Health care utilization for low back pain in Belgium. Influence of sociocultural factors and health beliefs

Factors associated with seeking medical care for low back pain in a twin adult sample

BACKGROUND

Previous studies have only investigated how symptom presentation and socio-demographic factors influence care-seeking for low back pain (LBP). However, the influence of health and lifestyle factors remains unclear, and the potential confounding effects of aggregated familial factors (including genetics and the early shared environment) has not been considered extensively.

METHODS

A cross-sectional analysis was performed on 1605 twins enrolled in the Murcia Twin Registry (Spain). The outcome was seeking medical care for LBP and various self-reported demographic, health and lifestyle factors were considered predictors. All variables except sleep quality and diabetes were collected in 2013, which were cross-referenced from 2009 to 2010. A multivariate logistic regression model was performed on the total sample, followed by a co-twin case-control analysis.

RESULTS

The only significant factor found to increase the odds of seeking medical care for LBP without being affected by familial factors was poor sleep quality (total sample OR = 1.58, 95%CI 1.24-2.01; case-control OR = 1.75, 95%CI 1.14-2.69). The factors that were associated with reduced odds of seeking medical care for LBP and not confounded by familial factors were male sex (case-control OR = 0.55, 95%CI 0.33-0.93), alcohol intake (case-control OR = 0.90, 95%CI 0.82-0.99) and a history of diabetes (case-control OR = 0.50, 95%CI 0.25-0.97). No other factors significantly influenced medical care-seeking for LBP.

CONCLUSIONS

People reporting poor sleep quality are more likely to seek medical care for LBP in the long term, with this relationship being independent from aggregated familial factors. Conversely, males, people reporting higher alcohol intake, and people with a history of diabetes are less likely to seek medical care for LBP.

SIGNIFICANCE

This is the first study investigating the factors that influence seeking medical care for LBP, while adjusting for the influence of familial factors using a co-twin control design. Poor sleep quality is associated with seeking medical care for LBP in the long term and does not appear to be confounded by familial factors. Early screening for indicators of poor sleep quality and appropriate referral to interventions for improving sleep quality or reducing pain in sleep may improve LBP management.

Determinants of healthcare utilisation for low back pain: A population-based study in Ethiopia

Low back pain (LBP) remains one of the major public health problems worldwide. However, in low-income countries, such as those in Africa, the epidemiological data on healthcare utilisation for LBP are lacking due to more pressing problems such as infectious diseases, to which the majority of health resources are channelled. Therefore, this study aimed at investigating the determinants of healthcare utilisation for LBP in the general population of Ethiopia. A population-based cross-sectional study was conducted in South-West Shewa zone of Ethiopia from June to November 2018. The data were collected by interviewing adults with LBP (n = 1812, randomly selected) using a psychometrically tested and validated instrument, analysed using R version 3.5.1. A log-binomial regression model was used to determine the prevalence ratio with a 95% confidence interval (CI) in identifying factors associated with healthcare utilisation for LBP. Estimates of population parameters were also presented with 95% CIs and p values. For all applications of inferential statistics, a p value of ≤.05 was taken as the significance level. The lifetime prevalence of healthcare utilisation for LBP was 36.1%, 95% CI: 33.9-38.1, while the annual prevalence rate was 30%, 95% CI: 27.9-32.2. Of those with a 1-year history of healthcare utilisation, while 7.4%, 95% CI: 4.9-10.3 rural and 36.6%, 95% CI: 29.5-44 urban populations utilised healthcare from general hospitals, 1.4%, 95% CI: 0.3-2.7 rural and 6.8%, 95% CI: 3.1-10.8 urban populations utilised healthcare from specialised hospitals. Several sociodemographic factors, modifiable health behaviours/lifestyle habits, pain interrelated factors, and specific factors such as beliefs about the pain, depressive symptoms and insomnia were associated with healthcare utilisation for LBP. The implications of this research are that it may be prudent for the Ethiopian healthcare policy makers to develop the necessary strategies to meet the health needs of both urban and rural populations with LBP.

Relationship between healthcare seeking and pain expansion in patients with nonspecific chronic low back pain

Objectives

Low back pain (LBP) is the most prevalent musculoskeletal problem, which implies a high rate of chronicity. The chronicity of symptoms can lead to pain expansion. The main objective of this study was to assess whether there were differences between patients with nonspecific chronic LBP (CLBP) who sought healthcare compared to those who did not in terms of pain expansion.

Methods

Ninety individuals participated in the study and were divided into three groups: 30 patients who sought care; 30 patients who did not seek care; and 30 asymptomatic individuals. The primary variable analyzed was pain expansion. Secondary physical and psychological variables were assessed later, and a regression analysis was performed.

Results

Patients who sought help showed significant differences in pain expansion and pain intensity compared with the group who did not seek help, with a medium effect size (0.50–0.79). The regression model for the care-seeking group showed that dynamic balance with the left leg and depression were predictors of percentage pain surface area (34.6%). The combination of dynamic balance, range of movement in flexoextension and depression were predictors of widespread pain (48.5%).

Conclusion

Patients who soughtcare presented greater pain expansion than patients whodidnot. A combination of functional and psychological variables can significantly predict pain expansion in patients with nonspecific CLBP who seek help.

Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review

Previous mass media campaigns have aimed to influence how people manage back pain, with mixed success. Campaigns should target beliefs which are related to the behaviours they aim to change. This systematic review brings together research that has measured the prevalence of beliefs about back pain in the general population and factors associated with these beliefs, including future pain‐related outcomes. Five databases were searched up until April 2017. Quantitative studies which reported a measure of agreement with a belief about back pain, cross‐sectional associations, or associations between beliefs and future outcomes were eligible. Eligibility was assessed and data extracted independently by two authors. Results were tabulated and narratively synthesized. Nineteen studies from 10 countries were eligible (median study n [IQR] = 990.5 [524.75–2387.5]). Beliefs were measured using eight questionnaires and 57 stand‐alone items. Beliefs about back pain's negative consequences were common across countries and populations, whereas most samples did not hold fear‐avoidance beliefs. Beliefs about back pain's consequences were associated with pain and disability, but only one study investigated this specific relationship prospectively. No studies investigated whether beliefs are associated with future pain management behaviours. Agreement with certain beliefs (e.g. about negative consequences) was associated with sociodemographic characteristics (e.g. older age) and poorer self‐rated health. Interventions may benefit from targeting beliefs about the perceived negative consequences of back pain in these populations. However, future research should explore how beliefs prospectively influence the management of back pain.

Significance

This review brings together studies which have assessed the prevalence of beliefs about back pain, and factors associated with holding them. It highlights that whether or not these beliefs represent important determinants of how people manage pain remains unknown.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists

AIM

To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients.

METHODS

Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ² tests.

RESULTS

The survey was divided into three subsections; PTs’ attitudes on LBP assessment, patients’ attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a “privilege” which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as “executers”, being unable to interfere with treatment plan, possibly implying lack of autonomy.

CONCLUSION

Although similarities on history taking methods and on patients’ attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

Predictors of improvement in quality of life and pain relief in lumbar spinal stenosis relative to patient age: a study based on the Spine Tango registry

BACKGROUND

An open decompression is the most common treatment for lumbar spinal canal stenosis (LSS), even in the elderly. However, it is not clear whether the treatment outcome is age dependent. The main purpose of this study was to evaluate the improvement in quality of life (QoL) and pain relief, after open decompression for LSS in relation to patient age.

METHODS

The study was performed on the basis of Spine Tango registry data. The database query resulted in 4768 patients from 40 international Spine Tango centres. The patients were subdivided into three age groups: (1) 20-64, (2) 65-74, and (3) ≥75 years. In multivariate logistic regression models, predictors for improvement in QoL and achievement of the minimum clinically relevant change in pain of two points were analysed.

RESULTS

All groups benefited from significant improvement in QoL and back and leg pain relief. Age group had no significant influence on the outcomes. The preoperative status of each outcome was a predictor for its own postoperative outcome. Fewer previous surgeries, rigid or dynamic stabilization, and lower patient comorbidity also had a partially predictive influence for one or the other outcome.

CONCLUSIONS

Our results confirm that all age groups significantly benefit from the open decompressive treatment of LSS. Age group had no significant influence on any outcome.

Return to work after spinal stenosis surgery and the patient's quality of life

INTRODUCTION

The return to work of patients who undergo spinal surgery poses important medical and social challenge.

OBJECTIVES

1) To establish whether patients who undergo spinal stenosis surgery later return to work. 2) To establish the patient's attitude towards employment. 3) To assess the quality of life of the patients and its influence on their attitude to work.

MATERIALS AND METHODS

The study population consisted of 58 patients aged from 21 to 80 years (the mean age was 52.33±14.12). There were 29 women (50%) and 29 men (50%) in the group. The patients' quality of life was measured by the use of the WHOQOL-BREF instrument. Individual interviews were conducted 3 to 8 months (a mean of 5.72 months ±1.6) after the surgery.

RESULTS

1) Although 13 patients (22.3%) returned to work, 44 (75.9%) did not, these being manual workers of vocational secondary education. 2) Almost half of the patients (27 patients, i.e. 44%) intend to apply for disability pension, 16 patients (27.6%) consider themselves unfit to work, 22 patients (37.9%) do not feel like working again. 3) The quality of life of the patients decreased. Domain scores for the WHOQOL-BREF are transformed to a 0-100 scale. The mean physical health amounted to 60.67 (±16.31), the mean psychological health was 58.78 (±16.01), while the mean social relations with family and friends were 59.91 (±20.69), and the mean environment 59.62 (±12.48).

CONCLUSIONS

1) A total of 75% of the patients operated for lumbar spinal stenosis do not return to their preoperative work. Difficulties in returning to work and decreased quality of life are associated with female sex, lower-level education, hard physical work and low income. 2) Physical health, psychological health, social relations and environment decreased to the mean of approximately 60. 3) The quality of life of the patients who did return to work was similar to that of healthy people.

Association between beliefs and care-seeking behavior for low back pain

STUDY DESIGN

Cross sectional population-based survey.

OBJECTIVE

To investigate the relationship between low back pain (LBP) beliefs and care seeking in LBP.

SUMMARY OF BACKGROUND DATA

Not all people experiencing LBP seek care for their problem. Consistent predictors of care-seeking behavior seem to be female sex and high perceived disability; the role of beliefs about LBP has not been investigated sufficiently.

METHODS

A questionnaire booklet was mailed to a random sample of 2860 individuals otherwise participating in an epidemiological study of musculoskeletal health. It contained the Back Beliefs Questionnaire (BBQ), the Fear-Avoidance Beliefs Questionnaire (FABQ; physical activity and work scales), and questions about sociodemographics, LBP characteristics, and LBP-related care seeking in the last month ("yes" = visit to specialist, general practitioner, physiotherapist, or other health care practitioner; "no" = none of these). Logistic regression was used to identify whether beliefs made a significant contribution to care-seeking behavior, beyond known predictors conceptualized in the behavioral model of health services use.

RESULTS

A total of 2507 of 2860 (88%) individuals completed the questionnaire; 1071 (43%) reported current LBP, 301 (28%) of which had sought care. In univariate analyses the following were all significantly related to care seeking (all P < 0.01): female sex; increasing age; not working full time; lower income; greater LBP frequency, LBP intensity, and limitations in activities of daily living; worse general health; higher FABQ-Physical Activity, FABQ-Work, and Back Beliefs Questionnaire scores. In multiple regression, female sex (odds ratio [OR], 1.731; 95% confidence interval [CI], 1.174-2.551; P = 0.006), LBP frequency (OR, 1.492; 95% CI, 1.249-1.783; P < 0.0001), limitations in activities of daily living (OR, 1.010; 95% CI, 1.001-1.020; P = 0.037), and high FABQ-Work Scores (OR, 1.025; 95% CI, 1.005-1.044, P = 0.012) contributed significantly to the final model.

CONCLUSION

That the odds of seeking care are higher in fear-avoidant individuals, even when controlling for other established predictors, emphasizes the importance of addressing such beliefs during the consultation; public health education programs may serve to underpin the delivery of positive messages, ultimately reducing health care demands.

Coping with chronic complex regional pain syndrome: advice from patients for patients

OBJECTIVE

To explore what advice people currently living with chronic complex regional pain syndrome would offer to another person coming to terms with a diagnosis of chronic complex regional pain syndrome.

METHODS

Semi-structured interviews with 21 adults (5 male) living with chronic complex regional pain syndrome who had completed a complex regional pain syndrome rehabilitation programme were conducted.

RESULTS

Effectively self-managing complex regional pain syndrome required individuals to play an active role. This could only be achieved if they felt they had sufficient control. Means of attaining control involved attaining a level of acceptance, becoming well-informed and accessing the right kind of support. The advice offered by patients for patients largely reflected that offered by healthcare professionals. One area where there was a conflict concerned sleep hygiene.

CONCLUSIONS

Our study provides support both for the argument put forward by Redman that without appropriate preparation and support, self-management is ineffective, and that by Skuladottir and Hallsdottir that the main challenge of the chronic pain trajectory is that of retaining a sense of control. The clinical implications of this are discussed.

Do work-related factors affect care-seeking in general practice for back pain or upper extremity pain?

OBJECTIVES

Musculoskeletal pain conditions remain a major cause of care-seeking in general practice. Not all patients with musculoskeletal pain (MP) seek care at their general practitioner (GP), but for those who do, the GP's knowledge of what work-related factors might have influenced the patient's decision to seek care could be important in order to give more well-founded advice to our patients. The objective of this study was to elucidate the effects of workloads on care-seeking for back pain or upper extremity pain during an eighteen-month follow-up period.

METHODS

This is a prospective study with a baseline questionnaire and eighteen-month follow-up. Among the registered patients of 8 GPs, we identified 8,517 persons between 17 and 65 years of age, who all received the questionnaire. A total of 5,068 (59.5 %) persons answered. During the eighteen months of follow-up, we used the International Classification for Primary Care (ICPC) to identify all care-seekers with either back pain or upper extremity pain. Of these, all currently employed persons were included in our analysis, in all 4,325 persons. For analysis, we used Cox proportional hazards regression analysis. Analyses were stratified by gender.

RESULTS

High levels of heavy lifting, defined as the upper tertile on a categorical scale, were associated with care-seeking for back pain (HR 1.90 [95 % CI: 1.14-3.15]) and upper extremity pain (HR 2.09 [95 % CI: 1.30-3.38]) among males, but not in a statistically significant way among females. Repetitive work and psychosocial factors did not have any statistically significant impact on care-seeking for neither back pain nor upper extremity pain.

CONCLUSION

Work-related factors such as heavy lifting do, to some extent, contribute to care-seeking with MP. We suggest that asking the patient about physical workloads should be routinely included in consultations dealing with MP.

A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

PURPOSE

The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade.

METHODS

This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome.

RESULTS

Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes.

CONCLUSIONS

Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.

Determinants of sickness absence duration after an occupational back injury in the Belgian population

BACKGROUND

This study aimed at assessing factors associated to the duration of sickness absence after a back injury in the Belgian working population, with a special emphasis on cultural factors.

METHODS

The data were retrieved from the Belgian Fund for Work Accidents database over a 3-year period (2001-2003). The population source involved all Belgian workers under a job contract in the private sector registered as compensated cases for an accident that occurred at the workplace (n = 558,276). From that database, all back injury cases involving a complete data set and registered during the first 6 months of each year (n = 11,262) were selected and eight factors (gender, age, seniority in the current job, job category, accident regional location, enterprise size, sector of activity, and accident circumstances) were analyzed in relation to the outcome variable, sick leave duration recorded as ordered time intervals between 0 and 183-366 days.

RESULTS

Sick leave duration was strongly associated in a multivariate model to age (≥40 years: OR = 2.18), blue-collar job (1.55), work in building industry (1.32), and enterprise size (>100: 0.85), and to a less extent to seniority (>10y: 0.88), and circumstance of accident (falls: 1.26). Injuries occurring in the French-speaking part of the country were associated to a longer sick leave (1.07; P = 0.034).

CONCLUSIONS

This study shows that besides well-known risk factors, subtle cultural language-linked factors and/or regional differences in economic climate may significantly influence the length of disability period after a back injury.

The significance of health anxiety and somatization in care-seeking for back and upper extremity pain

BACKGROUND

Patients with musculoskeletal pain account for a large number of consultations in primary care. Improving our understanding of factors that make patients seek care could be of interest in decision making and prevention in the health care system.

OBJECTIVES

Our objectives were to examine if health anxiety, somatization and fear-avoidance beliefs were of importance for care-seeking with either back pain or upper extremity pain and to look at possible differences between the two groups.

METHODS

This is a prospective study with a baseline questionnaire and 18 months follow-up. Using the International Classification for Primary Care (ICPC), we identified care-seekers with either back pain or upper extremity pain among the potential patients of eight GPs. For analysis, we used Cox proportional hazards regression analysis. Analysis was stratified by gender.

RESULTS

We found that previous regional pain was a strong predictor of care-seeking. Somatization was associated with seeking care for back pain. Health anxiety was a predictor among women suffering from back pain. Only previous pain was a predictor of care-seeking for upper extremity pain.

CONCLUSION

The study implies that prevention of back pain and upper extremity pain requires different strategies and that gender and health anxieties should be taken into account.

Do women consult more than men? A review of gender and consultation for back pain and headache

OBJECTIVES

Because women consult their general practitioners more frequently on average than men, it is commonly assumed that they consult more for all symptoms and conditions. This assumption is reinforced by qualitative studies reporting a widespread reluctance to consult by men. However, few studies directly compare consultation in men and women experiencing similar symptoms or conditions.

METHODS

A systematic review of the evidence on gender and consultation for two common symptoms, back pain and headache. Extensive electronic searches identified 15 papers reporting the relationship between gender and help-seeking for back pain and 11 papers for headache. Two independent reviewers assessed articles for inclusion and extracted data from eligible studies.

RESULTS

Few studies compared consultation patterns for these symptoms among men and women known to have experienced the symptom. The quality of the studies was variable. Overall, evidence for greater consultation by women with back pain was weak and inconsistent. Among those with back pain, the odds ratios for women seeking help, compared with men, ranged from 0.6 (95% confidence intervals 0.3, 1.2, adjusted only for age) to 2.17 (95% confidence intervals 1.35, 3.57, unadjusted), although none of the reported odds ratio, below 1.00 was statistically significant. The evidence for women being more likely to consult for headache was a little stronger. Five studies showed a statistically elevated odds ratio, and none suggested that men with headache symptoms were more likely to consult than women with headache symptoms. Limitations to the studies are discussed.

CONCLUSION

Given the strength of assumptions that women consult more readily for common symptoms, the evidence for greater consultation amongst women for two common symptoms, headache and back pain, was surprisingly weak and inconsistent, especially with respect to back pain.

The influence of socio-demographic characteristics on consultation for back pain--a review of the literature

BACKGROUND

There are several assumptions within clinical practice about who is more or less likely to consult a health care practitioner for particular symptoms, most commonly these focus around socio-demographic characteristics. We aimed to assess the evidence for the impact of socio-demographic characteristics on consultation for back pain.

METHODS

We conducted a review of the literature, using systematic methods, on consultation for back pain. Using systematic searching techniques we identified peer-reviewed publications that focused on health care consultation in response to symptoms of back pain and which included data on both users and non-users of health care.

RESULTS

We identified 23 studies. Definitions of help-seeking were inconsistent across studies. The majority of the 15 studies which considered the relationship between age and help-seeking for back pain did not find evidence of an association between these two factors. Seventeen studies considered whether socio-economic position was associated with help-seeking. The evidence largely supported the conclusion of no association (13 papers). Fifteen studies included gender as a variable in their analyses, and the majority (10 papers) presented the finding of no association.

CONCLUSIONS

The results from this review suggest that there is little evidence to support the common wisdom that socio-demographic characteristics impact on help-seeking in the context of back pain. As these assumptions relating to who is more or less likely to consult will ultimately affect patient care, it is important that they do not go unchallenged.

Seeking support: An interpretative phenomenological analysis of an Internet message board for people with Complex Regional Pain Syndrome

In this article, we report on the findings of a qualitative inquiry into how an online message board for people who have Complex Regional Pain Syndrome (CRPS) was used by its members. All messages (and responses) posted on the CRPS message board over a 4-month period were collected retrospectively. The data were analysed using the method of Interpretative Phenomenological Analysis. Members used the message board to seek (and provide) support to those with CRPS, and also to express their emotions, feelings and experiences linked to their condition. The message board provided an important source of support for a patient group that can otherwise become isolated as a result of their mobility problems. Furthermore, the analysis revealed the unrealistic hopes that patients can hold concerning the anticipated outcomes of their treatment. This is an important issue for healthcare professionals to explicitly address when interacting with the patient group.

Seeking care for lower back pain in the French population aged from 30 to 69: the results of the 2002-2003 Décennale Santé survey

OBJECTIVES

To describe the frequency with which members of the French general population in the 30-to-69 age class sought care for lower back pain (LBP) from various healthcare professionals and to identify associated parameters.

MATERIAL AND METHODS

Data were collected in the 2002-2003 Décennale Santé survey, which is representative of ordinary households in continental France. We assessed the frequency with which the 17,792 surveyed individuals sought care for LBP by considering consultations with healthcare professionals in general and consultations with general practitioners and physiotherapists in particular.

RESULTS

Among the survey subjects, 4.5% reported that they had sought treatment for LBP from a healthcare professional at least once during the 2-month survey period. The decision to seek care was correlated with the characteristics of the LBP. The duration of the pain was associated with the frequency of all types of consultation studied here. Sociodemographic, economic and occupational risk factors were also involved. Consultation with a physiotherapist was related to income.

CONCLUSION

These results from a representative sample of the French general population show that the factors associated with seeking treatment for LBP differ according to the type of healthcare professional consulted.

Pain and health-care utilization among older men in a veterans care home

Pain is a common health-care issue, and the prevalence increases with advancing age. Although it is often assumed that people with chronic pain are associated with a higher consumption of health care, evidence supporting this assertion is insufficient. Data from the Longitudinal Older VEterans (LOVE) study were stratified to explore the prevalence of pain and its relationship with health-care utilization. In total, data from 574 residents (mean age: 80.9+/-5.4 years, all male) were obtained. Among them, 92.8% were physically independent and 20.2% of them had mild to moderate cognitive impairment. Overall, 153 (26.3%) subjects reported pain; 114 (74.5%) subjects with mild pain and the remaining 39 (25.5%) subjects with moderate pain. The most commonly reported pain was lower back pain (40.5%, 62/153), which was followed by joint pain (29.4%, 45/153). Subjects with pain were more likely to have higher scores on the Geriatric Depression Scale (2.4+/-2.4 vs. 1.8+/-2.2, p = 0.023) and care-complexity problems (4.7+/-2.0 vs. 3.9+/-1.9, p < 0.001), despite being similar in age (81.3+/-5.0 vs. 80.8+/-5.5, p = 0.271), cognitive status and physical independence. Compared with pain-free subjects, subjects with pain were more likely to be hospitalized in the 12-month study period (0.71+/-1.20 vs. 0.46+/-1.00, p = 0.010), but the utilization of emergency department treatment (1.74+/-1.23 vs. 1.88+/-1.63, p = 0.560) was not statistically significant. In conclusion, the prevalence of pain among residents in a Taiwanese veterans care home was 26.3%; subjects with pain having more depressive symptoms, higher clinical-care complexity, and more likely to be hospitalized during the 12-month follow-up.

Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals

STUDY DESIGN

A cross-sectional population study of magnetic resonance imaging (MRI) changes. OBJECTIVE.: To examine the pattern and prevalence of lumbar spine MRI changes within a southern Chinese population and their relationship with back pain.

SUMMARY OF BACKGROUND DATA

Previous studies on MRI changes and back pain have used populations of asymptomatic individuals or patients presenting with back pain and sciatica. Thus, the prevalence and pattern of intervertebral disc degeneration within the population is not known.

METHODS

Lumbar spine MRIs were obtained in 1043 volunteers between 18 to 55 years of age. MRI changes including disc degeneration, herniation, anular tears (HIZ), and Schmorl's nodes were noted by 2 independent observers. Differences were settled by consensus. Disc degeneration was graded using Schneiderman's classification, and a total score (DDD score) was calculated by the summation of the Schneiderman's score for each lumbar level. A K-mean clustering program was used to group individuals into different patterns of degeneration.

RESULTS

Forty percent of individuals under 30 years of age had lumbar intervertebral disc degeneration (LDD), the prevalence of LDD increasing progressively to over 90% by 50 to 55 years of age. There was a positive correlation between the DDD score and low back pain. L5-S1 and L4-L5 were the most commonly affected levels. Apart from the usual patterns of degeneration, some uncommon patterns of degeneration were identified, comprising of subjects with skip level lesions (intervening normal levels) and isolated upper or mid lumbar degeneration.

CONCLUSION

LDD is common, and its incidence increases with age. In a population setting, there is a significant association of LDD on MRI with back pain.

Isometric trunk muscle strength and body sway in relation to low back pain in young adults

STUDY DESIGN

A cross-sectional study on young adults.

OBJECTIVE

To evaluate the relationships between low back pain (LBP), maximal isometric trunk muscle strength, and body sway among young adults.

SUMMARY OF BACKGROUND DATA

The results of previous studies evaluating the association between trunk muscle strength and LBP are conflicting and heterogeneous. Furthermore, there are only few studies on the association between body sway and LBP.

METHODS

The subjects (n = 874) belonged to a subcohort of the Northern Finland Birth Cohort 1986 (mean age 19 years). Trunk muscle strength and body sway were measured from all subjects. LBP symptoms were inquired with a questionnaire, which was completed concurrently with the examinations. Latent Class Analysis (LCA) was used to cluster the subjects according to their LBP symptoms.

RESULTS

LCA analysis produced 6 clusters differing with respect to LBP symptoms. There were no statistically significant differences between the clusters in trunk muscle strength or body sway.

CONCLUSION

LBP does not seem to be associated with maximal isometric trunk muscle strength or body sway in young adults.

Utilization of health resources due to low back pain: survey and registered data compared

STUDY DESIGN

Cross-sectional population-based survey and registration of general practice (GP).

OBJECTIVE

To describe the utilization of health care services among persons with low back pain on the basis of different databases, i.e., surveys and registrations. Special attention will be paid to utilization of GPs, specific medical specialists, and physiotherapists.

SUMMARY OF BACKGROUND DATA

Both surveys and health care registrations can provide data on utilization of health care services due to low back pain. It is unclear as to how the utilization figures from different data sources can be compared.

METHODS

Survey data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort study, a postal health survey among Dutch inhabitants aged 25 years or older (n = 3664) in 1998, and registered data from the second Dutch National Survey of General Practice, which represents 2 years (2000-2001) of GP-registration data for 293,636 persons aged 25 years or older.

RESULTS

The size of the population that in 1 year had GP-contact due to low back pain was estimated as 13.0% (survey) and 8.9% (registration data). Less than one-third of those with low back pain consult their GP due to low back pain in the past year. Survey data show that 33.2% of those with low back pain have had contact with the physiotherapist. Of those contacts, 76% were explicitly due to low back pain. Based on the registration data, these percentages were slightly different: 25.9% and 83.8%, respectively. Large differences between survey and registration data were found for the contact with a medical specialist.

CONCLUSION

Large health care resources are used for low back pain although the majority of low back pain sufferers do not have contact with health care. Survey data show slightly higher consultation figures than registration-based figures probably mainly due to response and recall bias, and registration thresholds.

Severity of chronic pain affects health care utilization after kidney transplantation

BACKGROUND

While the association between chronic pain and high health care utilization is a known issue in the general population, this relation has not been well studied among kidney transplantation patients.

METHODS

The subjects were first-time kidney transplant recipients engrafted between 2003 and 2006 and 6 months to 5 years postoperatively. Using SF-36 Bodily Pain Scale, patients were categorized in three groups: group I, those with scores over 66.6; group II, between 66.6 and 33.3; and group III, over 33.3. The subjects' health care utilization was prospectively assessed by recording the number of hospital admission days and the frequency of home nurse visits, outpatient physician visits, and emergency department visits for any medical reason in a 6-month period.

RESULTS

A stepwise increase in the frequency of patients admitted to the hospital (P=.017), and those referred to emergency departments (P=.007) was correlated with greater severity of pain in the three groups. However, the frequency of patients having outpatient physician visits (P=.30) or home nurse visits (P=.387) did not vary significantly. Similarly, with increased pain severity, an increase was observed in the number of emergency department visits (P=.005) and duration of hospital stays (P=.049), but not in the number of home nurse (P=.890) or physician visits (P=.112).

CONCLUSION

The severity of pain seems to increase the amount of health care use among kidney transplant patients. To minimize associated costs, appropriate pain rehabilitation programs are suggested.

Associations of physical activity and inactivity with low back pain in adolescents

Low back pain (LBP) is a common health problem already in adolescence. Physical activity has been suggested as a risk factor for LBP in adolescents, but the current evidence is conflicting. This study examined the association of physical activity and amount of sitting with LBP. The study population consisted of 5999 boy and girl members of the Northern Finland 1986 birth cohort who responded to mailed questions at the age of 15-16 years. LBP during the past 6 months was classified as "no LBP,""reporting LBP" (not seeking medical help), or "consultation for LBP." Odds ratios and 95% confidence intervals obtained by multinomial logistic regression were adjusted for smoking and body mass index. Being physically very active (more than 6 h of brisk physical activity per week) was associated with increased prevalence of "consultation for LBP" in both sexes, and with "reporting LBP" in girls, compared with being moderately active (2-3 h of brisk physical activity per week). High amount of sitting associated with "consultation for LBP" and "reporting LBP" in girls, but not in boys. We conclude that very active participation in physical activities in both sexes and a high amount of sitting in girls are related to self-reported LBP.

Neck and shoulder pains in relation to physical activity and sedentary activities in adolescence

STUDY DESIGN

A cross-sectional survey among adolescents aged 15-16 years.

OBJECTIVE

To evaluate whether physical activity or sedentary activities associate with neck and shoulder symptoms among adolescents.

SUMMARY OF BACKGROUND DATA

Findings of associations between physical exercise and neck or shoulder pain in adolescents are controversial.

METHODS

The study population consisted of adolescents belonging to the Northern Finland Birth Cohort 1986. The present analyses included 3185 girls and 2808 boys. Associations of physical activity level, total sitting time, and different kinds of sedentary activities with neck or occipital pain and shoulder pain were analyzed at 15-16 years of age using logistic regression. Reporting pain (not seeking medical help) and consultation for pain (seeking medical help) were assessed separately in girls but were combined in boys because of a low prevalence of severe pain.

RESULTS

Almost half of the girls and one third of the boys reported mild neck or occipital pain, or shoulder pain, and 5% of girls and 2% of boys reported severe neck or occipital pain, or shoulder pain during the past 6 months. High-level physical activity associated with an increased prevalence of both severe neck or occipital pain and severe shoulder pain in girls, but not in boys. Prolonged sitting was associated with a high prevalence of neck or occipital pain and shoulder pain in girls, and neck or occipital pain in boys. Of various sedentary activities, television watching and reading books associated with neck or occipital pain in girls, whereas playing or working with a computer associated with neck or occipital pain in boys. In girls, television watching also associated with mild shoulder pain.

CONCLUSIONS

Neck or occipital pain and shoulder pain are very common symptoms among adolescents, and both prolonged sitting and a high level of physical activity seem to be related to them.

Subclassification of low back pain: a cross-country comparison

Various health professionals have attempted to classify low back pain (LBP) subgroups and have developed several LBP classification systems. Knowing that culture has an effect on LBP symptomatology, assessment findings and clinical decision making, the aim of this review is to perform a cross-country comparative review amongst the published classification systems, addressing each country's similarities and differences as well as exploring whether cultural factors have been incorporated into the subclassification process. A systematic search of databases limited to human adults was undertaken by Medline, Cinahl, AMED and PEDro databases between January 1980 and October 2005. Classification systems from nine countries were identified. Most studies were classified according to pathoanatomic and/or clinical features, whereas fewer studies utilized a psychosocial and even less, a biopsychosocial approach. Most studies were limited in use to the country of the system's developer. Very few studies addressed cultural issues, highlighting the lack of information on the impact of specific cultural factors on LBP classification procedures. However, there seem to be certain 'cultural trends' in classification systems within each country, which are discussed. Despite the plethora of classification studies, there is still no system which is internationally established, effective, reliable and valid. Future research should aim to develop a LBP classification system within a well identified cultural setting, addressing the multi-dimensional features of the LBP presentation.

Health care use associated with work-related musculoskeletal disorders among hospital workers

INTRODUCTION

The purpose of this study was to investigate if work-related musculoskeletal disorders (WMSDs) are associated with increased health care use, over and above workers' compensation health care benefits, in the period prior to and following a workers' compensation claim indicating gradual progression and declining function associated with musculoskeletal morbidity.

METHODS

This study employed secondary analysis of employment data, workers' compensation claim data and provincial (universal) medical services data for a cohort of health care workers; and investigated rates of medical care contacts among injured workers with a WMSD claim (n=549) compared to a matched group of non-claim workers. Predictors of health care contacts were estimated using general linear regression.

RESULTS

WMSD injured workers had significantly higher rates of health care contacts associated with a claim compared to non-injured workers, over and above workers compensation health care benefits. In the final multi-variable model, a WMSD claim among injured workers was associated with an estimated 69% (95% CI, 1.50, 1.91) increase in health care use for the 12-month period immediately after the injury date compared to non injured workers.

CONCLUSION

The pattern of visits for WMSDs suggests that workers visit general practitioners as part of an ongoing pattern of symptoms, resulting in frequent utilization of health services prior to work disability that is also reflected in health care contacts after return-to-work.

Information and low back pain management: a systematic review

STUDY DESIGN

A systematic search of three electronic databases was done to identify randomized controlled trials on the effect of written or audiovisual information in low back pain.

OBJECTIVES

To determine whether information is an effective preventive action and/or therapy for low back pain and which type of information is most effective.

SUMMARY OF BACKGROUND DATA

Information is commonly used in the primary care of low back pain and mostly delivered by booklets.

METHODS

A systematic computer-aided search of the Medline, PsyclInfo, and Embase database. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.

RESULTS

Eleven randomized controlled trials were selected, including seven trials of high methodologic quality, as well as one parallel group controlled survey and one longitudinal study. Only three of the seven high-quality studies showed favorable results for information. There is strong evidence that a booklet increases knowledge and moderate evidence that physician-related cues increase the confidence in a booklet and adherence to exercises. There is limited evidence that a biopsychosocial booklet is more efficient than a biomedical booklet to shift patient's beliefs about physical activity, pain, and consequences of low back trouble. There is strong evidence that booklets are not efficient on absenteeism and conflicting evidence that they are efficient on healthcare use. There is no evidence that e-mail discussion or video programs alone are effective to reduce low back pain, disability, and healthcare costs.

CONCLUSIONS

Information based on a biopsychosocial model is recommended in primary care to shift patient beliefs on low back pain. Nevertheless, information delivery alone is not sufficient to prevent absenteeism and reduce healthcare costs.

The physician as disability advisor for patients with musculoskeletal complaints

STUDY DESIGN

Literature review.

OBJECTIVES

To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area.

SUMMARY OF BACKGROUND DATA

While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being.

METHODS

Medical literature search.

RESULTS

Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians.

CONCLUSIONS

Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

Chronic pain and frequent use of health care

Little is known about the relationship between chronic pain status and overall use of healthcare. We examined whether disabling chronic pain was associated with more frequent use of healthcare in three settings: primary care, emergency departments, and hospital admissions. We used data from Computer-Assisted Telephone Interviews (CATI) of 17,543 residents in New South Wales, Australia aged 16 and over who were randomly sampled using a population-based two-stage stratified sample and random digit dialing methods. The overall response rate was 70.8%. Compared to chronic pain respondents with no or limited pain-related disability, those with most pain-related disability reported more: primary care visits in the last 2 weeks and last 12 months (adjusted mean number of visits 0.59 vs 0.40 and 10.72 vs 4.81, both P < 0.005); hospital admissions (0.46 vs 0.18, P < 0.005); and emergency department visits (0.85 vs 0.17, P > 0.005). In modelling, having chronic pain per se, or having chronic pain with any level of activity interference predicted health care use after adjusting for age, gender, self-rated health, psychological distress, comorbidity and access to care. Higher levels of pain-related disability predicted health care use more than other pain status variables. There was a strong association between pain-related disability and greater use of services. Further work is needed to understand the nature of this association. Given the fluctuating course of chronic pain over time, there is a significant segment of the population that may be at risk of developing higher levels of disability associated with increased use of services.

A longitudinal, community-based study of low back pain outcomes

OBJECTIVES

To assess the report of low back pain (LBP) over 1 year and its predictors in individuals reporting symptoms during an initial cross-sectional survey.

STUDY DESIGN

A longitudinal community-based study.

SUMMARY OF BACKGROUND DATA

The natural history of LBP is poorly understood. Different studies report various rates of persistent and recurrent symptoms as well as different predictors of outcomes.

METHODS

Subjects from a single town in Israel reporting low back pain during the previous month were followed up after 2 and 12 months. The primary outcome was experiencing LBP and the secondary outcomes were pain and functional status as measured by the Roland & Morris Disability questionnaire and Pain Symptoms Frequency and Bothersomeness Indexes.

RESULTS

More than three fourths reported LBP (different levels of severity) after 2 and 12 months. This group did not show an improvement in pain measures. Baseline pain characteristics and perception of general health were predictors of both primary and secondary outcomes. Work satisfaction and experiencing a negative event during the past months were also predictors of the secondary outcomes.

CONCLUSIONS

In this community-based study, LBP symptoms after 1 year are common and symptoms of those experiencing LBP at follow up do not improve over time. Predictors of experiencing LBP and of LBP symptoms after 1 year included baseline pain characteristics and psychosocial factors.

Can health care utilization explain the association between socioeconomic status and back pain?

STUDY DESIGN

Cross-sectional population-based study.

OBJECTIVES

To assess whether the association between socioeconomic status and severe back pain can be explained by the preceding health care utilization for back pain.

SUMMARY OF BACKGROUND DATA

The ways in which socioeconomic status affects the occurrence of back pain are unclear.

METHODS

Age- and gender-adjusted odds ratios with 95% confidence intervals for the association between indicators of socioeconomic status and severe current back pain (high intensity and/or high disability: no/yes) were investigated in an interview among 770 study participants out of 1113 study participants with a recent history of back pain in a survey among 2731 adults.

RESULTS

The point prevalence of severe current back pain (39.8%) was related to educational level and health insurance status. Prior health care utilization for back pain was about 2-fold more prevalent in adults with severe current back pain. Members of private health insurance (odds ratio 0.60, 95% confidence interval 0.37-0.99) were less likely to report prior consultation of a general practitioner for back pain. Members of sick funds for white-collar workers (odds ratio 2.81, 95% confidence interval 1.43-5.51) and private insurance (odds ratio 2.81, 95% confidence interval 1.02-6.24) and individuals with intermediate educational level (odds ratio 1.76, 95% confidence interval 1.05-2.95) utilized more physical therapy for the treatment of back pain. After additionally adjusting for health care utilization, the associations between educational level or health insurance status and severe current back pain remained unchanged.

CONCLUSIONS

The data suggest that education, health insurance status, and health care utilization are independently associated with severe current back pain in a society with universal access to health care.

Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study

OBJECTIVE

To investigate the respective contribution of various biologic and psychosocial factors, especially initial health-related quality of life (HRQOL), in the natural history of acute low back pain (LBP) and to evaluate the impact of this condition on HRQOL.

METHODS

For 3 months, we assessed 113 patients consulting for nonspecific acute LBP of <72 hours duration at inclusion and treated with acetaminophen. Endpoints included pain, disability assessed by the Roland Disability Questionnaire, and HRQOL assessed by the Short Form 36 health survey (SF-36).

RESULTS

Seventy-three percent of patients recovered within 2 weeks and 5% of patients developed chronic LBP. Prior low back surgery, higher initial disability questionnaire score, lower SF-36 score, and temporary compensation status were independently associated with delayed recovery. The impact of the acute LBP episode on HRQOL was brief and moderate, except for patients with comorbidity, psychiatric disorders, those of foreign origin, unemployed, or with job dissatisfaction. The impact of compensation status, sick leave, and bed rest was more profound and lasting.

CONCLUSIONS

This study highlights the large contribution of work-related factors, but also initial HRQOL, to the prognosis of LBP. It also suggests that LBP impairs HRQOL mainly through compensation and inappropriate medical care, and that, in turn, impaired HRQOL favors the condition becoming chronic. These findings have implications for future research into the management of LBP.

Pain beliefs and perceived physical disability of patients with chronic low back pain

Cognitive-behavioural therapy and maintenance of exercise have emerged as major tools in the treatment of patients with chronic low back pain. Patients' beliefs about their problem may influence their uptake of and responses to particular treatment modalities. In particular, we hypothesised that patients' beliefs about the cause and treatment of pain may mediate changes in physical disability following participation in a multidisciplinary pain management programme. A cohort of 84 patients was invited to respond to booklets of self-report questionnaires prior to, immediately after and 3 months following participation in multidisciplinary pain management programmes. Questionnaires addressed subjects' beliefs about the nature and treatment of pain (Pain Beliefs Questionnaire), and their disability (Likert-modified Roland and Morris Disability Questionnaire, Physical Functioning scale of the Short Form-36 Health Survey, and Oswestry Low Back Pain Disability Questionnaire). Patients with chronic low back pain who more strongly endorsed 'organic' concepts about the nature and treatment of pain reported higher levels of physical disability at baseline, and displayed greater reductions in disability following participation in the pain management programmes. Reductions in reported 'organic' pain beliefs were associated with improvements in reported disability. Endorsement of 'psychological' concepts about the nature and treatment of pain was not associated with disability. These findings support a view that patients' beliefs about the nature and treatment of their pain can change during participation in a multidisciplinary pain management programme based on cognitive-behavioural intervention. Modification of these beliefs may be associated with improvements in patients' perceptions of the level of their disability.

Back pain reporting in children and adolescents: the impact of parents' educational level

BACKGROUND

Social class, including educational level, is a strong predictor for health-related perceptions and behavior and for health outcomes in general. It is not known whether parental education has an effect on back pain in their offspring.

OBJECTIVES

To establish whether parents' educational level is associated with back pain reporting and consequences of back pain in their children.

DESIGN

A cross-sectional survey.

DATA COLLECTION

Information on parental education was obtained through questionnaires to parents and back pain information through standardized interviews with the children.

PARTICIPANTS

Children aged 8 to 10 years (n = 481) and adolescents aged 14 to 16 years (n = 325) obtained through a proportional 2-stage cluster sample.

SETTING

Local schools in Odense, Denmark.

MAIN OUTCOME MEASURES

The strength of association and dose-response connection were studied between parental educational level (high/medium/low) and the outcome variables (back pain in the preceding month, and consequences of back pain) in their children.

RESULTS

There was a significant modest negative association between the level of parental education and back pain in children but not in adolescents. There was no significant association between parental educational level and back pain consequences.

CONCLUSIONS

Further research in this area requires a more ingenious approach such as use of more socially heterogeneous study populations than those usually found in Denmark.

Why do patients with chronic musculoskeletal disorders consult their primary care physicians?

Symptoms are a daily occurrence in the lives of most people, and many do not consult their doctors for their clinical complaints. Information on the frequency of musculoskeletal disorders and on healthcare utilization patterns can be obtained from population surveys or from records of visits to primary care physicians. A decision to consult a primary care physician for musculoskeletal disorders is not based simply on the presence or absence of physical symptoms, but also involves a complex mixture of social and psychological factors.

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.

Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects

STUDY DESIGN

A subanalysis of data derived from a randomized clinical trial was performed.

OBJECTIVE

To evaluate the association of a patient's expectation for benefit from a specific treatment with improved functional outcome.

SUMMARY OF BACKGROUND DATA

Psychosocial factors, ambiguous diagnoses, and lack of a clearly superior treatment have complicated the management of patients with chronic low back pain. The authors hypothesized that patient expectation for benefit from a specific treatment is associated with improved functional outcomes when that treatment is administered.

METHODS

In a randomized trial, 135 patients with chronic low back pain who received acupuncture or massage were studied. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. The primary outcome was level of function at 10 weeks as measured by the modified Roland Disability scale.

RESULTS

After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations (P = 0.01). Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa (P = 0.03).

CONCLUSIONS

The results of this study suggest that patient expectations may influence clinical outcome independently of the treatment itself. In contrast, general optimism about treatment, divorced from a specific treatment, is not strongly associated with outcome. These results may have important implications for clinical trial design and recruitment, and may help to explain the apparent success of some conventional and alternative therapies in trials that do not control for patient expectations. The findings also may be important for therapy choices made in the clinical setting.

Low back pain: reliability of a set of pain measurement tools

OBJECTIVES

To determine the reliability and internal consistency of a set of low back pain (LBP)-related measurement tools and to determine whether they are appropriate for use in a large-scale, community-based sample in Israel.

DESIGN

Test-retest reliability study, with an interval of 2 to 14 days between test and retest.

SETTING

Physiotherapy clinics.

PARTICIPANTS

One hundred fifty-one patients with LBP.

MAIN OUTCOME MEASURES

The Modified Roland-Morris Disability Questionnaire (MRMQ); a simple verbal pain severity scale; and modified pain symptoms frequency and bothersomeness indices. Three measures of variables with potential association with LBP were also used: a Fear-Avoidance Beliefs Questionnaire (FABQ), work satisfaction scale, and the Baecke Physical Activity Questionnaire (BPAQ).

RESULTS

Test-retest reliability was high for the MRMQ, pain symptom indices, work index of the FABQ, and occupational activity index of the BPAQ; the internal consistency of the MRMQ and FABQ work index were also high (intraclass correlation coefficient >or= .89; alpha = .89).

CONCLUSIONS

Most measurement tools are reliable and suitable for community LBP studies in Israel.

General practitioners' willingness to request plain lumbar spine radiographic examinations

OBJECTIVES

To examine general practitioners' attitudes to plain lumbar spine radiographic examinations.

DESIGN

A postal questionnaire consisting of questions on background data and doctors' opinions about plain lumbar spine radiographic examinations, as well as eight vignettes (imaginary patient cases) presenting indications for lumbar radiography, and five vignettes focusing on the doctors' willingness to request lumbar radiography on the basis of patients' age and duration of symptoms. The data were analysed according to the doctor's age, sex, workplace and the medical school of graduation.

SETTING

Finland.

SUBJECTS

Six hundred and fifteen randomly selected physicians working in primary health care (64% of original target group).

RESULTS

The vignettes revealed that the use of plain lumbar radiographic examination varied between 26 and 88%. Patient's age and radiation protection were the most prominent factors influencing doctors' decisions to request lumbar radiographies. Only slight differences were observed between the attitudes of male and female doctors, as well as between young and older doctors. Doctors' willingness to request lumbar radiographies increased with the patient's age in most vignettes. The duration of patients' symptoms had a dramatic effect on the doctor's decision: in all vignettes, doctors were more likely to request lumbar radiography when patient's symptoms had exceeded 4 weeks.

CONCLUSIONS

General practitioners commonly use plain lumbar spine radiographic examinations, despite its limited value in the diagnosis of low back pain. Further consensus and medical education is needed to clarify the indications for plain lumbar radiographic examination.

One-year prevalence of low back pain in two Swiss regions: estimates from the population participating in the 1992-1993 MONICA project

STUDY DESIGN

A cross-sectional survey was performed.

OBJECTIVE

To estimate the extent of low back pain as a public health problem.

SUMMARY OF BACKGROUND DATA

Health surveys converge on very high estimates of low back pain in general populations, but few studies have included severity criteria in their definition and conclusions. Because it is unlikely that interventions will influence the prevalence of minimal and infrequent symptoms, greater attention should be paid to characteristics of low back pain that indicate some impact on the life of survey respondents.

METHODS

Two regions participated in the MONICA (MONitoring of trends and determinants in CArdiovascular disease) project in Switzerland. Participants randomly selected from the general population completed a standard self-administered questionnaire on cardiovascular risk factors. A special section on low back pain was added in the third (1992-1993) MONICA survey and completed by 3227 participants.

RESULTS

A regional difference found in the 12-month prevalence rate disappeared with the inclusion of severity criteria. Low back pain over more than seven cumulated days was reported among men by 20.2% (age range, 25-34 years) to 28.5% (age range, 65-74 years), respectively, among women by 31.1% to 38.5%. Similar rates of reduction in activity (professional, housekeeping, and leisure time) and medical consultation (conventional and nonconventional) motivated by low back pain characterized the two participating regions. The cumulative duration of pain was related to all the indicators showing the impact of low back pain on everyday life.

CONCLUSIONS

Determining the cumulative duration of low back pain over the preceding year is a straightforward task, and a cutoff at 1 week seems appropriate for distinguishing between low- and high-impact low back pain.

A population study of factors associated with general practitioner consultation for non-inflammatory musculoskeletal pain

OBJECTIVE

To investigate factors associated with visiting a general practitioner (GP) for non-inflammatory musculoskeletal pain, and to examine whether these factors were affected by duration (chronic v non-chronic) or location (widespread v regional) of pain.

METHODS

From a cross sectional postal survey of 20 000 (response rate 59%) randomly selected adults in two counties of Norway, 6408 subjects who had experienced musculoskeletal pain during the past month were included. Patients who reported inflammatory rheumatic diagnoses made by a doctor were excluded.

RESULTS

2909 (45%) had consulted a GP for their musculoskeletal pain during the past 12 months. The odds of consulting were significantly increased by being a woman, by having a higher age and lower education, and by being a pensioner or on sick leave. Patients with widespread pain were more likely to consult than those with regional pain, as were patients with chronic compared with non-chronic pain. Greater than median pain intensity was the factor most prominently associated with consultation for men (odds ratio (OR)=2.4; 95% confidence interval (95% CI) 2.0 to 2.9) and for women (OR=2.6; 95% CI 2.3 to 2.9). Overall, consultation was significantly associated with mental distress for women but not for men. Subgroup analyses showed that consultation for chronic pain was significantly associated with greater than median mental distress for both women (OR=1.3; 95% CI 1.1 to 1.6) and men (OR=1.2; 95% CI 1. 0 to 1.4), whereas consultation for non-chronic pain was not.

CONCLUSION

The results show that about half of the patients with musculoskeletal pain consult a general practitioner (GP) each year, that demographic factors are associated with consulting, and that the role of mental distress for consulting a GP varies with duration of pain.

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

The effect of comorbidity on care seeking for back problems in the United States

PURPOSE

We assess the effect of comorbidity on self-reported use of health care for back problems in the United States.

METHODS

Data from the 1989 National Health Interview Survey (NHIS) were used to perform cross-sectional analyses of adults who reported a back-related condition. The presence of one or more nonback-related conditions (and associated disability and health care) were the primary predictor variables. Weighted logistic regression modeling was performed to estimate odds ratios (ORs) adjusted for the effects of covariates.

RESULTS

The 1989 NHIS included 84,572 adults, of which 4790 (5.7%) reported at least one back-related condition. Of these, 931 (19.6%) sought health care for their back condition during the 2-week reference period. Among all adults with reported back problems, those with disabling comorbidities and those who sought care for their comorbidities during the reference period were less likely to have sought back care than were those with no comorbidities. Subjects with back-related disabilities who reported nondisabling comorbidities without associated health care were much more likely to have sought back care than were similar subjects without any comorbidities.

CONCLUSIONS

The decision to seek care for a back problem is a complex process that depends upon the presence and impact of other conditions and the use of care for these conditions. Comorbid back problem sufferers may not seek back care when afflicted with other disabling conditions or conditions that may be perceived to be more amenable to care.

Community survey of factors associated with consultation for low back pain

OBJECTIVE

To investigate the psychosocial factors associated with consultation for low back pain.

DESIGN

Two phase cross sectional postal survey.

SETTING

Bradford Metropolitan Health District.

SUBJECTS

1813 adults responding to the phase 1 questionnaire. 540 of the 782 with an episode of low back pain in the past 12 months completed the second questionnaire.

MAIN OUTCOME MEASURES

Six psychosocial constructs.

RESULTS

406 (52%) of the respondents reporting back pain in the past 12 months had not consulted a health professional. Logistic regression showed that consultation was associated with externalised beliefs regarding pain management (odds ratio 3.6; 95% confidence interval 2.1 to 6.0). Duration of pain affected the factors associated with consultation. Consultation for episodes lasting less than two weeks (n=290) was associated with greater than median pain (3.0; 1.7 to 5.5), consultation for episodes over two weeks (n=243) was associated with increased disability (3.7; 1.5 to 9.0), and consultation for episodes over three months (n=143) with increased depression (3.9; 1.3 to 11.8).

CONCLUSIONS

The results support a role for psychosocial factors in consultation for low back pain and suggest that the reasons for consultation vary with duration of pain. Duration of the episode may be a useful guide to management of non-specific low back pain.

Patient-health care provider relationship in patients with non-specific low back pain: a review of some problem situations

Problem situations in the patient-health care relationship may relate to the patient or to the health care provider characteristics or to the way they interact; they may also relate to the general social context. Such situations force the clinician dealing with non-specific low back pain patients to look beyond the traditional biomedical model that assumes a linear connection between pathology and symptomatology. The introduction of the biopsychosocial model approximately 10 years ago has improved the understanding of common low back pain. This chapter gives some insight into areas relating to factors that may hamper the patient-therapist relationship and thus complicate treatment and recommendation outcomes. It emphasizes the necessity to involve the patient in the decision-making. Recognizing the patients' psychological, social and cultural background as well as the level of education and employability are important to make successful recommendations. This knowledge is not new but the difficulty is to implement it in today's cost effectiveness driven society. However the benefit at the end may be the decrease of chronicity and/or permanent disability, suffering for the patient and frustration for the clinician. Identifying the underlying cause of non-compliance or of unexpected delayed recovery is an exciting issue. The cause may or may not be biomedical. If a specific cause can be identified, it has to be diagnosed and evaluated. If the clinical examination has ruled out specific or emergency conditions, another perspective may be needed and the course of action could then be determined.