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Itz C, Huygen F, Kleef MV. A proposal for the organization of the referral of patients with chronicnon-specific low back pain. Curr Med Res Opin 2016; 32:1903-1909. [PMID: 27499500 DOI: 10.1080/03007995.2016.1220933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Low back pain in general and specifically chronic low back pain forms a major burden for the patient and society. Recently studies demonstrated that up to 65% of patients evolve to chronic pain as opposed to the previously accepted 8%. As low back pain patients present first with their general practitioner, the latter should establish a treatment plan, including the appropriate referrals. There are, however, no clear guidelines as to how to refer low back pain patients. The process of trial and error of different specialties and treatment possibilities often results in a long and costly trajectory. A better understanding of the subtypes of chronic low back pain, the risks for chronification and fast adequate referral may result in higher patient satisfaction and cost reduction. Proposed solutions: We propose a classification system based on the clinical and anatomical characteristics of axial low back pain, separated from radicular pain. It is important to recognize the risks for chronification, such as degenerative and/or herniated disk, a smaller cross-sectional area of the multifidus, erector spinae, and psoas muscles and psychological and social factors, to be able to provide appropriate management. Also stratification of the patients according to the degree of disability may help in defining the correct treatment approach. A one-and-a-half line approach, where a spine physician assistant works under the supervision of the general practitioner to establish the sub-diagnosis, the risk factors for chronicity and to explain the proposed management plan to the patient, may be helpful for an early appropriate treatment selection for the patient with chronic low back pain.
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Affiliation(s)
- Coen Itz
- a Department of Anesthesiology and Pain Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
- b Health Insurance Company VGZ Eindhoven , Eindhoven , The Netherlands
| | - Frank Huygen
- c Department of Anesthesiology , Centre of Pain Medicine, Erasmus Medical Center , Rotterdam , the Netherlands
| | - Maarten van Kleef
- a Department of Anesthesiology and Pain Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
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Arnbak B, Jensen RK, Manniche C, Hendricks O, Kent P, Jurik AG, Jensen TS. Identification of subgroups of inflammatory and degenerative MRI findings in the spine and sacroiliac joints: a latent class analysis of 1037 patients with persistent low back pain. Arthritis Res Ther 2016; 18:237. [PMID: 27733191 PMCID: PMC5062874 DOI: 10.1186/s13075-016-1131-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/20/2016] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to investigate subgroups of magnetic resonance imaging (MRI) findings for the spine and sacroiliac joints (SIJs) using latent class analysis (LCA), and to investigate whether these subgroups differ in their demographic and clinical characteristics. Methods The sample included 1037 patients aged 18–40 years with persistent low back pain (LBP). LCA was applied to MRI findings of the spine and SIJs. The resulting subgroups were tested for differences in self-reported demographic and clinical characteristics. Results A five-class model was identified: Subgroup 1, ‘No or few findings’ (n = 116); Subgroup 2, ‘Mild spinal degeneration’ (n = 540); Subgroup 3, ‘Moderate to severe spinal degeneration’ (n = 229); Subgroup 4, ‘Moderate to severe spinal degeneration with mild SIJ findings’ (n = 68); and Subgroup 5, ‘Mild spinal degeneration with moderate to severe SIJ findings’ (n = 84). The two SIJ subgroups (Subgroups 4 and 5) had a higher median activity limitation score (Roland Morris Disability Questionnaire calculated as a proportional score: 65 (IQR 48–78)/65 (48–78)) compared with Subgroups 1–3 (48 (35–74)/57 (39–74)/57 (39–74)), a higher prevalence of women (68 % (95 % CI 56–79)/68 % (58–78)) compared with Subgroups 2 and 3 (51 % (47–55)/40 % (33–46)), a higher prevalence of being overweight (67 % (95 % CI 55–79)/53 % (41–65)) compared with Subgroup 1 (36 % (26–46)) and a higher prevalence of previous LBP episodes (yes/no: 81 % (95 % CI 71–91)/79 % (70–89)) compared with Subgroup 1 (58 % (48–67)). Subgroup 5 was younger than Subgroup 4 (median age 29 years (IQR 25–33) versus 34 years (30–37)) and had a higher prevalence of HLA-B27 (40 % (95 % CI 29–50)) compared with the other subgroups (Subgroups 1–4: 12 % (6–18)/7 % (5–10)/6 % (3–9)/12 % (4–20)). Across the subgroups with predominantly spinal findings (Subgroups 1–3), median age, prevalence of men, being overweight and previous LBP episodes were statistically significantly lower in Subgroup 1, higher in Subgroup 2 and highest in Subgroup 3. Conclusions Five distinct subgroups of MRI findings in the spine and SIJs were identified. The results indicate that SIJ MRI findings not only can be seen as a part of the spondyloarthritis disease entity, but also are associated with age, gender and being overweight. Furthermore, the results indicate that LBP patients with SIJ MRI findings are more disabled compared with patients without SIJ MRI findings, and that moderate to severe spinal degeneration and/or SIJ MRI findings may be associated with recurrent pain. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1131-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bodil Arnbak
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Oestre Hougvej 55, Middelfart, 5500, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark.
| | - Rikke Krüger Jensen
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Oestre Hougvej 55, Middelfart, 5500, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark
| | - Claus Manniche
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Oestre Hougvej 55, Middelfart, 5500, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark
| | - Oliver Hendricks
- Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark.,King Christian 10th Hospital for Rheumatic Diseases, Toldbodgade 3, Graasten, 6300, Denmark
| | - Peter Kent
- School of Physiotherapy and Exercise Science, Curtin University, Kent Street, Bentley, Perth, Western Australia, 6102, Australia.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, Odense M, 5230, Denmark
| | - Anne Grethe Jurik
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Oestre Hougvej 55, Middelfart, 5500, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark.,Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, Aarhus C, 8000, Denmark
| | - Tue Secher Jensen
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Oestre Hougvej 55, Middelfart, 5500, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19-3, Odense C, 5000, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, Odense M, 5230, Denmark
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Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain? J Orthop Sports Phys Ther 2016; 46:894-901. [PMID: 27594663 DOI: 10.2519/jospt.2016.6588] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Secondary analysis of a prospective cohort study with cross-sectional and longitudinal analyses. Background The clinical importance of a history of whiplash-associated disorder (WAD) in people with neck pain remains uncertain. Objective To compare people with WAD to people with nonspecific neck pain, in terms of their baseline characteristics and pain and disability outcomes over 1 year. Methods Consecutive patients with neck pain who presented to a secondary-care spine center answered a comprehensive self-report questionnaire and underwent a physical examination. Patients were classified into a group of either those with WAD or those with nonspecific neck pain. We compared the outcomes of baseline characteristics of the 2 groups, as well as pain intensity and activity limitation at follow-ups of 6 and 12 months. Results A total of 2578 participants were included in the study. Of these, 488 (19%) were classified as having WAD. At presentation, patients with WAD were statistically different from patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index), others, including the presence of dizziness and memory difficulties, were substantial. The between-group differences in pain and disability increased significantly (P<.001) over 12 months. At 12-month follow-up, the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain. Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain. Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates. Level of Evidence Prognosis, level 2. J Orthop Sports Phys Ther 2016;46(10):894-901. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6588.
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Arnbak B, Jurik AG, Jensen RK, Schiøttz-Christensen B, van der Wurff P, Jensen TS. The diagnostic value of three sacroiliac joint pain provocation tests for sacroiliitis identified by magnetic resonance imaging. Scand J Rheumatol 2016; 46:130-137. [PMID: 27498748 DOI: 10.1080/03009742.2016.1184308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of the current study was to investigate the diagnostic value of three sacroiliac (SI) joint pain provocation tests for sacroiliitis identified by magnetic resonance imaging (MRI) and stratified by gender. METHOD Patients without clinical signs of nerve root compression were selected from a cohort of patients with persistent low back pain referred to an outpatient spine clinic. Data from Gaenslen's test, the thigh thrust test, and the long dorsal sacroilia ligament test and sacroiliitis identified by MRI were analysed. RESULTS The median age of the 454 included patients was 33 (range 18-40) years and 241 (53%) were women. The prevalence of SI joints with sacroiliitis was 5%. In the whole study group, only the thigh trust test was associated with sacroiliitis, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.58 [95% confidence interval (CI) 0.51-0.65], sensitivity 31% (95% CI 18-47), and specificity 85% (95% CI 82-87). In men, sacroiliitis was associated with all the SI joint tests assessed and multi-test regimens, with the greatest AUC found for at least one positive out of three tests [AUC 0.68 (95% CI 0.56-0.80), sensitivity 56% (95% CI 31-79), and specificity 81% (95% CI 77-85)]. In women, no significant associations were observed between the SI joint tests and sacroiliitis. CONCLUSIONS Only in men were the SI joint tests found to be associated with sacroiliitis identified by MRI. Although, the diagnostic value was relatively low, the results indicate that the use of SI joint tests for sacroiliitis may be optimized by gender-separate analyses.
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Affiliation(s)
- B Arnbak
- a Research Department , Spine Centre of Southern Denmark, Hospital Lillebaelt , Middelfart , Denmark.,b Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - A G Jurik
- a Research Department , Spine Centre of Southern Denmark, Hospital Lillebaelt , Middelfart , Denmark.,b Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark.,c Department of Radiology , Aarhus University Hospital , Aarhus , Denmark
| | - R K Jensen
- a Research Department , Spine Centre of Southern Denmark, Hospital Lillebaelt , Middelfart , Denmark.,b Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - B Schiøttz-Christensen
- a Research Department , Spine Centre of Southern Denmark, Hospital Lillebaelt , Middelfart , Denmark.,b Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - P van der Wurff
- d Research and Development, Military Rehabilitation Centre Aardenburg , Doorn , The Netherlands.,e Department of Physiotherapy , HU University of Applied Sciences , Utrecht , The Netherlands
| | - T S Jensen
- a Research Department , Spine Centre of Southern Denmark, Hospital Lillebaelt , Middelfart , Denmark.,b Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
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Arnbak B, Grethe Jurik A, Hørslev-Petersen K, Hendricks O, Hermansen LT, Loft AG, Østergaard M, Pedersen SJ, Zejden A, Egund N, Holst R, Manniche C, Jensen TS. Associations Between Spondyloarthritis Features and Magnetic Resonance Imaging Findings: A Cross-Sectional Analysis of 1,020 Patients With Persistent Low Back Pain. Arthritis Rheumatol 2016; 68:892-900. [DOI: 10.1002/art.39551] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/10/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Bodil Arnbak
- Hospital Lillebaelt, Middelfart, Denmark, and University of Southern Denmark; Odense Denmark
| | - Anne Grethe Jurik
- Hospital Lillebaelt, Middelfart, Denmark, University of Southern Denmark, Odense, Denmark, and Aarhus University Hospital; Aarhus Denmark
| | - Kim Hørslev-Petersen
- University of Southern Denmark, Odense, Denmark, and King Christian 10th Hospital for Rheumatic Diseases; Graasten Denmark
| | - Oliver Hendricks
- University of Southern Denmark, Odense, Denmark, and King Christian 10th Hospital for Rheumatic Diseases; Graasten Denmark
| | - Louise Thuesen Hermansen
- University of Southern Denmark, Odense, Denmark, and King Christian 10th Hospital for Rheumatic Diseases; Graasten Denmark
| | - Anne Gitte Loft
- Hospital Lillebaelt, Vejle, Denmark, and Aarhus University Hospital; Aarhus Denmark
| | - Mikkel Østergaard
- Rigshospitalet, Glostrup, Denmark and University of Copenhagen; Copenhagen Denmark
| | | | | | | | - René Holst
- University of Southern Denmark; Odense Denmark
| | - Claus Manniche
- Hospital Lillebaelt, Middelfart, Denmark, and University of Southern Denmark; Odense Denmark
| | - Tue Secher Jensen
- Hospital Lillebaelt, Middelfart, Denmark, and University of Southern Denmark; Odense Denmark
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