Evaluation of a physician education intervention to improve primary care for low-back pain. II. Impact on patients

The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial

BACKGROUND

Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.

OBJECTIVE

Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.

METHODS

This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.

RESULTS

Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.

CONCLUSION

Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.

TRIAL REGISTRATION

clinicaltrials.gov NCT02777983 .

Effect of Motor Skill Training in Functional Activities vs Strength and Flexibility Exercise on Function in People With Chronic Low Back Pain: A Randomized Clinical Trial

Importance

Chronic low back pain (LBP) is the most prevalent chronic pain in adults, and there is no optimal nonpharmacologic management. Exercise is recommended, but no specific exercise-based treatment has been found to be most effective.

Objective

To determine whether an exercise-based treatment of person-specific motor skill training (MST) in performance of functional activities is more effective in improving function than strength and flexibility exercise (SFE) immediately, 6 months, and 12 months following treatment. The effect of booster treatments 6 months following treatment also was examined.

Design, Setting, and Participants

In this single-blind, randomized clinical trial of people with chronic, nonspecific LBP with 12-month follow-up, recruitment spanned December 2013 to August 2016 (final follow-up, November 2017), and testing and treatment were performed at an academic medical center. Recruitment was conducted by way of flyers, physician and physical therapy offices, advertisements, and media interviews at Washington University in St Louis, Missouri. Of 1595 adults screened for eligibility, 1301 did not meet the inclusion criteria and 140 could not be scheduled for the first visit. A total of 154 people with at least 12 months of chronic, nonspecific LBP, aged 18 to 60 years, with modified Oswestry Disability Questionnaire (MODQ) score of at least 20% were randomized to either MST or SFE. Data were analyzed between December 1, 2017, and October 6, 2020.

Interventions

Participants received 6 weekly 1-hour sessions of MST in functional activity performance or SFE of the trunk and lower limbs. Half of the participants in each group received up to 3 booster treatments 6 months following treatment.

Main Outcomes and Measures

The primary outcome was the modified Oswestry Disability Questionnaire (MODQ) score (0%-100%) evaluated immediately, 6 months, and 12 months following treatment.

Results

A total of 149 participants (91 women; mean [SD] age, 42.5 [11.7] years) received some treatment and were included in the intention-to-treat analysis. Following treatment, MODQ scores were lower for MST than SFE by 7.9 (95% CI, 4.7 to 11.0; P < .001). During the follow-up phase, the MST group maintained lower MODQ scores than the SFE group, 5.6 lower at 6 months (95% CI, 2.1 to 9.1) and 5.7 lower at 12 months (95% CI, 2.2 to 9.1). Booster sessions did not change MODQ scores in either treatment.

Conclusions and Relevance

People with chronic LBP who received MST had greater short-term and long-term improvements in function than those who received SFE. Person-specific MST in functional activities limited owing to LBP should be considered in the treatment of people with chronic LBP.

Trial Registration

ClinicalTrials.gov Identifier: NCT02027623.

Observational Study: Predictors of a Successful Functional Outcome in Persons Who Receive Physical Therapy for Knee Osteoarthritis

A retrospective design was employed to determine what factors are predictive of achieving a successful outcome for individuals with knee osteoarthritis following an episode of physical therapy. Success was defined as achieving the minimum clinically important difference with the change in the lower extremity functional scale (LEFS). Receiving guideline adherent care was hypothesized to increase odds of success. Data for treatment interventions, health care utilization, patient characteristics, and LEFS scores were collected from electronic health records from 2014-2018 across 34 outpatient clinics. The sample (N = 706) was primarily female, White, and older adults. Receiving guideline adherent care did not predict odds of achieving success. Patient age, initial LEFS score, opioid prescription, number of visits, and Medicare/Medicaid insurance were predictive of the outcome. Increasing age after 65 years predicted decreased odds of success. Older adults showed improved odds with an opioid prescription and with increased number of visits from two through 18 therapy sessions. Opportunities exist for further health services research on optimal management of knee OA, including underutilization of physical therapy (only 6% in this study), measuring adherence to CPGs, determining recommended intensity for interventions, and the effects of non-physical therapy interventions such as opioid use on outcomes.

Meditation in Stressed Older Adults: Improvements in self-rated mental health not paralleled by improvements in cognitive function or physiological measures

To determine if mindfulness meditation (MM) in older adults improves cognition and, secondarily, if MM improves mental health and physiology, 134 at least mildly stressed 50-85 year olds were randomized to a six-week MM intervention or a waitlist control. Outcome measures were assessed at baseline and two months later at Visit 2. The primary outcome measure was an executive function/attentional measure (flanker task). Other outcome measures included additional cognitive assessments, salivary cortisol, respiratory rate, heart rate variability, Positive and Negative Affect Schedule (PANAS), Center for Epidemiologic Studies Depression (CESD), Perceived Stress Scale (PSS), Neuroticism-Extraversion-Openness (NEO) personality traits, and SF-36 health-related quality of life. 128 participants completed the study though Visit 2 assessments. There was no significant change in the primary or other cognitive outcome measures. Even after statistical adjustment for multiple outcomes, self-rated measures related to negative affect and stress were all significantly improved in the MM intervention compared to wait-list group (PANAS-negative, CESD, PSS, and SF-36 health-related quality of life Vitality and Mental Health Component). The SF-36 Mental Health Component score improved more than the minimum clinically important difference. There were also significant changes in personality traits such as Neuroticism. Changes in positive affect were not observed. There were no group differences in salivary cortisol, or heart rate variability. These moderate sized improvements in self-rated measures were not paralleled by improvements in cognitive function or physiological measures. Potential explanations for this discrepancy in stress-related outcomes are discussed to help improve future studies.

Developing predictive models for return to work using the Military Power, Performance and Prevention (MP3) musculoskeletal injury risk algorithm: a study protocol for an injury risk assessment programme

BACKGROUND

Musculoskeletal injuries are a primary source of disability in the US Military, and low back pain and lower extremity injuries account for over 44% of limited work days annually. History of prior musculoskeletal injury increases the risk for future injury. This study aims to determine the risk of injury after returning to work from a previous injury. The objective is to identify criteria that can help predict likelihood for future injury or re-injury.

METHODS

There will be 480 active duty soldiers recruited from across four medical centres. These will be patients who have sustained a musculoskeletal injury in the lower extremity or lumbar/thoracic spine, and have now been cleared to return back to work without any limitations. Subjects will undergo a battery of physical performance tests and fill out sociodemographic surveys. They will be followed for a year to identify any musculoskeletal injuries that occur. Prediction algorithms will be derived using regression analysis from performance and sociodemographic variables found to be significantly different between injured and non-injured subjects.

DISCUSSION

Due to the high rates of injuries, injury prevention and prediction initiatives are growing. This is the first study looking at predicting re-injury rates after an initial musculoskeletal injury. In addition, multivariate prediction models appear to have move value than models based on only one variable. This approach aims to validate a multivariate model used in healthy non-injured individuals to help improve variables that best predict the ability to return to work with lower risk of injury, after a recent musculoskeletal injury.

TRIAL REGISTRATION NUMBER

NCT02776930.

Dose-response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial

BACKGROUND

Cervicogenic headache is a prevalent and costly pain condition commonly treated by chiropractors. There is evidence to support the effectiveness for spinal manipulation, but the dose of treatment required to achieve maximal relief remains unknown. The purpose of this paper is to describe the methodology for a randomized controlled trial evaluating the dose-response of spinal manipulation for chronic cervicogenic headache in an adult population.

METHODS/DESIGN

This is a mixed-methods, two-site, prospective, parallel groups, observer-blind, randomized controlled trial conducted at university-affiliated research clinics in the Portland, OR and Minneapolis, MN areas. The primary outcome is patient reported headache frequency. Other outcomes include self-reported headache intensity, disability, quality of life, improvement, neck pain intensity and frequency, satisfaction, medication use, outside care, cervical motion, pain pressure thresholds, health care utilization, health care costs, and lost productivity. Qualitative interviews are also conducted to evaluate patients' expectations of treatment.

DISCUSSION

With growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT01530321).

Efficacy of classification-specific treatment and adherence on outcomes in people with chronic low back pain. A one-year follow-up, prospective, randomized, controlled clinical trial

BACKGROUND

It is unknown if low back pain (LBP) outcomes are enhanced by classification-specific treatment based on the Movement System Impairment classification system. The moderating effect of adherence to treatment also is unknown.

OBJECTIVES

Compare the efficacy of a classification-specific treatment (CS) and a non classification-specific (NCs) treatment and examine the moderating effect of adherence on outcomes.

DESIGN

2 center, 2 parallel group, prospective, randomized, clinical trial.

METHOD

Participants with chronic LBP were classified and randomized. Self-report data was obtained at baseline, post-treatment, and 6 and 12 months post-treatment. The primary outcome was the modified Oswestry Disability Index (mODI; 0-100%). Treatment effect modifiers were exercise adherence and performance training adherence. An intention to treat approach and hierarchical linear modeling were used.

RESULTS

47 people received CS treatment, 54 people received NCs treatment. Treatment groups did not differ in mODI scores (p > 0.05). For both groups, scores improved with treatment (p < 0.05), plateaued at 6 months (p > 0.05), and minimally regressed at 12 months (p < 0.05). Performance training adherence had a unique, independent effect on mODI scores above and beyond the effect of exercise adherence (p < 0.05). There were no treatment group effects on the relationship between mODI scores and the two types of adherence (p < 0.05).

CONCLUSIONS

There were no differences in function between the two treatment groups (CS and NCs). In both treatment groups, people with chronic LBP displayed clinically important long-term improvements in function. When both forms of adherence were considered, the improvements were uniquely related to adherence to performance training.

COMParative Early Treatment Effectiveness between physical therapy and usual care for low back pain (COMPETE): study protocol for a randomized controlled trial

Background

Low back pain is among the leading causes of medical visits and lost duty days among members of the United States Armed Forces and represents the highest 5-year risk of permanent disability in the US Army. For certain elements of care, the timing may be just as important as the type of care. The purpose of this study is to assess the impact of the timing of access to a physical therapist by patients with low back pain, by looking at outcomes and low back pain-related healthcare utilization over a 1-year period.

Methods/Design

This trial will be a two-arm pragmatic randomized clinical trial occurring at two different clinical sites in the Military Health System. We will assess outcomes and related downstream costs for patients who access physical therapy at the primary care level compared to those that receive usual care only. There will be 220 consecutive patients randomized to receive care in either group (early physical therapy or usual care only) for the first 4 weeks, and these patients will then be allowed to receive any additional care dictated by their primary care provider for the following year. The primary outcome measure is the Oswestry Disability Index. Secondary outcome measures are the Global Rating of Change, Patient Satisfaction and 1-year healthcare utilization. Follow-ups will occur at 4 weeks, 3 months and 1 year.

Discussion

This trial takes a pragmatic approach to delivering care by enabling a usual care environment for managing low back pain, while also allowing immediate access to physical therapy. After the initial intervention, the patient’s primary provider can continue to manage the patient as he/she normally would in practice. The Military Health System Data Repository will capture all low back pain-related healthcare utilization that occurs in order to allow for a comparison between groups. Analysis from retrospective cohorts has shown improved outcomes and decreased costs for patients that received early versus late physical therapy, but this has yet to be shown in prospective trials.

Trial registration

ClinicalTrials.Gov NCT01556581 initially on 14 March 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0959-8) contains supplementary material, which is available to authorized users.

Prediction of pain outcomes in a randomized controlled trial of dose-response of spinal manipulation for the care of chronic low back pain

Background

No previous studies have created and validated prediction models for outcomes in patients receiving spinal manipulation for care of chronic low back pain (cLBP). We therefore conducted a secondary analysis alongside a dose-response, randomized controlled trial of spinal manipulation.

Methods

We investigated dose, pain and disability, sociodemographics, general health, psychosocial measures, and objective exam findings as potential predictors of pain outcomes utilizing 400 participants from a randomized controlled trial. Participants received 18 sessions of treatment over 6-weeks and were followed for a year. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with a light-massage control at all remaining visits. Pain intensity was evaluated with the modified von Korff pain scale (0–100). Predictor variables evaluated came from several domains: condition-specific pain and disability, sociodemographics, general health status, psychosocial, and objective physical measures. Three-quarters of cases (training-set) were used to develop 4 longitudinal models with forward selection to predict individual “responders” (≥50 % improvement from baseline) and future pain intensity using either pretreatment characteristics or post-treatment variables collected shortly after completion of care. The internal validity of the predictor models were then evaluated on the remaining 25 % of cases (test-set) using area under the receiver operating curve (AUC), R², and root mean squared error (RMSE).

Results

The pretreatment responder model performed no better than chance in identifying participants who became responders (AUC = 0.479). Similarly, the pretreatment pain intensity model predicted future pain intensity poorly with low proportion of variance explained (R² = .065). The post-treatment predictor models performed better with AUC = 0.665 for the responder model and R² = 0.261 for the future pain model. Post-treatment pain alone actually predicted future pain better than the full post-treatment predictor model (R² = 0.350). The prediction errors (RMSE) were large (19.4 and 17.5 for the pre- and post-treatment predictor models, respectively).

Conclusions

Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50 % improvement and the individual’s future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

A path analysis of the effects of the doctor-patient encounter and expectancy in an open-label randomized trial of spinal manipulation for the care of low back pain

BACKGROUND

The doctor-patient encounter (DPE) and associated patient expectations are potential confounders in open-label randomized trials of treatment efficacy. It is therefore important to evaluate the effects of the DPE on study outcomes.

METHODS

Four hundred participants with chronic low back pain (LBP) were randomized to four dose groups: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for six weeks. They received light massage control at visits when manipulation was not scheduled. Treating chiropractors were instructed to have equal enthusiasm for both interventions. A path analysis was conducted to determine the effects of dose, patient expectations of treatment success, and DPE on LBP intensity (100-point scale) at the end of care (6 weeks) and primary endpoint (12 weeks). Direct, indirect, and total standardized effects (βtotal) were computed. Expectations and DPE were evaluated on Likert scales. The DPE was assessed as patient-rated perception of chiropractor enthusiasm, confidence, comfort with care, and time spent.

RESULTS

The DPE was successfully balanced across groups, as were baseline expectations. The principal finding was that the magnitude of the effects of DPE on LBP at 6 and 12 weeks (|β|total = 0.22 and 0.15, p < .05) were comparable to the effects of dose of manipulation at those times (|β|total = 0.11 and 0.12, p < .05). In addition, baseline expectations had no notable effect on follow-up LBP. Subsequent expectations were affected by LBP, DPE, and dose (p < .05).

CONCLUSIONS

The DPE can have a relatively important effect on outcomes in open-label randomized trials of treatment efficacy. Therefore, attempts should be made to balance the DPE across treatment groups and report degree of success in study publications. We balanced the DPE across groups with minimal training of treatment providers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00376350.

Patient satisfaction with psychotropic drugs: Validation of the PAtient SAtisfaction with Psychotropic (PASAP) scale in patients with bipolar disorder

PURPOSE

The PAtient SAtisfaction with Psychotropic (PASAP) scale is a self-completed questionnaire measuring satisfaction with psychotropic medication. The aim of the study was to describe its development in French and its psychometric properties.

MATERIALS AND METHODS

Scale construction was based on an extensive search of the literature. The item reduction process required semi-structured interviews of psychiatric outpatients (n=30). The final version of the PASAP is a 9-item, 5-point Likert-type scale, covering the scope of effectiveness and adherence. To assess the psychometric properties of the scale, French patients with an acute manic episode (n=314) from a large European observational cohort completed the PASAP scale 3 months after psychotropic treatment initiation/change. Internal validity and reliability were assessed using principal component analysis (PCA). Concurrent validity was assessed using comparisons to physician-rated satisfaction with life, illness severity, mood relapse, compliance and side effects.

RESULTS

Participation rate was 68.4%. PCA was in favour of uni-dimensionality. Cronbach's α coefficient was 0.85 (95%CI 0.83-0.88). All five concurrent measures were significantly associated with the PASAP score.

CONCLUSION

The PASAP scale showed good psychometric properties in a large bipolar population and thus seems adequate for evaluating treatment satisfaction. Its short length and good acceptability makes it suitable for clinical research.

Back pain outcomes in primary care following a practice improvement intervention:- a prospective cohort study

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.

"They don't want anything to do with you": patient views of primary care management of chronic pain

OBJECTIVE

Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care.

DESIGN

Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish.

PATIENTS

Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts.

RESULTS

Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care.

CONCLUSIONS

Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

A preliminary path analysis of expectancy and patient-provider encounter in an open-label randomized controlled trial of spinal manipulation for cervicogenic headache

OBJECTIVE

The purpose of this article was to present a preliminary model to identify the effects of expectancy of treatment success and the patient-provider encounter (PPE) on outcomes in an open-label randomized trial.

METHODS

Eighty participants with chronic cervicogenic headache (CGH) were randomized to 4 groups: 2 levels of treatment dose (8 or 16) and 2 levels of therapy from a chiropractor (spinal manipulation or light massage). Providers were instructed to have equal enthusiasm for all care. Structural equation modeling with standardized path coefficients (beta) was used in a path analysis to identify the effects of patient expectancy and the PPE on CGH pain. The model included monthly pain from baseline to 12 weeks. Expectancy and PPE were evaluated on Likert scales. The patient-provider encounter was measured as patient perception of chiropractor enthusiasm, confidence, and comfort with care.

RESULTS

Baseline patient expectancy was balanced across groups. The PPE measures were balanced across groups and consistent over the 8-week treatment period. Treatment and baseline pain had the strongest effects on pain outcomes (|beta| = .46-.59). Expectations had little effect on pain (abs value(beta) < .15). The patient-provider encounter had a weak effect on pain (abs value(beta)= .03-.27) and on subsequent confidence in treatment success (abs value(beta)= .09 and .12).

CONCLUSIONS

Encouraging equipoise in the PPE and balancing expectancy across treatment groups may protect against some confounding related to the absence of blinding in a randomized controlled trial of pain. In this trial, their effects were found to be small relative to the effects of treatment and baseline values.

Quality of integrated chronic care measured by patient survey: identification, selection and application of most appropriate instruments

OBJECTIVE

To identify the most appropriate generic instrument to measure experience and/or satisfaction of people receiving integrated chronic care.

BACKGROUND

Health care is becoming more user-centred and, as a result, the experience of users of care and evaluation of their experience and/or satisfaction is taken more seriously. It is unclear to what extent existing instruments are appropriate in measuring the experience and/or satisfaction of people using integrated chronic care.

METHODS

Instruments were identified by means of a systematic literature review. Appropriateness of instruments was analysed on seven criteria. The two most promising instruments were translated into Dutch, if necessary, and administered to a convenience sample of 109 people with a chronic illness. Data derived from respondents were analysed statistically. Focus-group interviews were conducted to assess the semantic and technical equivalence as well as opinions of people about the applicability and relevance of the translated instruments.

RESULTS

From 37 instruments identified, the Patients' Assessment of Care for chronIc Conditions (PACIC) and the short form of the Patient Satisfaction Questionnaire III (PSQ-18) were selected as most promising instruments. Both instruments produced similar median scores across people with different chronic conditions. The overall PACIC and its subscales and the overall PSQ-18 were highly internally consistent, but not the PSQ-18 subscales. Overall, the PACIC demonstrated better psychometric characteristics. PACIC and PSQ-18 scores were found to be moderately correlated. Whereas more respondents preferred the PSQ-18, focus-group participants regarded the PACIC to be more applicable and relevant. The technical and semantic equivalence of both instruments were sufficient.

CONCLUSIONS

Because of its psychometric characteristics, perceived applicability and relevance, the PACIC is the most appropriate instrument to measure the experience of people receiving integrated chronic care.

A pilot mixed methods study of patient satisfaction with chiropractic care for back pain

OBJECTIVE

Patient satisfaction is important to payers, clinicians, and patients. The concept of satisfaction is multifactorial and measurement is challenging. Our objective was to explore the use of a mixed-methods design to examine patient satisfaction with chiropractic care for low back pain.

METHODS

Patients were treated 3 times per week for 3 weeks. Outcomes were collected at week 3 and week 4. Qualitative interviews were conducted by the treating clinician and a nontreating staff member. Outcome measures were the Roland Morris Back Pain Disability Questionnaire, the visual analog scale for pain, and the Patient Satisfaction Scale. Interviews were recorded and transcribed and analyzed for themes and constructs of satisfaction. We compared qualitative interview data with quantitative outcomes, and qualitative data from 2 different interviewers.

RESULTS

All patients reported high levels of satisfaction. Clinical outcomes were unremarkable with little change noted on visual analog scale and Roland Morris Back Pain Disability Questionnaire scores. We categorized patient comments into the same constructs of satisfaction as those identified for the Patient Satisfaction Scale: Information, Effectiveness, and Caring. An additional construct (Quality of Care) and additional subcategories were identified. Satisfaction with care is not explained by outcome alone. The qualitative data collected from 2 different interviewers had few differences.

CONCLUSION

The results of this study suggest that it is feasible to use a mixed-methods design to examine patient satisfaction. We were able to refine data collection and analysis procedures for the outcome measures and qualitative interview data. We identified limitations and offer recommendations for the next step: the implementation of a larger study.

Effects of two guideline implementation strategies on patient outcomes in primary care: a cluster randomized controlled trial

STUDY DESIGN

Cluster randomized controlled trial.

OBJECTIVE

To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention.

SUMMARY OF BACKGROUND DATA

International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen.

METHODS

We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders.

RESULTS

After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls.

CONCLUSION

Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Patients' attitudes and beliefs about back pain and its management after physiotherapy for low back pain

BACKGROUND AND PURPOSE

Contemporary guidelines for the management of low back pain often consider patient involvement and responsibility an essential component; however, there has been little exploration of patients' opinions about back pain and its management.

METHOD

A qualitative study of patients' perspectives of back pain in the UK; 34 semi-structured interviews were conducted with participants who had recently received physiotherapy for back pain; interviews were transcribed and analysed using framework analysis. A topic guide was used to steer the interview and themes were extracted from the data.

RESULTS

Thirteen key themes were revealed; seven of these related to issues of satisfaction with physiotherapy and are described elsewhere. The six themes considered here dealt with the participants' experience of and attitudes to back pain and its management. Themes were: the impact of back pain on their life; perspectives about back pain; its management; their involvement in its management; what strategies they had for self-management; and expectations about the episode of physiotherapy beforehand.

CONCLUSIONS

In this group of participants with a history of back pain and physiotherapy treatment a common finding was a degree of acceptance of the back pain problem and the belief that patient involvement in management was essential. These findings would suggest that many patients with back pain may respond positively to the message of self-management. However, acceptance of this message was not automatic, but generally occurred gradually in line with patients' experience of back pain and treatment.

The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study

OBJECTIVE

This study describes both positive clinical outcomes and adverse events in patients treated for neck pain by a chiropractor.

METHODS

This study was a prospective, multicenter, observational cohort study. Patients with neck pain of any duration who fulfilled the inclusion criteria were recruited in a practice-based study. Data were collected on the patients and from the chiropractors at baseline, the first 3 visits, and at 3 and 12 months. Clinical outcome measures included (1) neck pain in the 24 hours preceding the visit, (2) neck disability, (3) treatment satisfaction, (4) global assessment, and (5) adverse events. Recovery was defined as "completely improved" or "much better" using the global assessment scale. An adverse event was defined as either a new related complaint or a worsening of the presenting or existing complaint by >30% based upon an 11-point numerical rating scale.

RESULTS

In all, 79 chiropractors participated, recruiting 529 subjects, representing 4891 treatment consultations. Follow-up was possible for 90% and 92%, respectively, at 3 and 12 months. Most patients had chronic, recurrent complaints; mild to moderate disability of the neck; and a mild amount of pain at baseline; and two thirds had sought previous care for the presenting complaint in the preceding 6 months. Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (<8%). Only 5 subjects (1%) reported to be much worse at 12 months. No serious adverse events were recorded during the study period. Of the patients who returned for a fourth visit, approximately half reported to be recovered, whereas approximately two thirds of the cohort were recovered at 3 and 12 months.

CONCLUSION

Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.

The challenge of using the low back pain guidelines: a qualitative research

PURPOSE

Current low back pain (LBP) clinical guidelines have helped to summarize the scientific evidence and research, but have failed to provide tools and guide family physicians (FPs). The purpose of this study is to identify barriers and facilitators for the implementation of LBP guidelines from family FPs' perspective.

METHODS

A qualitative focus group study of FPs in the north of Israel. Purposeful sampling was used to recruit participants, all of them board-certified FPs. Four focus groups were created, and discussions were taped, transcribed and analysed for major themes.

RESULTS

Focus groups findings have expanded the understanding of the intellectual and mental challenges faced by Israeli FPs caring for LBP patients and highlighted the many obstacles to implementing LBP guidelines. Physicians' decision-making, pertaining to LBP, functions on three levels simultaneously: the physicians' agenda based on familiarity with the guidelines; their need to remain grounded in the context of the specific patient-doctor relationship; and the constraints and demands of the physician's workplace, medical system and environment.

CONCLUSIONS

Despite an overall positive attitude towards LBP guideline implementation, FPs found it hard to come to terms with the conflicting dimensions of LBP patient care. The patient-doctor interaction determined the outcome of the encounter, whether it complied with the guidelines and whether the encounter leads to a healing process or to a vicious circle of unnecessary utilization of services.

Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study

STUDY DESIGN

Observational study conducted within a randomized clinical trial.

OBJECTIVES

The objective of this study is to estimate the effects of patient satisfaction on subsequent changes in pain and disability among low back pain patients randomized to chiropractic or medical care in a managed-care practice setting.

SUMMARY OF BACKGROUND DATA

Recent studies of low back pain treatments have shown chiropractic patients to be more satisfied with their care than medical patients. However, little is known about the relation between patient satisfaction and clinical outcomes.

METHODS

A total of 681 low back pain patients presenting to three southern California healthcare clinics and screened for serious spinal pathology and contraindications were randomized to medical care with and without physical therapy, and chiropractic care with and without physical modalities, and followed for 18 months. Satisfaction with back care was measured on a 40-point scale and observed at 4 weeks following randomization. The primary outcome variables, observed between 6 weeks and 18 months of follow-up, are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire, and remission from clinically meaningful pain and disability. Perceived change in low back symptoms was a secondary outcome.

RESULTS

Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10-point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18-month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients.

CONCLUSIONS

Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.

Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain

BACKGROUND

The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.

METHODS

We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses.

RESULTS

In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31.

CONCLUSION

Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.

Cost-effectiveness of an intensive group training protocol compared to physiotherapy guideline care for sub-acute and chronic low back pain: design of a randomised controlled trial with an economic evaluation. [ISRCTN45641649]

Background

Low back pain is a common disorder in western industrialised countries and the type of treatments for low back pain vary considerably.

Methods

In a randomised controlled trial the cost-effectiveness and cost-utility of an intensive group training protocol versus physiotherapy guideline care for sub-acute and chronic low back pain patients is evaluated. Patients with back pain for longer than 6 weeks who are referred to physiotherapy care by their general practitioner or medical specialist are included in the study. The intensive group training protocol combines exercise therapy with principles of behavioural therapy ("graded activity") and back school. This training protocol is compared to physiotherapy care according to the recently published Low Back Pain Guidelines of the Royal Dutch College for Physiotherapy. Primary outcome measures are general improvement, pain intensity, functional status, work absenteeism and quality of life. The direct and indirect costs will be assessed using cost diaries. Patients will complete questionnaires at baseline and 6, 13, 26 and 52 weeks after randomisation.

Discussion

No trials are yet available that have evaluated the effect of an intensive group training protocol including behavioural principles and back school in a primary physiotherapy care setting and no data on cost-effectiveness and cost-utility are available.

A primary care musculoskeletal clinic for residents: success and sustainability

Musculoskeletal complaints are common, but are often underemphasized in residency training. We evaluated the experience of residents (12) in 4 sessions of an innovative concentrated ambulatory, community-based musculoskeletal (MS) clinic precepted by general internists with additional training in teaching MS medicine. Compared with the year long longitudinal house staff (HS) clinic experience, the mean number of musculoskeletal diagnoses per resident seen in MS clinic was higher (13.9 [standard deviation 4.0] vs 5.4 [standard deviation 4.0]; P <.01). Common diagnoses in MS clinic included shoulder, hip, and knee tendonitis/bursitis, and the majority of diagnoses in HS clinic were nonspecific arthralgia (66%). Fifty-two injections were performed in MS clinic over the year, compared with one in HS clinic.

Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study

BACKGROUND

Minor side effects associated with chiropractic are common. However, little is known about their predictors or the effects of reactions on satisfaction and clinical outcomes.

OBJECTIVE

The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain.

METHODS

Neck pain patients were randomized to receive cervical spine manipulation or mobilization. At 2 weeks, subjects were queried about possible treatment-related adverse reactions and followed for 6 months with assessments for pain and disability at 2, 6, 13, and 26 weeks. Numerical rating scales and the Neck Disability Index were used to measure pain and disability. Perceived improvement and satisfaction with care were assessed at 4 weeks.

RESULTS

Of 960 eligible patients, 336 enrolled and 280 responded to the adverse event questionnaire. Thirty percent of respondents reported at least 1 adverse symptom, most commonly increased pain and headache. Patients randomized to manipulation were more likely than those randomized to mobilization to report an adverse reaction (adjusted odds ratio = 1.44, 95% confidence interval = 0.85, 2.43). Subjects reporting adverse reactions were less satisfied with care and less likely to have clinically meaningful improvements in pain and disability.

CONCLUSIONS

Adverse reactions are more likely to be reported following cervical spine manipulation than mobilization. Chiropractors may reduce iatrogenesis and increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.

Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain

OBJECTIVE

The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain.

DESIGN

Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation.

PARTICIPANTS

Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices.

INTERVENTIONS

Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain.

MAIN RESULTS

The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior.

CONCLUSIONS

Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.

Developing patient-centred information for back pain sufferers

OBJECTIVE

To identify information needs among a group of back pain sufferers as well as the barriers that may prevent them from accessing this information.

DESIGN

Data were collected through the use of open, in-depth interviews, through contributions to the Norwegian Back Pain Association's online discussion list, and through a search of the literature.

PARTICIPANTS

Norwegian back pain sufferers and their carers.

MAIN VARIABLES STUDIED

Information needs and barriers.

RESULTS

The informants described information needs that covered a wide range of topics, clinical, financial, emotional and social. Informants wanted to understand the cause of their pain and wanted information about existing diagnoses and diagnostic procedures. Informants asked for information about treatment alternatives, both within and outside the established health-care system, the effects of these treatment alternatives, their procedures, side-effects and costs. In addition, informants wanted information about the social and emotional effects of long-term pain; coping with everyday life; other people's experiences; and about welfare benefits and patient rights. Barriers to this information included the use of medical, legal and other jargon, doctors' lack of time, lack of communication skills, lack of knowledge about back pain and attitudes to back pain patients.

CONCLUSIONS

To successfully address the questions and concerns of users, there should be an attempt to present information on as many of these topics as possible. Information should be presented in the user's own language, at several levels of understanding, and should include both evidence- and experienced-based knowledge.

Evaluation of the impact of a low back pain educational intervention on physicians' practice patterns and patients' outcomes

This study was designed to evaluate the effects of an educational intervention on physicians' management of low back pain patients. The study universe composed of 64 providers employed by a large occupational health group, with 4411 LBP cases pretraining and 4665 cases posttraining selected from the organization's database. The control group had 151 providers with 8478 pretraining and 8876 posttraining cases. Results showed that practices of physicians who participated in the intervention strategy underwent significant changes between the two intervals. Specifically, the intervention group reduced the percentage of restricted work cases, reduced the percentage of lost-time cases for male patients and female patients (less than 40 years old), and shortened restricted workday duration and total case duration for female patients. These results provide early indication for the effectiveness of this type of educational intervention strategy.

Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study

OBJECTIVES

This study examined the difference in satisfaction between patients assigned to chiropractic vs medical care for treatment of low back pain in a managed care organization.

METHODS

Satisfaction scores (on a 10-50 scale) after 4 weeks of follow-up were compared among 672 patients randomized to receive medical or chiropractic care.

RESULTS

The mean satisfaction score for chiropractic patients was greater than the score for medical patients (crude difference = 5.5; 95% confidence interval = 4.5, 6.5). Self-care advice and explanation of treatment predicted satisfaction and reduced the estimated difference between chiropractic and medical patients' satisfaction.

CONCLUSIONS

Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients' satisfaction.

Implementation barriers for general practice guidelines on low back pain a qualitative study

STUDY DESIGN

Qualitative study design, using semi-structured interviews.

OBJECTIVE

To explore factors that determine non-adherence to the guidelines for low back pain.

SUMMARY OF BACKGROUND DATA

Guidelines for low back pain have been published in the past decade in various countries. In the Netherlands, general practitioners adhere to them to a fair extent, and it is unclear whether room for improvement remains.

METHODS

Forty semistructured, in-depth interviews were conducted with twenty patients who consulted for low back pain, and with their general practitioners. The interviews were fully transcribed and analyzed qualitatively.

RESULTS

Patients often had limited expectations of the consultation. They wanted to hear a diagnosis or expected to receive simple advice. The general practitioners said they were well informed about the guideline and mostly agreed with its content. Reasons for non-adherence were mainly related to patients' experiences in the past and general practitioners' interpretations of their preferences. General practitioners stated that they were inclined to give in to patients' demands, for example the request for radiographic films or a referral to a physical therapist. In general, patients and their general practitioners were satisfied with the chosen management.

CONCLUSIONS

Improvement of the quality of back pain care may still be possible. Implementation strategies should aim at training physicians in communication skills, especially about subjects for debate, where patients' beliefs and experiences color their expectations.

The characteristics of patient satisfaction measures

Information on patient satisfaction is considered a way of including patients' perspectives in the planning and assessment of services. The study of patient satisfaction is a relatively new field, and despite the surge in popularity and use of satisfaction measures during the past three decades, different issues remain to be explored. This is not meant to dissuade clinicians from using satisfaction measures, but rather to allow them to proceed in a thoughtful way, recognizing what these measures can reasonably show us about patients' perceptions of the care and treatment interventions they receive. The proposed approach to classifying the characteristics of patient satisfaction measures should help to highlight potential reasons for variation in results when satisfaction measures perform differently and will be of value if it increases the specificity with which clinicians select measures to achieve their purposes.

Training primary care physicians to give limited manual therapy for low back pain: patient outcomes

STUDY DESIGN

Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice.

OBJECTIVES

To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain.

SUMMARY OF BACKGROUND DATA

Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training.

METHODS

Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care.

RESULTS

No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02).

CONCLUSION

Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Continuous quality improvement for patients with back pain

Recent evidence has changed traditional approaches to low back pain, suggesting minimal bed rest, highly selective imaging, and early return to normal activities. However, there are wide geographical variations in care, and substantial gaps between practice and evidence. This project sought to merge scientific evidence about back pain and knowledge about behavior change to help organizations improve care for back pain. Participating insurance plans, HMOs, and group practices focused on problems they themselves identified. The year-long program included quarterly meetings, coaching for rapid cycles of change, a menu of potential interventions, and recommendations for monitoring outcomes. Participants interacted through meetings, e-mail, and conference calls. Of the 22 participating organizations, 6 (27%) made major progress. Typical changes were reduced imaging, bed rest, and work loss, and increased patient education and satisfaction. Specific examples were a 30% decrease in plain x-rays, a 100% increase in use of patient education materials, and an 81% drop in prescribed bed rest. Despite the complexity of care for back pain, rapid improvements appear feasible. Several organizations had major improvements, and most experienced at least modest improvements. Key elements of successful programs included focus on a small number of clinical goals, frequent measurement of outcomes among small samples of patients, vigilance in maintaining gains; involvement of office staffs as well as physicians, and changes in standard protocols for imaging, physical therapy, and referral.

Association between recovery outcomes for work-related low back disorders and personal, family, and work factors

STUDY DESIGN

Incident cases of work-related low back disorders were identified in an automotive metal stamping plant. Individuals were asked to recall health and work habits at the time of diagnosis of the work-related disorder and to report their current low back pain and physical functioning.

OBJECTIVES

To evaluate five measures of health outcomes for work-related low back disorders in an industrial population and to determine potentially modifiable correlates of recovery.

SUMMARY OF BACKGROUND DATA

The factors that influence recovery in actively working adults and how to best measure recovery outcome in this population are not well known.

METHODS

Eighty-eight hourly employees of a metal stamping plant who experienced a work-related low back disorder were interviewed. Health status, health habits, and family and work relations were assessed with a structured interview to determine their association with various recovery outcomes (low back pain, low back pain disability, physical functioning, general physical health, and lost workdays). Interview information was supplemented with data from the plant's Occupational Safety and Health Administration Form 200 log.

RESULTS

The clinical measures of recovery from the work-related low back disorders examined had similar overall predictive ability. However, in multivariate analyses, different potentially modifiable prognostic variables emerged as significant among them. Poorer self-rated health status and high personal stress were correlated with low back pain disability. Higher levels of cigarette smoking were correlated with higher levels of low back pain disability, lower physical functioning, and more severe low back pain at follow-up.

CONCLUSION

The choice of measure of recovery from work-related low back disorders should be made in the context of the rehabilitation intervention goal. Interventions designed to modify and promote healthful personal behavior should be given more emphasis in rehabilitation efforts for work-related low back disorders.

Continuing medical education-driven skills acquisition and impact on improved patient outcomes in family practice setting

BACKGROUND

An abundance of educational theory, design, and delivery of continuing medical education (CME) learning interventions, including their impact on learners, are described in the health and social sciences literature. However, establishing a direct correlation between the acquisition of new skills by learners and patient outcomes as a result of a planned CME learning intervention has been difficult to demonstrate.

METHODS

The learning intervention described here tested the impact of an injection skills-acquisition program for family physicians treating osteoarthritis of the knee by measuring patient outcomes using the pain and function subscales of the Western Ontario and McMaster (WOMAC) 3.0 osteoarthritis index, a standardized and fully validated patient-centered outcome measurement. It was hypothesized that patients of family physicians who participated in this skills-acquisition CME program would benefit from treatment administered by their physician during the time between injection skills acquisition to 6 weeks post-injection. Inclusion of a validated health status measure administered pre- and post-injection in addition to more traditional faculty and participant program evaluations was deemed necessary to test this hypothesis. Rheumatology, orthopedic surgery, and family medicine specialists from across Canada were invited to contribute to the planning, curriculum elaboration, and delivery of the viscosupplement injector preceptorship (VIP) program. Thirty-nine orthopedic and rheumatology specialists agreed to serve as expert faculty and participated in training 474 Canadian family and general practitioners over 8 months. The learning intervention involved a review of pertinent literature by a local preceptor and a summary of recommendations of the planning committee, followed by demonstration of injector skills and then supervised practice with patients, who received hylan G-F 20 (Synvisc, Ridgefield, NJ) usually in the offices of the family physicians. The pain and function subscales of the WOMAC 3.0 questionnaire were self-administered to each patient in their physician's office, prior to receiving their joint injection and again at or near 6-weeks post-injection. Data were analyzed in the Department of Epidemiology and Biostatistics at The University of Western Ontario, London, ON.

RESULTS

Clinically important statistically significant improvements in pain and physical function were noted in patients who received viscosupplementation treatment from family physicians who had recently acquired the necessary injection skills. Approximately three-quarters of the patients experienced a reduction in pain and an improvement in physical function of at least 20%.

IMPLICATIONS

These results suggest a positive relationship between acquisition of a new skill by learners and improved patient outcomes as a result of this planned CME learning intervention.

Developing occupational and environmental medicine curricula for primary care residents: project EPOCH-Envi. Educating Physicians in OCupational Health and the Environment

To help primary care residency programs develop or improve residency curricula in occupational and environmental medicine, the National Institute for Occupational Safety and Health launched a train-the-trainer initiative. This project was called EPOCH-Envi (Educating Physicians in OCcupational Health and the Environment). From 1990 to 1996, 46 2-day curriculum development workshops were held. These featured (1) guidelines on how to plan, implement, and evaluate a curriculum, (2) continuing education on occupational illnesses and injuries, (3) a worksite or environmental site visit, and (4) information resources. A total of 435 faculty from 305 residency programs participated, representing 42.5% of the family practice residencies and 24.9% of the internal medicine residencies in the United States. A survey conducted among attendees (60.4% response rate) 17 months after their workshop revealed that 65.6% of respondents had added lectures on occupational and environmental topics to the residency curriculum. Other curriculum improvements were also made. Primary care physicians manage most patients with occupational and environmental health problems or concerns. Providing technical assistance specifically designed to support occupational and environmental health education in primary care residencies can have a positive impact on curriculum content.

Reasons for repeated medical visits among patients with chronic back pain

OBJECTIVE

This study identifies the key motivations of patients repeatedly seeking medical care for chronic back problems.

DESIGN

We conducted one-on-one, in-depth interviews with patients to discuss their experiences with low back pain and its care. To validate our interpretation of the qualitative data, participants were mailed questionnaires listing the themes identified in the interviews and asked to rate the importance to them of each of the themes.

SETTING

Managed health care plans in Atlanta, Dallas, and Seattle.

PARTICIPANTS

Fifty-four patients (37% male, 63% female) who were 25 to 65 years of age and had three or more medically attended episodes of low back pain during the 3 years preceding the study.

MAIN RESULTS

In describing their motivations for seeking medical care for back pain, nearly all participants cited difficulty in performing normal activities and the desire to discover the cause of the pain. Other motivations for seeking medical care for back pain included increased pain and the desire for a diagnostic test or a new treatment. Many of the verbalized reasons for repeated medical visits among patients with chronic back pain are probably best understood as seeking validation of their suffering.

CONCLUSIONS

Patients with chronic back pain report many unmet needs and expectations. Overall satisfaction might be improved if clinicians elicit patients' views of underlying causes and their expectations from office visits.

Educational and behavioral interventions for back pain in primary care

STUDY DESIGN AND OBJECTIVES

A review of the literature was undertaken to identify and summarize randomized trials of educational, cognitive, and behavioral interventions for people with chronic low back pain.

SUMMARY OF BACKGROUND DATA

Studies of back schools have varied widely in patient characteristics, back school length and content, and comparison treatment. The available evidence suggests that back schools do not affect long-term outcomes of people with back pain.

METHODS

MEDLINE and PsycLIT databases were searched to identify randomized trials of cognitive and behavioral treatments for chronic low back pain. Outcome data were extracted from articles that met the meta-analysis inclusion criteria.

RESULTS

The meta-analysis found that cognitive and behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain behavior, and disability. Follow-up comparisons of cognitive and behavioral treatments versus control conditions were not available. This meta-analysis did not find cognitive and behavioral therapies to differ from other active treatments on specific outcome measures, although only a few studies were available for each measure.

CONCLUSION

It may be useful to incorporate cognitive-behavioral interventions in primary care settings, but additional research is needed to evaluate their efficacy in improving specific outcomes.

The gap between back pain patients' prior knowledge and scientific knowledge and its evolution after a back school teaching programme: a quantitative evaluation

This study presents a method for quantitative evaluation of the congruence between patients' representations and teachers' scientific knowledge, which is used as the standard of assessment. First, the patients' knowledge and the teachers' scientific concepts before a back school (BS) programme were compared (T0). Then the evolution of patients' knowledge at 1 month (T1) and 1 year (T2) after the teaching was evaluated. Patients' knowledge was assessed blind by a multidisciplinary panel of nine independent judges. Mean scores were computed for each set of data (T0,T1,T2); these scores were then submitted to an analysis of variance. The results showed an important gap between patients and teachers before BS with an improvement after the teaching. Knowledge referring to know-how and/or attitudes evolved differently when compared to theoretical knowledge.

Pitfalls of patient education. Limited success of a program for back pain in primary care

STUDY DESIGN

Low back pain patients seen in primary care were allocated randomly to one of two educational interventions or to usual care.

OBJECTIVE

To evaluate educational interventions designed to improve the outcomes of primary care for low back pain.

SUMMARY OF BACKGROUND DATA

Patients with back pain are frequently dissatisfied with their medical care and identify lack of information as the most insufficient aspect.

METHODS

In a large Health Maintenance Organization clinic, 293 subjects were allocated randomly to receive usual care, an educational booklet, or a 15-minute session with a clinic nurse, including the booklet and a follow-up telephone call. Outcome measures included satisfaction with care, perceived knowledge, participation in exercise, functional status, symptom relief, and health care use. Outcomes were assessed 1, 3, 7, and 52 weeks after the intervention.

RESULTS

The nurse intervention resulted in higher patient satisfaction than usual care (P < 0.001) and higher perceived knowledge (P < 0.001). Self-reported exercise participation was also higher in the nurse intervention group after a 1-week follow-up period (97% vs. 65% in the other groups; P < 0.0001). There were no significant differences among the three groups in worry, symptoms, functional status, or health care use at any follow-up interval. Differences in self-reported exercise and perceived knowledge were no longer significant after 7 weeks.

CONCLUSIONS

These findings challenge the value of purely educational approaches in reducing functional impact or health care use related to back pain and also challenge the value of fitness exercise in the most acute phase of back pain.

Chronic back pain and work disability: Vocational outcomes following multidisciplinary rehabilitation

Studies indicate that work disabled chronic back pain patients out of work for longer than three months have a reduced probability of returning to work. The escalating personal and economic costs (indemnity and health care) associated with such long term disability have facilitated efforts at multiple levels to prevent and more effectively manage work disability. Multidisciplinary rehabilitation (MDR) targeted at return to work represents one such approach. The approach is based upon a multidimensional conceptualization of work disability and integrates medical, physical, psychological, educational and vocational interventions to increase physical function, reduce pain, increase stress coping skills and facilitate return to work. Seven outpatient multidisciplinary rehabilitation outcome studies for chronic back pain were identified that met the following selection criteria: 1) diagnosis of back pain, low back pain, spinal disorder (specific and nonspecific diagnosis), 2) chronic back pain of either longer than three months since injury or longer than three months absence from work, 3) use of an outpatient multidisciplinary rehabilitation approach that included some combination of medical management, physical conditioning, pain and stress management, vocational counseling/placement and education regarding back safety and health, and 4) work reentry was the primary focus of outcome. These were reviewed to determine the effectiveness of MDR in terms of return to work outcome. Analyses revealed that an average of 71 percent of work disabled chronic back pain patients who completed a multidisciplinary rehabilitation program were working or involved in vocational rehabilitation efforts at 12 month follow-up in contrast to an average of 44 percent in corresponding comparison groups. While these studies suggest the clinical utility of a multidisciplinary approach as compared to usual care in facilitating return to work for chronic back pain patients, the literature was characterized by several methodological limitations including the absence of randomization in the majority of studies, use of insurance company denials as control groups, heterogenous samples in terms of duration of work disability, job availability at discharge, extent of impairment and disability, age and duration of pain disorder, lack of specification as to exact treatment delivered in the control or usual care groups and varying definitions of return to work outcome. Research on predictors of return to work outcome following MDR were identified and included variables in five categories: demographics, medical history, physical findings, pain and psychological characteristics. The literature provides support for the use of integrated approaches that target the medical, physical, ergonomic and psychosocial factors that can exacerbate and/or maintain work disability. Future research should address current methodological limitations in the literature and focus on: 1) identifying critical treatment components of such approaches, 2) developing innovative screening methods to identify high risk cases to facilitate earlier more targeted efforts to assist such individuals, and 3) consider variations in the staging of various combinations of interventions in an effort to develop more cost-effective variations in the multidisciplinary approach.