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Turner KM, Huntley A, Yardley T, Dawson S, Dawson S. Defining usual care comparators when designing pragmatic trials of complex health interventions: a methodology review. Trials 2024; 25:117. [PMID: 38342896 PMCID: PMC10860249 DOI: 10.1186/s13063-024-07956-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Pragmatic trials evaluating complex health interventions often compare them to usual care. This comparator should resemble care as provided in everyday practice. However, usual care can differ for the same condition, between patients and practitioners, across clinical sites and over time. Heterogeneity within a usual care arm can raise methodological and ethical issues. To address these it may be necessary to standardise what usual care entails, although doing so may compromise a trial's external validity. Currently, there is no guidance detailing how researchers should decide the content of their usual care comparators. We conducted a methodology review to summarise current thinking about what should inform this decision. METHODS MEDLINE, Embase, CINAHL and PsycINFO were searched from inception to January 2022. Articles and book chapters that discussed how to identify or develop usual care comparators were included. Experts in the field were also contacted. Reference lists and forward citation searches of included articles were screened. Data were analysed using a narrative synthesis approach. RESULTS One thousand nine hundred thirty records were identified, 1611 titles and abstracts screened, 112 full texts screened, and 16 articles included in the review. Results indicated that the content of a usual care comparator should be informed by the aims of the trial, existing care practices, clinical guidelines, and characteristics of the target population. Its content should also be driven by the trial's requirements to protect participants, inform practice, and be methodologically robust, efficient, feasible and acceptable to stakeholders. When deciding the content of usual care, researchers will need to gather information about these drivers, balance tensions that might occur when responding to different trial objectives, and decide how usual care will be described and monitored in the trial. DISCUSSION When deciding the content of a usual care arm, researchers need to understand the context in which a trial will be implemented and what the trial needs to achieve to address its aim and remain ethical. This is a complex decision-making process and trade-offs might need to be made. It also requires research and engagement with stakeholders, and therefore time and funding during the trial's design phase. TRIAL REGISTRATION PROSPERO CRD42022307324.
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Affiliation(s)
- Katrina M Turner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Alyson Huntley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tom Yardley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Madsen SD, Morsø L, Vach W, Andersen MK, Lykkegaard J, Schiøttz-Christensen B, Stochkendahl MJ. Exploring usual care for patients with low back pain in primary care: a cross-sectional study of general practitioners, physiotherapists and chiropractors. BMJ Open 2023; 13:e071602. [PMID: 37648390 PMCID: PMC10471879 DOI: 10.1136/bmjopen-2023-071602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 08/04/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES To explore the elements and composition of care provided by general practitioners (GPs), physiotherapists (PTs) and chiropractors (DCs) to patients with low back pain (LBP). DESIGN Observational study. SETTING Primary care setting, Denmark. PARTICIPANTS Primary care clinicians (GPs, PTs and DCs) in the Region of Southern Denmark were invited to register consecutive adult patient visits with LBP as the primary complaint. PRIMARY OUTCOME MEASURES Clinicians reported care elements provided to patients with LBP. Elements varied due to professional differences (eg, prescriptive rights). Data were descriptively analysed, on group and individual levels, for frequency and combination of care elements, and practice patterns were explored with latent class analysis. RESULTS The clinicians (33 GPs, 67 PTs and 43 DCs with a median experience of 15 years and 59% were females) registered 3500 patient visits. On average, the visits involved patients aged 51 years, and 51% were with females. The frequencies of common care elements across professions were information (42%-56% of visits between professions) and advice (56%-81%), while other common elements for GPs were pain medication (40%) and referrals to PTs (36%), for PTs, use of exercises (81%) and for DCs, use of manual therapy (96%). Substantial variation was observed within professions and distinct practice patterns, with different focuses of attention to information and advice versus exercise and manual therapy, were identified for PTs and DCs. CONCLUSIONS These data indicate substantial variation in the care elements provided by GPs, PTs and DCs to LBP patients. The compositions of care and practice patterns identified challenge the understanding of usual care as a uniform concept and professions as homogeneous groups. Strategic use of particular care elements in different parts of treatment courses is indicated. Longitudinal data and qualitative enquiry are needed to assess if or how care is tailored to individual patients.
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Affiliation(s)
- Simon Dyrløv Madsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Lars Morsø
- Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, OPEN Research Unit, University of Southern Denmark, Odense, Denmark
| | - Werner Vach
- Basel Academy for Quality and Research in Medicine, Basel, Switzerland
| | - Merethe Kirstine Andersen
- Faculty of Health Sciences, Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Faculty of Health Sciences, Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Berit Schiøttz-Christensen
- Faculty of Health Sciences, Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Mette Jensen Stochkendahl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
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Petersson EL, Forsén E, Björkelund C, Hammarbäck L, Hessman E, Weineland S, Svenningsson I. Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review. J Affect Disord 2023; 326:1-10. [PMID: 36708952 DOI: 10.1016/j.jad.2023.01.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care. METHOD A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022. RESULTS The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU. LIMITATIONS The limitations were that only studies published in English were included. CONCLUSIONS The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.
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Affiliation(s)
- E-L Petersson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - E Forsén
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - C Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - L Hammarbäck
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - E Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - S Weineland
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden; Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - I Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden.
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Demont A, Benaïssa L, Recoque V, Desmeules F, Bourmaud A. Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France. PLoS One 2022; 17:e0274021. [PMID: 36067139 PMCID: PMC9447922 DOI: 10.1371/journal.pone.0274021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives
To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.
Methods
This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.
Results
Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).
Conclusions
We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.
Trial registration
ClinicalTrials.gov: NCT04177121
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Affiliation(s)
- Anthony Demont
- Université Paris Cité, Inserm, ECEVE, Paris, France
- AP-HP, Hôpital Robert Debré, Paris, France
- * E-mail:
| | - Leila Benaïssa
- Physiotherapy School, University of Orléans, Orléans, France
| | | | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada
| | - Aurélie Bourmaud
- Université Paris Cité, Inserm, ECEVE, Paris, France
- AP-HP, Hôpital Robert Debré, Paris, France
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Walker-Bone K, Storkey H, Peacock J, Ellis B, Ly M, Hill J, O’Malley J. Quantifying the population burden of musculoskeletal disorders, including impact on sickness absence: analysis of national Scottish data. Rheumatol Adv Pract 2022; 6:rkac030. [PMID: 35591902 PMCID: PMC9113281 DOI: 10.1093/rap/rkac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Musculoskeletal disorders (MSDs) account for the greatest burden of years lived with disability globally. To prevent disability, good-quality services need to be commissioned, appropriate for local need. We analysed data collected systematically from a new musculoskeletal service serving 70% of the population of Scotland to evaluate: age- and sex-specific occurrence; anatomical distribution; and impact and effect on work ability. Methods A new centralized telephone-based triage for people with musculoskeletal disorders was set up in Scotland in 2015. Available to most of the population aged >16 years (>3 million people), data were collected systematically into a database detailing: anatomical site, nature of onset, duration, impact/risk (modified STarT score), deprivation level and, for those in employment, sickness absence. Results Data were available from 219 314 new callers, 2015–18. Calls were more frequently from women (60%), increased with age until the eighth decade, and 66% reported symptoms that had been present for >6 weeks. Callers were more likely to be living in more deprived areas in each age band between 20 and 64 years and tended to have higher-impact symptoms. The majority (53%) of callers were in employment, and 19% of these were off sick because of their symptoms. Sickness absence was more common among those with highest impact/risk scores from deprived areas with more acute symptoms. Discussion Large-scale systematic data collection for MSDs emphasizes the size and impact of the burden among adults aged >16 years. A socio-economic gradient is evident in terms of prevalence and impact of MSDs, particularly for sickness absence.
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Affiliation(s)
- Karen Walker-Bone
- MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | | | | | - Benjamin Ellis
- Versus Arthritis, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Jonathan Hill
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, UK
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Proposing six criteria to improve reproducibility of “usual care” interventions in back pain trials: a systematic review. J Clin Epidemiol 2022; 149:227-235. [DOI: 10.1016/j.jclinepi.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/25/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
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Powell PA, Roberts J, Gabbay M, Consedine NS. Care Starts at Home: Emotional State and Appeals to Altruism may Reduce Demand for Overused Health Services in the UK. Ann Behav Med 2021; 55:356-368. [PMID: 32964915 DOI: 10.1093/abm/kaaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Overuse of unnecessary services, screening tests, and treatments is an ongoing problem for national health care systems. Overuse is at least partly driven by patient demand. PURPOSE This study examined whether altering patients' emotional state and appealing to patient altruism would reduce demand for three commonly overused UK health services. METHODS In an online experiment, 1,267 UK volunteers were randomized to anxiety, compassion, or neutral conditions before viewing three overuse vignettes. In each vignette, use of the health service was recommended against by the doctor and participants were further randomized to one of three altruism frames, emphasizing the impact of overuse on the self, the self and others locally, or the self and others nationally. Participants rated the likelihood that they would pursue the health service and, assuming that they did not, how long they would be willing-to-wait for it. RESULTS Altruism frame had a small effect on intentions to use the health service. Those in the local or national (vs. self) frame were 4.7 and 6.1 percentage points, respectively, less likely to ask for the service. Emotion induction had no direct effect on outcomes. However, self-reporting higher levels of anxiety or compassion post-induction was associated with a small, greater likelihood in intentions to ask for the health service or willingness-to-wait, respectively. No interactions between frame and emotion were observed. CONCLUSIONS As a low-cost initiative, emphasizing the benefits to the self and local or national communities could be embedded in appeals designed to appropriately reduce health care overuse in the UK.
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Affiliation(s)
- Philip A Powell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Mark Gabbay
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Nathan S Consedine
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
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AlAteeq M, Alseraihi AA, Alhussaini AA, Binhasan SA, Ahmari EA. Plain lumbosacral X-rays for low back pain: Findings correlate with clinical presentation in primary care settings. J Family Med Prim Care 2021; 9:6115-6120. [PMID: 33681049 PMCID: PMC7928145 DOI: 10.4103/jfmpc.jfmpc_1238_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/08/2020] [Accepted: 10/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Low back pain (LBP) is a common disabling condition frequently seen and managed in primary care. LBP is considered to be the most common health problem for which general practitioners order an imaging test. Objective: To correlate radiological findings of plain lumbosacral X-rays with the initial clinical presentation of patients with back pain. Materials and Methods: This is a descriptive cross-sectional retrospective chart review study, conducted for 384 adult patients, with back pain who had plain lumbosacral X-rays, at three primary healthcare centers at King Abdul-Aziz Medical City (KAMC) in Riyadh, Saudi Arabia, in the period from 1 Jan 2017 to 31 Dec 2018. Results: The majority of cases had either normal lumbosacral X-rays (32.8%) or incidental findings that were nonspecific. The most abnormal findings were degenerative changes such as spondylosis (osteophytosis) and narrowing of the intervertebral foraminal space (45.3%). The vast majority of cases of chronic back pain was associated with abnormal findings on a plain lumbosacral X-ray, which constituted most cases with abnormal findings among subjects. Conclusion: Lumbosacral X-ray findings in the vast majority of cases do not correlate with clinical presentation and do not justify routinely ordering imaging studies for nonspecific back pain in a primary care setting.
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Affiliation(s)
- Mohammed AlAteeq
- Family Medicine Department, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdelelah A Alseraihi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulaziz A Alhussaini
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sultan A Binhasan
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Emad A Ahmari
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Corp N, Mansell G, Stynes S, Wynne‐Jones G, Morsø L, Hill JC, van der Windt DA. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain 2021; 25:275-295. [PMID: 33064878 PMCID: PMC7839780 DOI: 10.1002/ejp.1679] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE This systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe. DATABASES AND DATA TREATMENT Comprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up-to-date evidence-based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines. RESULTS Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain-specific subgroups-work-based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain. CONCLUSIONS This review of European CPGs identified a range of mainly non-pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe. SIGNIFICANCE Consensus regarding evidence-based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non-pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back-UP research team will transfer these evidence-based treatment options to an accessible clinician decision support tool for first contact clinicians.
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Affiliation(s)
- Nadia Corp
- Primary Care Centre Versus ArthritisSchool of MedicineKeele UniversityStaffordshireUK
| | - Gemma Mansell
- Primary Care Centre Versus ArthritisSchool of MedicineKeele UniversityStaffordshireUK
- Department of PsychologySchool of Life & Health SciencesAston UniversityBirminghamUK
| | - Siobhán Stynes
- Primary Care Centre Versus ArthritisSchool of MedicineKeele UniversityStaffordshireUK
- Haywood HospitalSpinal Interface ServiceMidlands Partnership Foundation NHS TrustStaffordshireUK
| | - Gwenllian Wynne‐Jones
- Primary Care Centre Versus ArthritisSchool of MedicineKeele UniversityStaffordshireUK
| | - Lars Morsø
- Open Patient data Explorative NetworkDepartment of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Jonathan C. Hill
- Primary Care Centre Versus ArthritisSchool of MedicineKeele UniversityStaffordshireUK
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Hill J, Garvin S, Chen Y, Cooper V, Wathall S, Bartlam B, Saunders B, Lewis M, Protheroe J, Chudyk A, Birkinshaw H, Dunn KM, Jowett S, Oppong R, Hay E, van der Windt D, Mallen C, Foster NE. Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e17939. [PMID: 32442141 PMCID: PMC7381066 DOI: 10.2196/17939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Musculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations. OBJECTIVE This study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care. METHODS This is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain-related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons. RESULTS Trial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020. CONCLUSIONS This trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020. TRIAL REGISTRATION ISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17939.
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Affiliation(s)
- Jonathan Hill
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Stefannie Garvin
- Keele Clinical Trials Unit, Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Ying Chen
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Vincent Cooper
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Simon Wathall
- Keele Clinical Trials Unit, Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | | | - Benjamin Saunders
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Martyn Lewis
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Joanne Protheroe
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Adrian Chudyk
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Hollie Birkinshaw
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Kate M Dunn
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Elaine Hay
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Danielle van der Windt
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Christian Mallen
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Nadine E Foster
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
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Hill JC, Garvin S, Chen Y, Cooper V, Wathall S, Saunders B, Lewis M, Protheroe J, Chudyk A, Dunn KM, Hay E, van der Windt D, Mallen C, Foster NE. Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial. BMC FAMILY PRACTICE 2020; 21:30. [PMID: 32046647 PMCID: PMC7014664 DOI: 10.1186/s12875-019-1074-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Musculoskeletal (MSK) pain from the five most common presentations to primary care (back, neck, shoulder, knee or multi-site pain), where the majority of patients are managed, is a costly global health challenge. At present, first-line decision-making is based on clinical reasoning and stratified models of care have only been tested in patients with low back pain. We therefore, examined the feasibility of; a) a future definitive cluster randomised controlled trial (RCT), and b) General Practitioners (GPs) providing stratified care at the point-of-consultation for these five most common MSK pain presentations. METHODS The design was a pragmatic pilot, two parallel-arm (stratified versus non-stratified care), cluster RCT and the setting was 8 UK GP practices (4 intervention, 4 control) with randomisation (stratified by practice size) and blinding of trial statistician and outcome data-collectors. Participants were adult consulters with MSK pain without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records were tagged and individuals sent postal invitations using a GP point-of-consultation electronic medical record (EMR) template. The intervention was supported by the EMR template housing the Keele STarT MSK Tool (to stratify into low, medium and high-risk prognostic subgroups of persistent pain and disability) and recommended matched treatment options. Feasibility outcomes included exploration of recruitment and follow-up rates, selection bias, and GP intervention fidelity. To capture recommended outcomes including pain and function, participants completed an initial questionnaire, brief monthly questionnaire (postal or SMS), and 6-month follow-up questionnaire. An anonymised EMR audit described GP decision-making. RESULTS GPs screened 3063 patients (intervention = 1591, control = 1472), completed the EMR template with 1237 eligible patients (intervention = 513, control = 724) and 524 participants (42%) consented to data collection (intervention = 231, control = 293). Recruitment took 28 weeks (target 12 weeks) with > 90% follow-up retention (target > 75%). We detected no selection bias of concern and no harms identified. GP stratification tool fidelity failed to achieve a-priori success criteria, whilst fidelity to the matched treatments achieved "complete success". CONCLUSIONS A future definitive cluster RCT of stratified care for MSK pain is feasible and is underway, following key amendments including a clinician-completed version of the stratification tool and refinements to recommended matched treatments. TRIAL REGISTRATION Name of the registry: ISRCTN. TRIAL REGISTRATION NUMBER 15366334. Date of registration: 06/04/2016.
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Affiliation(s)
- J C Hill
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - S Garvin
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - Y Chen
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - V Cooper
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - S Wathall
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - B Saunders
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - M Lewis
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - J Protheroe
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - A Chudyk
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - K M Dunn
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - E Hay
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - D van der Windt
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - C Mallen
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - N E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
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12
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Bienek K, Marnitz U, Seidel W, Seifert C, von Pickardt B, Lindena G. [Interdisciplinary multimodal assessment and risk-tailored pathways for patients with back pain : Prospective evaluation of an integrated healthcare delivery project]. Schmerz 2019; 33:116-127. [PMID: 30560494 DOI: 10.1007/s00482-018-0348-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Back pain is prevalent in the population, sometimes recurrent and may result in everyday and work disabilities. It is often a reason for seeking healthcare support. Analyzing the need of treatment and chronification-risk tailored intervention is a particular demand in healthcare delivery. OBJECTIVES Reducing downstream consequences of back pain (e. g. pain and disability) by using an interdisciplinary multimodal assessment followed by a risk-tailored intervention. METHODS Patients with back pain (n = 1638) underwent assessments based on the German Pain Questionnaire (GPQ) and the diagnostic assessment each by a team comprising a physician, a psychologist and a physiotherapist. They were assessed answering a follow-up questionnaire after 6 and/or 12 months (n = 832) for success criteria sensitive to change as pain, everyday and work disability. RESULTS Patients had on average 62.5 days of work disability and 53.3% had pain up to one year. After assessment, 1447 patients (88.3%) were assigned to receive an intensive interdisciplinary multimodal back pain intervention. Intervention groups were: 120 h of full-time treatment for 4 weeks (n = 1030) or 60 h (n = 224), 48 h part time treatment for 3 months (n = 87), and in-patient hospital treatment for about 17 days (n = 106). The effect sizes of success criteria were large to very large in all treatment groups. CONCLUSIONS Tailored, interdisciplinary and intensive intervention is effective in reducing downstream consequences of back pain. The treatment assignment was based on patient reports (GPQ score) and multidisciplinary assessments (clinical evidence score). Tailored interventions should include sufficient intensity for highly disabled patients. Care integration such as timely communication between the health insurance system, back pain centers and usual healthcare services as well as patient- and process-related documentation are crucial for this intervention.
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Affiliation(s)
- K Bienek
- Rückenzentrum Tagesklinik im Forum Pankow GmbH & Co. KG, Hadlichstraße 19, 13187, Berlin, Deutschland
| | - U Marnitz
- Rückenzentrum Am Markgrafenpark GmbH, Markgrafenstraße 19, 10969, Berlin, Deutschland
- Gelenk- und Rückenzentrum Köpenick GmbH, Freiheit 1, 12555, Berlin, Deutschland
| | - W Seidel
- Klinik für Manuelle Medizin Sana Kliniken Sommerfeld, Waldhausstraße 44, 16766, Kremmen, Deutschland
| | - C Seifert
- Rückenzentrum Reha Vita GmbH Klinik für Gesundheit und Sport, Feigestraße 1, 03046, Cottbus, Deutschland
| | - B von Pickardt
- Rückenzentrum im Reha-Zentrum Teltow, Oderstraße 69, 14513, Teltow, Deutschland
| | - G Lindena
- CLARA Clinical Analysis, Research and Application, Klinische Analyse, Forschung und Anwendung, Clara-Zetkin-Str. 34, 14532, Kleinmachnow, Deutschland.
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13
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Meroni R, Piscitelli D, Ravasio C, Vanti C, Bertozzi L, De Vito G, Perin C, Guccione AA, Cerri CG, Pillastrini P. Evidence for managing chronic low back pain in primary care: a review of recommendations from high-quality clinical practice guidelines. Disabil Rehabil 2019; 43:1029-1043. [PMID: 31368371 DOI: 10.1080/09638288.2019.1645888] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM Chronic low back pain represents a major problem throughout the world which is increasing largely because of the aging world population. Clinical practice Guidelines can be powerful tools for promoting evidence-based practice, as they integrate research findings in order to support decision making. This study aimed to review recommendations for the management of Chronic low Back Pain in primary care based on high-quality recent and recently updated Clinical practice Guidelines. METHODS CINHAL, PubMed, EMBASE, PEDro, Google Scholar, Government websites, Scientific Association websites were searched until April 2019. The retrieved documents underwent several consecutive selection steps: semi-automated duplicate screening, documents selection based on title and abstract screening. Finally, three independent investigators screened the documents for the selected inclusion criteria and reviewed the retrieved documents by means of the AGREE II instrument. RESULTS A total of 3055 records were retrieved, of which 10 Clinical practice Guidelines met the inclusion criteria. The overall quality of these Clinical practice Guidelines was moderately variable. The recommendations of four Clinical practice Guidelines deemed as "excellent" were extracted and summarized. Although we tried to implement the most comprehensive research strategies, some Clinical practice Guidelines may be missing due to publication bias or incomplete indexing. CONCLUSIONS This study showed a partial progress in respect of the methodological quality of the Clinical practice Guidelines. Several AGREE II domains demonstrated low scores, particularly the "applicability" and "monitoring and auditing criteria" are the domains most susceptible to amendments in future.Implications for rehabilitationClinicians should be aware that among recently published/updated clinical practice guidelines for the management of chronic low back pain in primary care only few were deemed to have high quality.Increasing evidence suggests the efficacy for self-management to improve low back pain outcome.Physical treatments are recommended in order to improve low back pain outcome while many physical modalities such as TENS, ultrasound, laser therapy are not.Psychological treatments are recommended and should be included as part of a broader treatment plan.
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Affiliation(s)
- Roberto Meroni
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Zucchi Clinical Institutes, Carate Brianza, Italy
| | - Daniele Piscitelli
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Claudio Ravasio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Carla Vanti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Lucia Bertozzi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Giovanni De Vito
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Cecilia Perin
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Zucchi Clinical Institutes, Carate Brianza, Italy
| | - Andrew A Guccione
- Department of Rehabilitation Science, George Mason University, Fairfax, VA, USA
| | - Cesare G Cerri
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Zucchi Clinical Institutes, Carate Brianza, Italy
| | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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14
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Bienek K, Marnitz U, Seidel W, Seifert C, von Pickardt B, Lindena G. Interdisziplinär-multimodales sektorenübergreifendes Assessment und bedarfsorientierte Steuerung für Patienten mit Rückenschmerzen. MANUELLE MEDIZIN 2019. [DOI: 10.1007/s00337-019-0557-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Delitto A, Patterson CG, Stevans JM, Brennan GP, Wegener ST, Morrisette DC, Beneciuk JM, Freel JA, Minick KI, Hunter SJ, Ephraim PL, Friedman M, Simpson KN, George SZ, Daley KN, Albert MC, Tamasy M, Cash J, Lake DS, Freburger JK, Greco CM, Hough LJ, Jeong JH, Khoja SS, Schneider MJ, Sowa GA, Spigle WA, Wasan AD, Adams WG, Lemaster CM, Mishuris RG, Plumb DL, Williams CT, Saper RB. Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial). Contemp Clin Trials 2019; 82:66-76. [PMID: 31136834 DOI: 10.1016/j.cct.2019.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. METHODS AND STUDY DESIGN The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DISCUSSION The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT. TRIAL REGISTRATION ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.
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Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 4028 Forbes Tower, Pittsburgh, PA 15260, USA.
| | - Charity G Patterson
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Joel M Stevans
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gerard P Brennan
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - David C Morrisette
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Box 100154, UFHSC, Gainesville, FL 32610, USA
| | - Jennifer A Freel
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Kate I Minick
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen J Hunter
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27705, USA
| | - Kelly N Daley
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Michael C Albert
- Johns Hopkins Community Physicians, 6225 Smith Avenue, Baltimore, MD 21209, USA
| | - Marie Tamasy
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jewel Cash
- Boston Medical Center, Boston, MA 02118, USA
| | - D Scott Lake
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Janet K Freburger
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Linda J Hough
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA
| | - Samannaaz S Khoja
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Michael J Schneider
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gwendolyn A Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Wendy A Spigle
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - William G Adams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Chelsey M Lemaster
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Rebecca G Mishuris
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Dorothy L Plumb
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Charles T Williams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
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16
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Carnide N, Hogg-Johnson S, Koehoorn M, Furlan AD, Côté P. Relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers' compensation claimants: a historical cohort study. Occup Environ Med 2019; 76:573-581. [PMID: 31092628 PMCID: PMC6703123 DOI: 10.1136/oemed-2018-105626] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/11/2019] [Accepted: 04/14/2019] [Indexed: 11/17/2022]
Abstract
Objectives To examine and compare whether dispensing of prescription opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) within 8 weeks after a work-related low back pain (LBP) injury is associated with work disability. Methods A historical cohort study of 55 571 workers’ compensation claimants with LBP claims in British Columbia from 1998 to 2009 was conducted using linked compensation, dispensing and healthcare data. Four exposures were constructed to estimate the effect on receipt of benefits and days on benefits 1 year after injury: drug class(es) dispensed, days' supply, strength of opioids dispensed and average daily morphine-equivalent dose. Results Compared with claimants receiving NSAIDs and/or SMRs, the incidence rate ratio (IRR) of days on benefits was 1.09 (95% CI 1.04 to 1.14) for claimants dispensed opioids only and 1.26 (95% CI 1.22 to 1.30) for claimants dispensed opioids with NSAIDs and/or SMRs. Compared with weak opioids only, the IRR for claimants dispensed strong opioids only or strong and weak opioids combined was 1.21 (95% CI 1.12 to 1.30) and 1.29 (95% CI 1.20 to 1.39), respectively. The incident rate of days on benefits associated with each 7-day increase in days supplied of opioids, NSAIDs and SMRs was 10%, 4% and 3%, respectively. Similar results were seen for receipt of benefits, though effect sizes were larger. Conclusions Findings suggest provision of early opioids leads to prolonged work disability compared with NSAIDs and SMRs, though longer supplies of all drug classes are also associated with work disability. Residual confounding likely partially explains the findings. Research is needed that accounts for prescriber, system and workplace factors.
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Affiliation(s)
- Nancy Carnide
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada.,Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Mieke Koehoorn
- Institute for Work and Health, Toronto, Ontario, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea D Furlan
- Institute for Work and Health, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Pierre Côté
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.,Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
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17
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French SD, Green ME, Bhatia RS, Peng Y, Hayden JA, Hartvigsen J, Ivers NM, Grimshaw JM, Booth CM, Rühland L, Norman KE. Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study. BMC Musculoskelet Disord 2019; 20:50. [PMID: 30711002 PMCID: PMC6359752 DOI: 10.1186/s12891-019-2427-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.
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Affiliation(s)
- Simon D French
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada. .,Department of Chiropractic, Macquarie University, Macquarie, NSW, 2109, Australia. .,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
| | - Michael E Green
- Department of Family Medicine, Queen's University, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - R Sacha Bhatia
- Choosing Wisely Canada, Women's College Hospital, University of Toronto, Toronto, ON, Canada.,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Yingwei Peng
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jill A Hayden
- Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Noah M Ivers
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Lucia Rühland
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Kathleen E Norman
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
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18
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Gatchel RJ, Reuben DB, Dagenais S, Turk DC, Chou R, Hershey AD, Hicks GE, Licciardone JC, Horn SD. Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy. THE JOURNAL OF PAIN 2018; 19:837-851. [DOI: 10.1016/j.jpain.2018.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/16/2018] [Accepted: 02/22/2018] [Indexed: 01/13/2023]
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19
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McKelvie S, Hall AM, Richmond HR, Finnegan S, Lasserson D. Improving the rehabilitation of older people after emergency hospital admission. Maturitas 2018; 111:20-30. [PMID: 29673829 DOI: 10.1016/j.maturitas.2018.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/14/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE Older adults are at risk of functional decline during emergency hospital admissions. This review aims to understand which exercise-based interventions are effective in improving function for older adults who experience unplanned admissions. METHODS Database searches identified randomised control trials (RCTs) comparing exercise-based interventions with usual hospital care. The primary outcome was functional status measured by activities of daily living (ADL) scores. Secondary outcomes were length of hospital stay (LOS), mortality and readmissions. Sub-group meta-analyses were conducted on interventions delivered in-hospital only compared with interventions provided both in hospital and after discharge. RESULTS After reviewing 8365 studies, nine were eligible for inclusion. Seven were included in the meta-analysis. Participants from five countries had a mean age of 79 years (1602 participants). Usual care varied considerably and the interventions showed heterogeneity, with different combinations of strengthening, resistance, high-intensity or mobility exercises. There were limited descriptions of exercise intervention delivery and participant adherence. There is low-quality evidence supporting exercise interventions that have both in-hospital and post-discharge components (3 trials, SMD 0.56 (-0.02, 1.13)). Trials involving only in-hospital interventions were inconclusive for functional gains (5 trials, SMD -0.04 (-0.31, 0.22)). CONCLUSIONS Exercise-based rehabilitation for older patients after emergency hospitalisation improves functional ability if the intervention starts in hospital and continues after discharge. No conclusions can be made regarding the effective exercise 'dose' or content. IMPLICATIONS Understanding the components of exercise interventions will improve service planning and delivery. Further studies are needed to understand the effective 'dose' and content of exercise for hospitalised older adults.
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Affiliation(s)
- S McKelvie
- NIHR CLAHRC Oxford, Nuffield Department of Primary Care, Oxford, United Kingdom.
| | - A M Hall
- Faculty of Medicine, Memorial University, Canada; The George Institute for Global Health, University of Oxford, United Kingdom
| | - H R Richmond
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom
| | - S Finnegan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom
| | - D Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
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McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB, Dreger M. Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With Low Back Pain. J Occup Environ Med 2017; 59:e240-e244. [PMID: 29023338 PMCID: PMC5957077 DOI: 10.1097/jom.0000000000001180] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim of this study was to describe the process by which a group of subject matter experts in the area of return to work developed a resource tool to provide clinical decision support (CDS) for primary care clinicians. METHODS A common musculoskeletal disorder, low back pain (LBP), was selected, pertinent literature reviewed, and specific recommendations for action in the clinical setting developed. RESULTS Primary care practitioners (PCPs) are routinely expected to create work activity prescriptions. The knowledge base for a CDS tool that could be embedded in electronic health records has been developed. CONCLUSION Improved clinical support should help prevent and manage work limitations associated with LBP not caused by work. The proposed decision support should reduce administrative burden and stimulate PCPs to explore the role of occupation and its demands on patients.
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Affiliation(s)
- Robert K McLellan
- From the Occupational and Environmental Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr McLellan); The Permanente Medical Group, San Francisco, California (Dr Kownacki); University of Massachusetts Medical School, Sudbury, Massachusetts (Dr Pransky; and ACOEM, Elk Grove Village, Illinois (Ms Dreger)
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21
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Tannor AY. Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based? Ghana Med J 2017; 51:24-29. [PMID: 28959069 DOI: 10.4314/gmj.v51i1.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Abena Y Tannor
- Family Medicine Department, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
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22
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The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain. Scand J Pain 2017; 16:101-104. [DOI: 10.1016/j.sjpain.2017.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 11/21/2022]
Abstract
Abstract
Background and aims
Knowledge, attitudes and beliefs towards low back pain (LBP) can significantly impact a health care provider’s clinical decision making. Several studies have investigated interventions designed to change practitioner attitudes and beliefs towards LBP, however no such studies involving medical students have been identified.
Methods
This study explored medical students ‚ knowledge, attitudes and beliefs towards LBP before and after a brief educational intervention on LBP. Responses from medical students (n = 93) were evaluated before and after a 15-min educational video on back pain. The intervention was developed using Camtasia™ video editor and screen recorder. Knowledge, attitudes and beliefs were measured using the “Modified Back Beliefs Questionnaire”, with items from two previously reported questionnaires on back beliefs. The questionnaire asks participants to indicate their agreement with statements about LBP on a 5-point Likert scale. Preferred responses were based on guidelines for the evidence-based management of LBP. The primary analysis evaluated total score on the nine-inevitability items of the Back Beliefs Questionnaire (“inevitability score”).
Results
Following the brief intervention there was a significant improvement in the inevitability score (post-workshop mean [SD] 20.8 [4.9] vs pre-workshop mean [SD] 26.9 [4.2]; mean difference (MD) 6.1, p < 0.001; lower score more favourable 1) and large improvements in the proportion of students providing correct responses to items on activity (pre: 49% vs post: 79%), bed rest (41% vs 75%), imaging (44% vs 74%) and recovery (25% vs 66%).
Conclusions
After watching the educational video students’ knowledge, beliefs and attitudes towards LBP improved and thus aligned more closely with evidence-based guidelines.
Implications
Medical doctors are at the forefront of managing low back pain in the community, however there is a need to strengthen musculoskeletal education in medical training programmes. The results from this research suggest educational interventions on back pain do not need to be extensive in order to have favourable outcomes on medical students’ knowledge, attitudes and beliefs towards back pain. The translational effects of these changes into clinical practice are not known.
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Turner KM, Percival J, Kessler D, Donovan J. Exploring patients' treatment journeys following randomisation in mental health trials to improve future trial conduct: a synthesis of multiple qualitative data sets. Trials 2017; 18:279. [PMID: 28619121 PMCID: PMC5472926 DOI: 10.1186/s13063-017-2030-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/31/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The way in which pragmatic trials are designed suggests that there are differences between the experiences of participants randomised to usual care and intervention arms. These potential differences relate not only to which treatment participants receive but also how they access and engage with their allocated treatment. Such differences could affect trial results. The aim of this study was to assess whether such differences exist and, if they do, to consider their implications for the design of future trials. METHODS Interview transcripts were sampled from data sets gathered during three qualitative studies, all of which had been nested within large, primary care depression trials. Each study had explored trial participants' views and experiences of treatments received following randomisation. Transcripts from 37 participants were purposefully sampled, 20 of which were from interviews held with individuals allocated to receive usual GP care. Data were analysed thematically. RESULTS There was evidence of differences between trial arms across all three data sets. Intervention participants were willing and able to engage with the treatment to which they had been allocated. Randomisation had led to them embarking upon a clear treatment pathway and receiving care in a context where they felt comfortable discussing their mental health and had sufficient time to do so. Intervention participants also had continuity with and confidence in the practitioners they saw. A few usual-care participants talked about having continuity with and confidence in their GPs. However, most of the usual-care participants reported a reluctance to consult GPs about mental health, difficulties in securing treatment appointments, and little or no changes in care following randomisation. Additionally, most reported a lack of continuity of care and a lack confidence in the treatment available to them. CONCLUSIONS There are important differences between usual-care and intervention arms that go beyond treatment received, and they relate to how participants experience accessing and engaging with their allocated care. As these differences could affect trial results, researchers may want to measure or reduce them in order to fully appreciate or control for the range of factors that might affect treatment outcomes.
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Affiliation(s)
- Katrina M. Turner
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - John Percival
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Epstein-Sher S, Jaffe DH, Lahad A. Are They Complying? Physicians' Knowledge, Attitudes, and Readiness to Change Regarding Low Back Pain Treatment Guideline Adherence. Spine (Phila Pa 1976) 2017; 42:247-252. [PMID: 28207666 DOI: 10.1097/brs.0000000000001714] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional survey of 145 primary care practitioners (PCPs). OBJECTIVE To examine low back pain (LBP) guideline knowledge, readiness to implement (RTI) these guidelines, and LBP attitudes and beliefs among Israeli PCPs and determine whether physician age, guideline familiarity, and medical specialty affect these variables. SUMMARY OF BACKGROUND DATA LBP is a common condition managed primarily by PCPs. Little is known, however, about physician's LBP knowledge, attitudes, and beliefs and how these factors (knowledge, A&B) influence their practice behavior. Knowledge, attitudes, and beliefs of PCPs have been shown to influence the course of their patients' LBP, and guidelines were devised in an attempt to improve the effectiveness and quality of LBP care. Research worldwide and in Israel has shown that LBP guideline implementation is not yet optimal. METHODS Participants completed a questionnaire. Variables were measured using a translated, validated version of the Health Care Providers' Pain and Impairment Relationship Scale; demographic and professional characteristics were analyzed for correlation with the outcome variables. RESULTS The likelihood of PCPs having nonguideline-consistent attitudes and beliefs (A&B) was greater among those older than 50 years (P < 0.05). Family medicine specialists (family practitioners [FPs]) were more likely to have a high level of guideline knowledge as compared to nonfamily medicine specialists (general practitioners (83.8 vs. 61.9, respectively; P < 0.001). Differences between FPs and general practitioners were also observed for the mean Health Care Providers' Pain and Impairment Relationship Scale score (34.6 vs. 41.1, respectively, P = 0.00), indicating a higher consistency of attitudes and beliefs with guidelines among FPs. No significant association was found between PCPs' knowledge level and RTI the guidelines. CONCLUSION The present study showed that PCPs, especially FPs, had high levels of LBP guideline knowledge, although RTI was limited. The need for greater exposure to and understanding of the importance of implementation of LBP guidelines is essential for future guideline adherence. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | - Dena H Jaffe
- Health Outcomes Practice, Kantar Health, Jerusalem, Israel
| | - Amnon Lahad
- Department of Family Medicine, Hebrew University, Jerusalem, Israel
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25
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Hill JC, Kang S, Benedetto E, Myers H, Blackburn S, Smith S, Dunn KM, Hay E, Rees J, Beard D, Glyn-Jones S, Barker K, Ellis B, Fitzpatrick R, Price A. Development and initial cohort validation of the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways. BMJ Open 2016; 6:e012331. [PMID: 27496243 PMCID: PMC4985936 DOI: 10.1136/bmjopen-2016-012331] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/07/2016] [Accepted: 06/22/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Current musculoskeletal outcome tools are fragmented across different healthcare settings and conditions. Our objectives were to develop and validate a single musculoskeletal outcome measure for use throughout the pathway and patients with different musculoskeletal conditions: the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ). SETTING A consensus workshop with stakeholders from across the musculoskeletal community, workshops and individual interviews with a broad mix of musculoskeletal patients identified and prioritised outcomes for MSK-HQ inclusion. Initial psychometric validation was conducted in four cohorts from community physiotherapy, and secondary care orthopaedic hip, knee and shoulder clinics. PARTICIPANTS Stakeholders (n=29) included primary care, physiotherapy, orthopaedic and rheumatology patients (n=8); general practitioners, physiotherapists, orthopaedists, rheumatologists and pain specialists (n=7), patient and professional national body representatives (n=10), and researchers (n=4). The four validation cohorts included 570 participants (n=210 physiotherapy, n=150 hip, n=150 knee, n=60 shoulder patients). OUTCOME MEASURES Outcomes included the MSK-HQ's acceptability, feasibility, comprehension, readability and responder burden. The validation cohort outcomes were the MSK-HQ's completion rate, test-retest reliability and convergent validity with reference standards (EQ-5D-5L, Oxford Hip, Knee, Shoulder Scores, and the Keele MSK-PROM). RESULTS Musculoskeletal domains prioritised were pain severity, physical function, work interference, social interference, sleep, fatigue, emotional health, physical activity, independence, understanding, confidence to self-manage and overall impact. Patients reported MSK-HQ items to be 'highly relevant' and 'easy to understand'. Completion rates were high (94.2%), with scores normally distributed, and no floor/ceiling effects. Test-retest reliability was excellent, and convergent validity was strong (correlations 0.81-0.88). CONCLUSIONS A new musculoskeletal outcome measure has been developed through a coproduction process with patients to capture prioritised outcomes for use throughout the pathway and with different musculoskeletal conditions. Four validation cohorts found that the MSK-HQ had high completion rates, excellent test-retest reliability and strong convergent validity with reference standards. Further validation studies are ongoing, including a cohort with rheumatoid/inflammatory arthritis.
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Affiliation(s)
- Jonathan C Hill
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK
| | - Sujin Kang
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Elena Benedetto
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Helen Myers
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK
| | - Steven Blackburn
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK
| | - Stephanie Smith
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK
| | - Elaine Hay
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Ray Fitzpatrick
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
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Zgierska AE, Burzinski CA, Cox J, Kloke J, Singles J, Mirgain S, Stegner A, Cook DB, Bačkonja M. Mindfulness Meditation-Based Intervention Is Feasible, Acceptable, and Safe for Chronic Low Back Pain Requiring Long-Term Daily Opioid Therapy. J Altern Complement Med 2016; 22:610-20. [PMID: 27267151 DOI: 10.1089/acm.2015.0314] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Although mindfulness meditation (MM) is increasingly used for chronic pain treatment, limited evidence supports its clinical application for opioid-treated chronic low back pain (CLBP). The goal of this study was to determine feasibility, acceptability, and safety of an MM-based intervention in patients with CLBP requiring daily opioid therapy. DESIGN 26-week pilot randomized controlled trial comparing MM-based intervention, combined with usual care, to usual care alone. SETTING Outpatient. PATIENTS Adults with CLBP treated with ≥30 mg of morphine-equivalent dose (MED) per day for 3 months or longer. INTERVENTIONS Targeted MM-based intervention consisted of eight weekly 2-hour group sessions and home practice (30 minutes/d, 6 days/wk) during the study. "Usual care" for opioid-treated CLBP was provided to participants by their regular clinicians. OUTCOME MEASURES Feasibility and acceptability of the MM intervention were assessed by adherence to intervention protocol and treatment satisfaction among experimental participants. Safety was evaluated by inquiry about side effects/adverse events and opioid dose among all study participants. RESULTS Thirty-five participants enrolled during the 10-week recruitment period. The mean age (±standard deviation) was 51.8 ± 9.7 years; the patients were predominantly female, with substantial CLBP-related pain and disability, and treated with 148.3 ± 129.2 mg of MED per day. All participants completed baseline assessments; none missed both follow-up assessments or withdrew. Among experimental participants (n = 21), 19 attended 1 or more intervention sessions and 14 attended 4 or more. They reported, on average, 164.0 ± 122.1 minutes of formal practice per week during the 26-week study and 103.5 ± 111.5 minutes of brief, informal practice per week. Seventeen patients evaluated the intervention, indicating satisfaction; their qualitative responses described the course as useful for pain management (n = 10) and for improving pain coping skills (n = 8). No serious adverse events or safety concerns occurred among the study participants. CONCLUSIONS MM-based intervention is feasible, acceptable, and safe in opioid-treated CLBP.
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Affiliation(s)
- Aleksandra E Zgierska
- 1 Department of Family Medicine and Community Health, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - Cindy A Burzinski
- 1 Department of Family Medicine and Community Health, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - Jennifer Cox
- 1 Department of Family Medicine and Community Health, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - John Kloke
- 2 Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - Janice Singles
- 3 Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - Shilagh Mirgain
- 3 Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI
| | - Aaron Stegner
- 4 Research Service, William S. Middleton Memorial Veterans Hospital, Madison, WI.,5 Department of Kinesiology, University of Wisconsin-Madison , School of Education, Madison, WI
| | - Dane B Cook
- 4 Research Service, William S. Middleton Memorial Veterans Hospital, Madison, WI.,5 Department of Kinesiology, University of Wisconsin-Madison , School of Education, Madison, WI
| | - Miroslav Bačkonja
- 6 Department of Neurology, University of Wisconsin-Madison , School of Medicine and Public Health, Madison, WI.,7 PRAHS Clinical Research Company Lifetree , Salt Lake City, UT
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Zgierska AE, Burzinski CA, Cox J, Kloke J, Stegner A, Cook DB, Singles J, Mirgain S, Coe CL, Bačkonja M. Mindfulness Meditation and Cognitive Behavioral Therapy Intervention Reduces Pain Severity and Sensitivity in Opioid-Treated Chronic Low Back Pain: Pilot Findings from a Randomized Controlled Trial. PAIN MEDICINE 2016; 17:1865-1881. [PMID: 26968850 DOI: 10.1093/pm/pnw006] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess benefits of mindfulness meditation and cognitive behavioral therapy (CBT)-based intervention for opioid-treated chronic low back pain (CLBP). DESIGN 26-week parallel-arm pilot randomized controlled trial (Intervention and Usual Care versus Usual Care alone). SETTING Outpatient. SUBJECTS Adults with CLBP, prescribed ≥30 mg/day of morphine-equivalent dose (MED) for at least 3 months. METHODS The intervention comprised eight weekly group sessions (meditation and CLBP-specific CBT components) and 30 minutes/day, 6 days/week of at-home practice. Outcome measures were collected at baseline, 8, and 26 weeks: primary-pain severity (Brief Pain Inventory) and function/disability (Oswestry Disability Index); secondary-pain acceptance, opioid dose, pain sensitivity to thermal stimuli, and serum pain-sensitive biomarkers (Interferon-γ; Tumor Necrosis Factor-α; Interleukins 1ß and 6; C-reactive Protein). RESULTS Thirty-five (21 experimental, 14 control) participants were enrolled and completed the study. They were 51.8 ± 9.7 years old, 80% female, with severe CLBP-related disability (66.7 ± 11.4), moderate pain severity (5.8 ± 1.4), and taking 148.3 ± 129.2 mg/day of MED. Results of the intention-to-treat analysis showed that, compared with controls, the meditation-CBT group reduced pain severity ratings during the study (P = 0.045), with between-group difference in score change reaching 1 point at 26 weeks (95% Confidence Interval: 0.2,1.9; Cohen's d = 0.86), and decreased pain sensitivity to thermal stimuli (P < 0.05), without adverse events. Exploratory analyses suggested a relationship between the extent of meditation practice and the magnitude of intervention benefits. CONCLUSIONS Meditation-CBT intervention reduced pain severity and sensitivity to experimental thermal pain stimuli in patients with opioid-treated CLBP.
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Affiliation(s)
| | | | - Jennifer Cox
- Department of *Family Medicine and Community Health
| | - John Kloke
- Department of Biostatistics and Medical Informatics
| | - Aaron Stegner
- Department of Research Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, Wisconsin
| | - Dane B Cook
- Department of Research Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, Wisconsin
| | | | | | - Christopher L Coe
- Department of Harlow Center for Biological Psychology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Miroslav Bačkonja
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison,Wisconsin.,Department of **PRAHS Clinical Research Company Lifetree, Salt Lake City, Utah, USA
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"Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England. Spine (Phila Pa 1976) 2015; 40:1842-50. [PMID: 26571064 DOI: 10.1097/brs.0000000000001215] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A qualitative study in south-west England primary care. OBJECTIVE To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. SUMMARY OF BACKGROUND DATA Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians' perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice. METHODS We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis. RESULTS Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology-"non-specific LBP"-unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments. CONCLUSION The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients. LEVEL OF EVIDENCE N/A.
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The effects of educational interventions on pharmacists’ knowledge, attitudes and beliefs towards low back pain. Int J Clin Pharm 2015; 37:616-25. [DOI: 10.1007/s11096-015-0112-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 03/25/2015] [Indexed: 11/26/2022]
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30
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French SD, McKenzie JE, O'Connor DA, Grimshaw JM, Mortimer D, Francis JJ, Michie S, Spike N, Schattner P, Kent P, Buchbinder R, Page MJ, Green SE. Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial. PLoS One 2013; 8:e65471. [PMID: 23785427 PMCID: PMC3681882 DOI: 10.1371/journal.pone.0065471] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 04/18/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. METHODS General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. RESULTS 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. CONCLUSIONS The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN012606000098538.
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Affiliation(s)
- Simon D French
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia.
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Georgy EE, Carr ECJ, Breen AC. Met or matched expectations: what accounts for a successful back pain consultation in primary care? Health Expect 2013; 16:143-54. [PMID: 21679288 PMCID: PMC5060651 DOI: 10.1111/j.1369-7625.2011.00706.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients' as well as doctors' expectations might be key elements for improving the quality of health care; however, previous conceptual and theoretical frameworks related to expectations often overlook such complex and complementary relationship between patients' and doctors' expectations. The concept of 'matched patient-doctor expectations' is not properly investigated, and there is lack of literature exploring such aspect of the consultation. AIM The paper presents a preliminary conceptual model for the relationship between patients' and doctors' expectations with specific reference to back pain management in primary care. METHODS The methods employed in this study are integrative literature review, examination of previous theoretical frameworks, identification of conceptual issues in existing literature, and synthesis and development of a preliminary pragmatic conceptual framework. OUTCOME A simple preliminary model explaining the formation of expectations in relation to specific antecedents and consequences was developed; the model incorporates several stages and filters (influencing factors, underlying reactions, judgement, formed reactions, outcome and significance) to explain the development and anticipated influence of expectations on the consultation outcome. CONCLUSION The newly developed model takes into account several important dynamics that might be key elements for more successful back pain consultation in primary care, mainly the importance of matching patients' and doctors' expectations as well as the importance of addressing unmet expectations.
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Affiliation(s)
- Ehab E Georgy
- School of Health and Social Care, Bournemouth University, Dorset, UK.
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Williams ACDC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012; 11:CD007407. [PMID: 23152245 PMCID: PMC6483325 DOI: 10.1002/14651858.cd007407.pub3] [Citation(s) in RCA: 453] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review. OBJECTIVES To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking. SEARCH METHODS We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators. SELECTION CRITERIA Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20. DATA COLLECTION AND ANALYSIS Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25. MAIN RESULTS Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not. AUTHORS' CONCLUSIONS Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.
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Affiliation(s)
- Amanda C de C Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK.
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Abstract
STUDY DESIGN A systematic review of the literature. OBJECTIVES Sick-listing is a complex process that involves stakeholders at several levels. Although the physicians are the ones who issue a sick note, little is known about the mechanisms and determinants they use in making a decision about whether to sick-list a patient with low back pain (LBP). The aim of this systematic review is to describe the evidence on determinants used by physicians to sick-list patients with LBP. METHODS Electronic searches of Medline, EMBASE, PsychInfo, and Cochrane Central were conducted (all years to June 2011). Inclusion criteria included studies of workers with LBP presenting to a physician where sick-listing certification was an outcome of the consultation process. Studies were critically appraised for their internal validity by 2 independent reviewers using a modified version the criteria proposed by Hayden et al. Findings from papers were synthesized into internal and external factors related to the physician. RESULTS The search identified 1419 unique citations from which 11 papers met the inclusion criteria. The evidence suggests that 2 internal factors are important determinants of sick listing: physicians' personal fear avoidance and distress regarding the complexity of LBP. External factors included patients' expectations, the presence of clinical findings, and the support and general attitude demonstrated by a patients' employer and the availability of modified work. CONCLUSIONS The current review suggests that physicians need to improve their knowledge regarding options for modified work in the workplace, and about the management of LBP in general. The otherwise beneficial patient-physician relationship and physicians' care for their patients may be an obstacle to following guidelines on LBP management in the sick-listing process. Future studies should address these issues.
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Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain 2012; 16:3-17. [PMID: 21719329 DOI: 10.1016/j.ejpain.2011.06.006] [Citation(s) in RCA: 298] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population. METHODS Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined. RESULTS Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP. CONCLUSION HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.
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Affiliation(s)
- B Darlow
- Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, 6242, New Zealand.
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Sowden G, Hill JC, Konstantinou K, Khanna M, Main CJ, Salmon P, Somerville S, Wathall S, Foster NE. Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281). Fam Pract 2012; 29:50-62. [PMID: 21708984 PMCID: PMC3261797 DOI: 10.1093/fampra/cmr037] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 05/19/2011] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it. THE SUBGROUPING AND TARGETED TREATMENT SYSTEM: This system differs from 'one-size fits all' usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity. THE SUBGROUPING TOOLS: Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs. The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk). THE TRAINING PACKAGES: Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists. DISCUSSION This paper describes in detail the IMPaCT Back study's subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study. STUDY REGISTRATION ISRCTN55174281.
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Affiliation(s)
- Gail Sowden
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
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Abstract
Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.
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Kroenke K, Wu J, Bair MJ, Damush TM, Krebs EE, Tu W. Impact of Depression on 12-Month Outcomes in Primary-Care Patients with Chronic Musculoskeletal Pain. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/10582452.2011.635844] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kidane B, Gandhi R, Sarro A, Valiante TA, Harvey BJ, Rampersaud YR. Is referral to a spine surgeon a double-edged sword?: patient concerns before consultation. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2011; 57:803-810. [PMID: 21753108 PMCID: PMC3135451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess the concerns of adult patients with spine-related complaints during the period between referral to and consultation with a spine surgeon. DESIGN Prospective survey. SETTING Toronto, Ont. PARTICIPANTS A total of 338 consecutive, nonemergent patients before consultation with a single spine surgeon over a 5-month period. MAIN OUTCOME MEASURES Patient concerns, effect of referral to a spine surgeon, and effect of waiting to see a spine surgeon. RESULTS The issues patients reported to be most concerning were ongoing pain (45.6% rated this as most concerning), loss of function (23.4%), need for surgery (12.1%), and permanence of the condition (9.6%). Regression analysis demonstrated that older age was an independent predictor of increased level of concern regarding pain (P=.01) and disability (P=.04). Forty-seven percent of all patients listed the need for surgery among their top 3 concerns. Mere referral to a spine surgeon (P=.03) was an independent predictor of increased concern regarding the need for surgery. Sex, diagnosis, surgical candidacy, and actual wait time were not predictive of increased concerns. Patients reported family physicians to be their most influential information source regarding spinal conditions. CONCLUSION Timely provision of more specific information regarding the benign and non-surgical nature of most degenerative spinal conditions might substantially reduce patients' exaggerated concerns regarding the probability of surgery for a considerable number of patients referred to spine surgeons.
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Breen AC, Carr E, Langworthy JE, Osmond C, Worswick L. Back pain outcomes in primary care following a practice improvement intervention:- a prospective cohort study. BMC Musculoskelet Disord 2011; 12:28. [PMID: 21272310 PMCID: PMC3040163 DOI: 10.1186/1471-2474-12-28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 01/27/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Back pain is one of the UK's costliest and least understood health problems, whose prevalence still seems to be increasing. Educational interventions for general practitioners on back pain appear to have had little impact on practice, but these did not include quality improvement learning, involve patients in the learning, record costs or document practice activities as well as patient outcomes. METHODS We assessed the outcome of providing information about quality improvement techniques and evidence-based practice for back pain using the Clinical Value Compass. This included clinical outcomes (Roland and Morris Disability Questionnaire), functional outcomes, costs of care and patient satisfaction. We provided workshops which used an action learning approach and collected before and after data on routine practice activity from practice electronic databases. In parallel, we studied outcomes in a separate cohort of patients with acute and sub-acute non-specific back pain recruited from the same practices over the same time period. Patient data were analysed as a prospective, split-cohort study with assessments at baseline and eight weeks following the first consultation. RESULTS Data for 1014 patients were recorded in the practice database study, and 101 patients in the prospective cohort study. We found that practice activities, costs and patient outcomes changed little after the intervention. However, the intervention was associated with a small, but statistically significant reduction in disability in female patients. Additionally, baseline disability, downheartedness, self-rated health and leg pain had small but statistically significant effects (p < 0.05) on follow-up disability scores in some subgroups. CONCLUSIONS GP education for back pain that both includes health improvement methodologies and involves patients may yield additional benefits for some patients without large changes in patterns of practice activity. The effects in this study were small and limited and the reasons for them remain obscure. However, such is the impact of back pain and its frequency of consultation in general practice that this kind of improvement methodology deserves further consideration. TRIAL REGISTRATION NUMBER ISRCTN: ISRCTN30420389.
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Affiliation(s)
- Alan C Breen
- Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Parkwood Road, Bournemouth BH52DF, UK.
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Chan WS, Whitford DL, Conroy R, Gibney D, Hollywood B. A multidisciplinary primary care team consultation in a socio-economically deprived community: an exploratory randomised controlled trial. BMC Health Serv Res 2011; 11:15. [PMID: 21261966 PMCID: PMC3032651 DOI: 10.1186/1472-6963-11-15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 01/24/2011] [Indexed: 01/04/2023] Open
Abstract
Background Psychosocial problems in socioeconomically deprived communities are not always amenable to traditional medical approaches. Mothers living in these areas are a particularly vulnerable group. The objective of this study was to evaluate the effectiveness of a lengthened multi-disciplinary team consultation in primary care in reducing anxiety and depression in mothers. Methods This was a prospective randomised controlled trial of a multidisciplinary team consultation against normal care. 94 mothers were recruited from three general practices from an area of extreme socio-economic deprivation. Mothers randomised into the intervention group attended a multidisciplinary consultation with up to four case-specific health care professionals. Consultations addressed medical, psychological and social problems and lasted up to one hour. Conventional primary care continued to be available to the intervention families. Control group families received normal primary care services. The outcomes measured were anxiety and depression as using the Hospital Anxiety and Depression Scale (HADS), health status using SF36v2, and quality of life using the abbreviated Schedule for the Evaluation of Individual Quality of Life (SEIQoL-DW) at baseline, 6 months and 12 months. Results Ordered logistic regression was used to analyse the data. There was no significant difference found between intervention and control groups after 6 months and 12 months in all of the measured outcomes. Conclusions The new lengthened multi-disciplinary team consultation did not have any impact on the mental health, general health, and quality of life of mothers after 6 and 12 months. Other methods of primary health care delivery in socio-economically deprived communities need to be evaluated.
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Affiliation(s)
- Wai-Sun Chan
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 120 St Stephens Green, Dublin 2, Ireland.
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How usual is usual care in pragmatic intervention studies in primary care? An overview of recent trials. Br J Gen Pract 2010; 60:e305-18. [PMID: 20594432 DOI: 10.3399/bjgp10x514819] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking. AIM To explore the variety of approaches to the usual care concept in pragmatic trials, and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group. DESIGN OF STUDY Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation. RESULTS In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult. CONCLUSION Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group.
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Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10:514-29. [PMID: 20494814 DOI: 10.1016/j.spinee.2010.03.032] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 02/24/2010] [Accepted: 03/29/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Low back pain (LBP) is a prevalent, costly, and challenging condition to manage. Clinicians must choose among numerous assessment and management options. Several recent clinical practice guidelines (CPGs) on LBP have attempted to inform these decisions by evaluating and summarizing the best available supporting evidence. The quality and consistency of recommendations from these CPGs are currently unknown. PURPOSE To conduct a systematic review of recent CPGs and synthesize their recommendations on assessing and managing LBP for clinicians. STUDY DESIGN/SETTING Systematic review. METHODS Literature search using MEDLINE, National Guidelines Clearinghouse, National Institute for Clinical Excellence, Internet search engines, and references of known articles. Only CPGs related to both assessment and management of LBP written in English were eligible; CPGs that summarized evidence from before the year 2000 were excluded. Data related to methods and recommendations for assessment and management of LBP were abstracted independently by two reviewers. Methodological quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument by two reviewers. RESULTS The search uncovered 669 citations, of which 95 were potentially relevant and 10 were included in the review; 6 discussed acute LBP, 6 chronic LBP, and 6 LBP with neurologic involvement. Methods used to develop CPGs varied, but the overall methodological quality was high as defined by AGREE scores. Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested. Management of LBP with neurologic involvement was similar, with additional consideration given to magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful. CONCLUSIONS Recommendations from several recent CPGs regarding the assessment and management of LBP were similar. Clinicians who care for patients with LBP should endeavor to adopt these recommendations to improve patient care. Future CPGs may wish to invite coauthors from targeted clinician user groups, increase patient participation, update their literature searches before publication, conduct their own quality assessment of studies, and consider cost-effectiveness and other aspects in their recommendations more explicitly.
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Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, Potter R, Underwood MR. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010; 375:916-23. [PMID: 20189241 DOI: 10.1016/s0140-6736(09)62164-4] [Citation(s) in RCA: 243] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Low-back pain is a common and costly problem. We estimated the effectiveness of a group cognitive behavioural intervention in addition to best practice advice in people with low-back pain in primary care. METHODS In this pragmatic, multicentre, randomised controlled trial with parallel cost-effectiveness analysis undertaken in England, 701 adults with troublesome subacute or chronic low-back pain were recruited from 56 general practices and received an active management advisory consultation. Participants were randomly assigned by computer-generated block randomisation to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). Primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff scores at 12 months. Assessment of outcomes was blinded and followed the intention-to-treat principle, including all randomised participants who provided follow-up data. This study is registered, number ISRCTN54717854. FINDINGS 399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included in the primary analysis at 12 months. The most frequent reason for participant withdrawal was unwillingness to complete questionnaires. At 12 months, mean change from baseline in the Roland Morris questionnaire score was 1.1 points (95% CI 0.39-1.72) in the control group and 2.4 points (1.89-2.84) in the cognitive behavioural intervention group (difference between groups 1.3 points, 0.56-2.06; p=0.0008). The modified Von Korff disability score changed by 5.4% (1.99-8.90) and 13.8% (11.39-16.28), respectively (difference between groups 8.4%, 4.47-12.32; p<0.0001). The modified Von Korff pain score changed by 6.4% (3.14-9.66) and 13.4% (10.77-15.96), respectively (difference between groups 7.0%, 3.12-10.81; p<0.0001). The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was 1786 pound sterling, and the probability of cost-effectiveness was greater than 90% at a threshold of 3000 pound sterling per QALY. There were no serious adverse events attributable to either treatment. INTERPRETATION Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Sarah E Lamb
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
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Phelan SM, van Ryn M, Wall M, Burgess D. Understanding primary care physicians' treatment of chronic low back pain: the role of physician and practice factors. PAIN MEDICINE 2010; 10:1270-9. [PMID: 19818037 DOI: 10.1111/j.1526-4637.2009.00717.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND An increasing number of Operation Iraqi Freedom/Operation Enduring Freedom veterans experience chronic pain. Despite treatment guidelines, there is wide variation in physicians' approaches to pain treatment, and many physicians are unsure of the best treatment approach. Research has examined factors associated with opioid prescribing, but there is little information on physician characteristics that predict patterns of clinical responses to pain. OBJECTIVES To identify patterns in primary care physicians' treatment decisions for nonmalignant chronic pain, and identify physician and practice characteristics that predict treatment decision patterns. METHODS A national sample of 381 primary care physicians who responded to a mailed vignette involving a veteran with chronic low back pain (LBP) were categorized into latent classes by clinical actions taken to treat the pain. The associations between newly derived treatment patterns and physician and practice characteristics were examined with multivariate models. RESULTS Latent class analysis identified three treatment approaches: 1) Multimodal/Aggressive (14%); 2) Low Action (38%); and 3) Psychosocial/Non-Opioid (48%). In a multivariate model, treatment pattern was associated with demographic and personality factors; opioid-related attitudes, beliefs, and concerns; perceptions of the patient; availability of resources; and practice characteristics. CONCLUSIONS There may be distinct patterns in primary care physicians' responses to patients with chronic pain. Relatively few physicians use the multimodal approach endorsed by proponents of the biopsychosocial model of pain treatment. Several physician and practice characteristics predict patterns of clinical action.
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Affiliation(s)
- Sean M Phelan
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA.
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Morris LD, Louw QA. Physiotherapists and General Practitioners as first-line of management for acute low back pain: Which is better? A systematic review. ACTA ACUST UNITED AC 2010; 8:382-404. [PMID: 27819955 DOI: 10.11124/01938924-201008090-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND- Significant acute low back pain (LBP) is experienced by at least 70% of adults in developing and developed countries at some point during their lifetime.LBP is a common cause leading to disability. There has been an increase in the need for consistency in the management of acute LBP across professions and at present there is no clear indication whether patients with acute LBP should consult a general practitioner or a physiotherapist. OBJECTIVE- The main objective of the review was to evaluate the effectiveness of physiotherapy primary care compared to general practitioner primary care in outcomes such as pain reduction and improvement of function, for adults with acute LBP. SEARCH STRATEGY- A comprehensive search of keywords contained in the title and abstract, and the relevant MeSH headings and descriptor terms was performed on the following computerized bibliographic databases: PubMed, CINAHL and Sports Discus on EBSCOHost, Cochrane Library, Scirus, BioMed Central, PEDro, ScienceDirect, Proquest Medical Library, Ingenta Connect, ClinicalTrials.gov, PsycINFO, AMI, DARE, TRIP, Digital Dissertations, Current Content Connect, Current Controlled Trials, and Scopus, during November 2007 and January 2008. An update of the search was conducted in September 2009, prior to publication. SELECTION CRITERIA- Papers were considered if they were randomized controlled trials focusing on the effectiveness of physiotherapy management compared to general practitioner management in reducing pain and improving function in acute LBP in adults. DATA COLLECTION AND ANALYSIS- Study design and quality were tabulated, and effect sizes, mean differences and associated 95% confidence intervals were calculated from studies which provided sufficient data, using Thalheimer's effect sizes spreadsheet and RevMan 5. All other data were presented in a narrative summary. RESULTS- The comprehensive search identified six studies that satisfied the inclusion criteria. However, two studies were excluded as the one did not present subgroup data individually and a usable full report could not be retrieved for the other. Consequently, four studies were included in this review. CONCLUSION- A firm conclusion as to whether physiotherapists or general practitioners are more effective in managing acute low back pain cannot be made from the results of this review. Further research into the most effective and most cost-effective treatments and referral pathways for acute LBP are therefore warranted.
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Affiliation(s)
- Linzette D Morris
- 1. Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Stellenbosch University, South Africa
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Godfrey JR, Dugan SA. Toward optimal health: advances in chronic back pain management for women. J Womens Health (Larchmt) 2009; 18:1533-7. [PMID: 19788369 DOI: 10.1089/jwh.2009.1688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Abstract
BACKGROUND Although most depressive disorders are treated in primary care and several studies have examined the effects of psychological treatment in primary care, hardly any meta-analytic research has been conducted in which the results of these studies are integrated. AIM To integrate the results of randomised controlled trials of psychological treatment of depression in adults in primary care, and to compare these results to psychological treatments in other settings. DESIGN OF STUDY A meta-analysis of studies examining the effects of psychological treatments of adult depression in primary care. SETTING Primary care. METHOD An existing database of studies on psychological treatments of adult depression that was built on systematic searches in PubMed, PsychINFO, EMBASE, and Dissertation Abstracts International was used. Randomised trials were included in which the effects of psychological treatments on adult primary care patients with depression were compared to a control condition. RESULTS In the 15 included studies, the standardised mean effect size of psychological treatment versus control groups was 0.31 (95% CI = 0.17 to 0.45), which corresponds with a numbers-needed-to-treat (NNT) of 5.75. Studies in which patients were referred by their GP for treatment had significantly higher effect sizes (d = 0.43; NNT = 4.20) than studies in which patients were recruited through systematic screening (d = 0.13, not significantly different from zero; NNT = 13.51). CONCLUSIONS Although the number of studies was relatively low and the quality varied, psychological treatment of depression was found to be effective in primary care, especially when GPs refer patients with depression for treatment.
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Author's response. Br J Gen Pract 2009. [DOI: 10.3399/bjgp09x419583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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