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

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.

The relationship between physical activity and low back pain outcomes: a systematic review of observational studies

Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.

Health status of caregivers of children with cerebral palsy

BACKGROUND AND AIMS

While a 'Family-Centered' approach to care is accepted as best practice in the context of childhood disability, it may lead to increased demands on family members by requiring them to be active participants in their child's care. This may impact upon the physical and mental health of the caregiver and therefore needs to be investigated. This study aimed to assess the health status of caregivers of children with cerebral palsy (CP) in Ireland and to identify vulnerable subgroups.

METHODS

A cross-sectional postal survey was conducted using a questionnaire incorporating the SF-36v2.0. The sample consisted of male and female caregivers of children with CP, representing all levels of ability. Two questionnaires were sent to each child's home; a total of 312 questionnaires were sent to the homes of 156 children.

RESULTS

Completed questionnaires were returned by 161 caregivers (100 women, 61 men) of 101 children, giving a response rate of 65%. Caregivers of children with CP were found to have poorer health than the Irish general population, for whom normative data exist. Female caregivers had poorer health than male caregivers in both the physical (P < 0.05) and mental health (P < 0.001) domains of the SF-36. Caregivers spending more time caring had significantly poorer mental health than those spending less time caring (P < 0.05). There was no difference in the health of caregivers of 'more independent' versus 'more dependent' children, apart from the latter group reporting higher levels of bodily pain (P < 0.05).

CONCLUSION

This study provides evidence of the inferior health status of caregivers of children with CP in Ireland, particularly that of women.

Chronic low back pain: non-clinical factors impacting on management by Irish doctors

INTRODUCTION

General practitioners and consultants in the Republic of Ireland manage patients with chronic low back pain (LBP), but little is known about the non-clinical factors that impact on their management.

AIM

To establish the non-clinical factors that impact on the management of chronic LBP by a cohort of general practitioners and consultants.

METHODS

Using a multiple case study design, semi-structured interviews were conducted with general practitioners (n = 7) and consultants (n = 7). Interviews were transcribed and analysed qualitatively.

RESULTS

Two main themes emerged: policy factors (the health care system, the medico-legal system), and patient factors (need for reassurance, lack of patient adherence).

CONCLUSIONS

These factors operate at national and local levels. Nationally, they underscore the lack of resources, and the impact of the medico-legal system. Local issues include changing practice by reassuring patients using evidence-based biopsychosocial strategies to maximise patient care and reduce healthcare costs.

Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review

The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n=3) and quantitative (n=12) methodologies. Themes that emerged included doctors' attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors' specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors' specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors' attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient-care, and reduce costs to health services.

Tender point count and total myalgic score in fibromyalgia: changes over a 28-day period

Tender point count (TPC) is central to fibromyalgia syndrome (FMS), and with total myalgic score (TMS) is often used to monitor the patient's condition. This study aimed to determine the stability of TPC and TMS over time, and to examine how well these measures reflected patients' perceptions of their condition. Twenty-four patients with FMS completed the Fibromyalgia Impact Questionnaire (FIQ) and a visual analogue scale (VAS) measuring well-being, at entrance into the study, and 7 and 28 days later. There was no significant change in TPC (P = 0.074), FIQ score (P = 0.291) or VAS (P = 0.079) of well-being with time. However, mean TMS score did change over time (P = 0.021). There was no correlation between total FIQ score and the other measures (all P-values > 0.05). The significant change in TMS over time may reflect the natural fluctuation in the clinical presentation of FMS.

The need for a national strategy for chronic pain management in Ireland

BACKGROUND

Chronic pain is defined as pain on a daily basis for more than six months. It affects 13% of the Irish population. Despite its prevalence and the impact on patient's quality of life there is no national strategy for this problem.

AIM

To determine the need for a national strategy for chronic pain in Ireland.

METHODS

The cost of low back pain (LBP) (common chronic pain condition), the level of education and research and current chronic pain clinic resources were investigated.

RESULTS

The cost of LBP in Ireland is enormous: disability payments from the Department of Social and Family Affairs amounted to euros 348 million and insurance payments cost euros 10.5 million. The number of teaching hours timetabled for pain education in the schools of Medicine, Physiotherapy, Dentistry, Nursing and Psychology in Ireland's six universities varied significantly (e.g. 11.5-72 hrs in nursing). Research grants awarded from state organisations were limited to one over a four-year period. No current chronic pain clinics comply with recommended International Association for the Study of Pain (IASP) guidelines.

CONCLUSION

A national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.

Patients' perceptions of exercise therapy in the treatment of fibromyalgia syndrome: a survey

OBJECTIVE

To identify patients' perceptions of the role and benefits of exercise in the treatment of fibromyalgia syndrome (FMS).

DESIGN

A postal questionnaire was sent to all 225 members of the Northern Ireland Fibromyalgia Support Group. The questionnaire consisted of 19 questions and was sub-divided into four sections: (1) background information; (2) previous treatment; (3) opinions on the role of exercise in FMS and (4) current participation in, and barriers to, exercise. Data were analysed using descriptive statistics.

RESULTS

A response rate of 51.1% (115/225) was achieved. Forty nine percent (57) of respondents were receiving FMS-associated disability benefits and 13% (15) were working full-time. All reported previous treatment for FMS. Ninety-six (84%) had received medication and 82 (71%) exercise-based therapy. Just over half (42/82) of those who had participated in exercise therapy reported it to be an effective management strategy. Two thirds (48/71) of those who used bedrest, and over half (52/96) of those who used medications reported these interventions to be effective. Eighty-two per cent (94) 'agreed' or 'strongly agreed' that exercise improved fitness and 60% (69) 'agreed' or 'strongly agreed' that exercise increased feelings of well-being, but only 13.9% (16) reported that it reduced their pain. The most commonly reported barriers to exercise were fatigue (85%, 98) and pain (73%, 84).

CONCLUSION

Exercise therapy is a common treatment for fibromyalgia syndrome, but while respondents accepted its general health benefits, the vast majority did not report that it reduced their pain.

How effective is the acute low back pain screening questionnaire for predicting 1-year follow-up in patients with low back pain?

OBJECTIVES

The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain.

STUDY DESIGN

A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective.

PATIENTS

Ninety patients (76% response rate) returned the completed questionnaire package.

RESULTS

The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation).

CONCLUSIONS

The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.

Interferential therapy electrode placement technique in acute low back pain: a preliminary investigation

OBJECTIVE

To determine the efficacy of interferential therapy (IFT) electrode placement technique compared with a control treatment in subjects with acute low back pain (LBP).

DESIGN

Single-blind, randomized, controlled trial with a 3-month follow-up.

SETTING

Outpatient physiotherapy departments in hospital and university settings.

PATIENTS

A random sample of 60 eligible patients with back pain (28 men, 32 women) were recruited by general practitioners and self-referral for physiotherapy treatment and randomly assigned to 1 of 3 groups.

INTERVENTIONS

(1) "IFT painful area" and The Back Book, (2) "IFT spinal nerve" and The Back Book, and (3) "Control," The Back Book only. Standardized IFT stimulation parameters were used: carrier frequency 3.85 kHz; 140 Hz constant; pulse duration 130 micros; 30 minutes' duration.

MAIN OUTCOME MEASURES

Pain Rating Index, Roland-Morris Disability Questionnaire (RMDQ), and EuroQol were completed by subjects pretreatment, at discharge, and 3-month follow-up.

RESULTS

All groups had significant improvements in all outcomes at follow-up. Subjects managed by IFT spinal nerve and The Back Book displayed both a statistically significant (p = .030) and clinically meaningful reduction in functional disability (RMDQ), compared with management via IFT painful area and The Back Book combined or The Back Book alone.

CONCLUSIONS

The findings showed that IFT electrode placement technique affects LBP-specific functional disability, providing preliminary implications for future clinical studies.

Biopsychosocial screening questionnaire for patients with low back pain: preliminary report of utility in physiotherapy practice in Northern Ireland

OBJECTIVE

The aim of this study was to investigate the potential utility of a new biopsychosocial screening questionnaire (Acute Low Back Pain Screening Questionnaire) by exploring the relation between it and several physical risk factors and posttreatment outcomes so as to establish a cutoff point for the local population. The relation between the screening questionnaire and valid and reliable outcome measures of pain and functional disability was also explored.

DESIGN

Cross-sectional and longitudinal studies were conducted on patients referred for physiotherapy for low back pain to a large Healthcare Trust in Northern Ireland. Before initial assessment, patients completed the screening questionnaire and outcome measures, were questioned about known physical risk factors, and then received physiotherapy. At final discharge, the outcome variables--the "number of treatments" and patient's current work status ("return to work [yes/no]")--were recorded, and patients recompleted the outcome measures.

PATIENTS

One hundred eighteen patients gave written informed consent to participate in this study.

RESULTS

Significant associations were detected between questionnaire scores and pretreatment "leisure time exercise," "analgesic medication use," and "subjective anesthesia"; posttreatment "return to work"; and "number of physiotherapy treatments" as well as pain and functional disability measures. A cutoff "at-risk" score of 112 was calculated, which correctly classified 74% of patients who received more than six treatments and 80% of patients who failed to return to work at the end of treatment.

CONCLUSIONS

The findings of this study provide preliminary evidence of the utility of this biopsychosocial screening questionnaire for future use in clinical intervention studies in the Northern Ireland National Health Service. Further comparative investigations in other health care settings are warranted.

Depreciation of the Warmwater Fish Community in the Bay of Quinte, Lake Ontario

The sequence of fish species shifts since the 1930s in the Bay of Quinte is interpreted in terms of climatic changes and the influences of man. Among the latter, eutrophication is judged most important. The marked decrease in large piscivores in both eastern Lake Ontario and the Bay of Quinte as a consequence of these changes resulted in instability, exemplified by the explosions in populations of alewife (Alosa pseudoharengus) and white perch (Morone americana). Nutrients are imported to the bay, from Lake Ontario by way of alewife. This source has increased in the 1970s with the further decline of piscivores, and it brought about a greater fish production in the bay. We conclude that the Bay of Quinte and Lake Ontario interact significantly and should be studied as a single system.Because of its specialized feeding habits, the post-World War II rise of the walleye (Stizostedion vitreum vitreum) was related to events outside the Bay of Quinte, but its later decline was attributable to direct and indirect effects of eutrophication. Yellow perch (Perca flavescens), by contrast, were apparently not affected adversely by severe habitat changes induced by cultural eutrophication. Key words: Percidae, community ecology, species shifts, eutrophication, habitat changes

Effects of Eutrophication on Salmonid Communities in Oligotrophic Lakes

Oligotrophic lakes respond to progressive eutrophication by a sequence of predictable events. Increased nutrient loads and subsequent increased plant production result in alterations in the abiotic environment, including changes in the color and transparency of the water, increased turbidity, oxygen depletion in the hypolimnion, and increased chemical stratification. The physico-chemical changes precipitate biotic changes among the phytoplankton, littoral algae, zooplankton, and benthos. The salmonid community may respond initially with an increased body growth rate in various taxa and a higher incidence of parasitism, but later inhibition of natural reproduction occurs, and finally, the taxa are replaced by others that can survive in the changed environment.A relation between natural nutrient loading (expressed in terms of a morphoedaphic index) and yield (both quantitative and qualitative) is proposed as an aid to determining the natural successional status of a lake. Knowing the natural baseline of a particular lake the fisheries managers can judge the nature and size of responses due to cultural nutrient loading and then alter the rate of cultural nutrient loading to modify the ecological effects, or they can use biological engineering to capitalize on the present conditions.Among the most important effects of eutrophication is the increased vulnerability of sedentary discrete stocks to changes in other stresses such as fishing.