. Most primary care patients do not become pain-free within a year, but only a small proportion reports constant severe pain. Some distinct patterns exist which were identified independently of the way the outcome was modeled. These patterns would not be revealed by using the simple summary measures traditionally applied in LBP research or when describing a patient's pain history only in terms of duration. The appropriate number of subgroups will depend on the intended purpose of subgrouping.

Retention in physically demanding jobs of individuals with low back pain: study protocol for a randomised controlled trial

Background

Low back pain is prevalent and is a frequent cause of disability and sick leave among working adults. Individuals with low back pain often consult general practice or other health care providers which often results in a unilateral intervention focussed on their symptoms. Employment is associated with physical and mental well-being, so, patients may benefit from an early additional occupational medicine intervention. For individuals with physically demanding jobs it can be especially challenging to retain their jobs. The aim of the ‘GoBack trial' is to develop and evaluate the efficacy and feasibility of an occupational medicine intervention for individuals with low back pain in physically demanding jobs.

Methods/design

We will conduct a randomised controlled trial enrolling 300 participants with difficulty in maintaining physically demanding jobs due to low back pain for a current period of 2 to 4 weeks. Participants will be randomised and stratified according to their age and gender before being allocated in a 1:1 ratio to either control or additional occupational medicine intervention. Both groups will receive conventional treatment for their low back pain during the study. All participants will be thoroughly assessed for causes of low back pain and potential prognostic factors by questionnaires, clinical specialist assessments and magnetic resonance imaging (MRI) scans of the lumbar spine. Primary outcome is the accumulated duration of self-assessed sick leave (in days) due to low back pain during 6 months from baseline. Secondary outcomes include general self-rated back pain, disability and screening for potential prognostic factors: fear avoidance behaviour, disability, health status and degenerative MRI findings. For tertiary purposes selected outcomes will also be assessed after 1 and 2 years from baseline.

Discussion

Many guidelines exist for the management of low back pain, but they provide limited guidance on occupational aspects. The findings from this randomised trial will provide high-quality evidence for the efficacy and feasibility of an occupational medicine intervention model for individuals with low back pain in physically demanding jobs.

Trial registration

This trial was registered with ClinicalTrials.gov (identifier: NCT02015572) on 29 November 2013.

The prognostic ability of the STarT Back Tool was affected by episode duration

PURPOSE

The prognostic ability of the STarT Back Tool (SBT) reportedly varies, but the factors affecting this are unclear. This study investigated the influences of care setting (chiropractic, GP, physiotherapy, spine centre), episode duration (0-2, 3-4, 4-12, >12 weeks), and outcome time period (3, 6, 12 months) on SBT prognostic ability.

METHODS

This was a secondary analysis of data from three primary care cohorts [chiropractic (n = 416), GP (n = 265), and physiotherapy (n = 200) practices] and one cohort from a secondary care outpatient spine centre (n = 974) in Denmark. Care pathways were not systematically affected by SBT risk subgroup (non-stratified care). Using generalised estimating equations, we investigated statistical interactions between SBT risk subgroups and potentially influential factors on the prognostic ability of the SBT subgroups, when Roland Morris Disability Questionnaire scores were the outcome.

RESULTS

SBT risk subgroup, age, care setting, and episode duration were all independent prognostic factors. The only investigated factor that modified the prognostic ability of the SBT subgroups was episode duration.

CONCLUSIONS

These results indicate that the prognostic ability of the SBT in these non-stratified care settings was unaffected by care setting on its own. However, the prognosis of patients is affected by diverse clinical characteristics that differ between patient populations, many of which are not assessed by the SBT. When controlling for some of those factors and testing potential interactions, the results showed that only episode duration affected the SBT prognostic ability and, specifically, that the SBT was less predictive in very acute patients (<2 weeks duration).