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Leininger BD, Johnson PJ, Bronfort G, Kuntz KM, Enns E, Hodges JS, Evans R. How well do participants in clinical trials represent the U.S. population with chronic neck or back pain? BMC Musculoskelet Disord 2024; 25:414. [PMID: 38802802 PMCID: PMC11129496 DOI: 10.1186/s12891-024-07524-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/14/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Randomized clinical trials (RCTs) are the gold standard for assessing treatment effectiveness; however, they have been criticized for generalizability issues such as how well trial participants represent those who receive the treatments in clinical practice. We assessed the representativeness of participants from eight RCTs for chronic spine pain in the U.S., which were used for an individual participant data meta-analysis on the cost-effectiveness of spinal manipulation for spine pain. In these clinical trials, spinal manipulation was performed by chiropractors. METHODS We conducted a retrospective secondary analysis of RCT data to compare trial participants' socio-demographic characteristics, clinical features, and health outcomes to a representative sample of (a) U.S. adults with chronic spine pain and (b) U.S. adults with chronic spine pain receiving chiropractic care, using secondary data from the National Health Interview Survey (NHIS) and Medical Expenditure Panel Survey (MEPS). We assessed differences between trial and U.S. spine populations using independent t-tests for means and z-tests for proportions, accounting for the complex multi-stage survey design of the NHIS and MEPS. RESULTS We found the clinical trials had an under-representation of individuals from health disparity populations with lower percentages of racial and ethnic minority groups (Black/African American 7% lower, Hispanic 8% lower), less educated (No high school degree 19% lower, high school degree 11% lower), and unemployed adults (25% lower) with worse health outcomes (physical health scores 2.5 lower and mental health scores 5.3 lower using the SF-12/36) relative to the U.S. population with spine pain. While the odds of chiropractic use in the U.S. are lower for individuals from health disparity populations, the trials also under-represented these populations relative to U.S. adults with chronic spine pain who visit a chiropractor. CONCLUSIONS Health disparity populations are not well represented in spine pain clinical trials. Embracing key community-based approaches, which have shown promise for increasing participation of underserved communities, is needed.
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Affiliation(s)
- Brent D Leininger
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN, 55414, USA.
| | - Pamela Jo Johnson
- Department of Public Health, North Dakota State University, 640R Aldevron Tower, 1455 14th Ave N, Fargo, ND, 58102, USA
| | - Gert Bronfort
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN, 55414, USA
| | - Karen M Kuntz
- Division of Health Policy & Management School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729 Mayo, Minneapolis, MN, 55455, USA
| | - Eva Enns
- Division of Health Policy & Management School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729 Mayo, Minneapolis, MN, 55455, USA
| | - James S Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, 2221 University Ave SE, Room 200 University Office Plaza, Minneapolis, MN, 55414, USA
| | - Roni Evans
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN, 55414, USA
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Zimmer JM, Fauser D, Golla A, Bethge M, Mau W. Contextual factors in persistent severe back pain: A longitudinal analysis among German employees. Eur J Pain 2024; 28:649-658. [PMID: 37994204 DOI: 10.1002/ejp.2209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 10/31/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Chronic back pain in employees compromises participation in social and daily activities, as well as work. OBJECTIVES To examine the severity of back pain after 2 years and identify factors predicting stagnation at this level of pain. METHODS Data were derived from a prospective cohort study with randomized sampling of insurants in the German Pension Insurance using a questionnaire at baseline and follow-up after 2 years. The sample consisted of middle-aged employees (45-59 years) with strong limitations due to back pain (Chronic Pain Grade III or IV), who had not applied for disability pension and did not use medical rehabilitation in the previous 4 years before baseline. Stepwise multivariable logistic regression models with backwards selection were used to identify relevant contextual factors in the stagnation of severe back pain. RESULTS Of 1208 persons with severe back pain at baseline, 48% had stagnated at that pain level after 2 years. Predictors of persistent severe back pain were older age, poorer general health, more additional disabling conditions, more depressive symptoms, caregiving burden, less pain-related self-efficacy and more fear avoidance beliefs. CONCLUSIONS In a high-risk subgroup with several co-existing conditions, this analysis highlights (mental) health, social and personal (contextual) factors associated with long-term unfavourable back pain progression. SIGNIFICANCE Back pain is a condition that often has a chronic or recurrent course, threatening participation in many areas of life. In this study it was found that the unfavourable condition of severe back pain can remain stable for long periods of time in a significant proportion of sufferers. Contextual factors (self-efficacy, fear-avoidance beliefs, caregiving burden) as well as additional health problems should be considered when identifying persons with stagnating pain courses.
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Affiliation(s)
- Julia-Marie Zimmer
- Institute for Rehabilitation Medicine, Interdisciplinary Centre of Health Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - David Fauser
- Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - André Golla
- Institute for Rehabilitation Medicine, Interdisciplinary Centre of Health Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Matthias Bethge
- Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Wilfried Mau
- Institute for Rehabilitation Medicine, Interdisciplinary Centre of Health Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Lemmers GPG, Melis RJF, Pagen S, Hak R, Snoo EKD, Westert GP, van der Wees PJ, Staal JB. The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study. BMC Musculoskelet Disord 2024; 25:193. [PMID: 38439000 PMCID: PMC10910701 DOI: 10.1186/s12891-024-07301-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/22/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain. METHODS This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up. RESULTS A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up. CONCLUSION The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain. TRIAL REGISTRATION Clinicaltrials.gov: 109,643.
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Affiliation(s)
- Gijs P G Lemmers
- Radboud University Medical Center, IQ Health, Kapittelweg 54, Nijmegen, 6525 EP, The Netherlands.
- Dutch Healthcare Authority, Utrecht, The Netherlands.
| | - René J F Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Robin Hak
- Fysius Back Experts, Nijverdal, The Netherlands
| | | | - Gert P Westert
- Radboud University Medical Center, IQ Health, Kapittelweg 54, Nijmegen, 6525 EP, The Netherlands
| | - Philip J van der Wees
- Radboud University Medical Center, IQ Health, Kapittelweg 54, Nijmegen, 6525 EP, The Netherlands
| | - J Bart Staal
- Radboud University Medical Center, IQ Health, Kapittelweg 54, Nijmegen, 6525 EP, The Netherlands
- Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences, Nijmegen, The Netherlands
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Grenier JP, Rothmund M. A critical review of the role of manual therapy in the treatment of individuals with low back pain. J Man Manip Ther 2024:1-14. [PMID: 38381584 DOI: 10.1080/10669817.2024.2316393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/04/2024] [Indexed: 02/23/2024] Open
Abstract
The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.
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Affiliation(s)
- Jean-Pascal Grenier
- Department of Physiotherapy, Health University of Applied Sciences Tyrol, Innsbruck, Austria
- Department of Internal Medicine II, University Clinic Innsbruck, Innsbruck, Austria
| | - Maria Rothmund
- Department of Psychiatry, Psychotherapy, Psychosomatics, and Medical Psychology, University Clinic for Psychiatry II, Medical University Innsbruck, Innsbruck, Austria
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Wallwork SB, Braithwaite FA, O'Keeffe M, Travers MJ, Summers SJ, Lange B, Hince DA, Costa LOP, Menezes Costa LDC, Chiera B, Moseley GL. The clinical course of acute, subacute and persistent low back pain: a systematic review and meta-analysis. CMAJ 2024; 196:E29-E46. [PMID: 38253366 PMCID: PMC10805138 DOI: 10.1503/cmaj.230542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Understanding the clinical course of low back pain is essential to informing treatment recommendations and patient stratification. Our aim was to update our previous systematic review and meta-analysis to gain a better understanding of the clinical course of acute, subacute and persistent low back pain. METHODS To update our 2012 systematic review and meta-analysis, we searched the Embase, MEDLINE and CINAHL databases from 2011 until January 2023, using our previous search strategy. We included prospective inception cohort studies if they reported on participants with acute (< 6 wk), subacute (6 to less than 12 wk) or persistent (12 to less than 52 wk) nonspecific low back pain at study entry. Primary outcome measures included pain and disability (0-100 scale). We assessed risk of bias of included studies using a modified tool and assessed the level of confidence in pooled estimates using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. We used a mixed model design to calculate pooled estimates (mean, 95% confidence interval [CI]) of pain and disability at 0, 6, 12, 26 and 52 weeks. We treated time in 2 ways: time since study entry (inception time uncorrected) and time since pain onset (inception time corrected). We transformed the latter by adding the mean inception time to the time of study entry. RESULTS We included 95 studies, with 60 separate cohorts in the systematic review (n = 17 974) and 47 cohorts (n = 9224) in the meta-analysis. Risk of bias of included studies was variable, with poor study attrition and follow-up, and most studies did not select participants as consecutive cases. For the acute pain cohort, the estimated mean pain score with inception time uncorrected was 56 (95% CI 49-62) at baseline, 26 (95% CI 21-31) at 6 weeks, 22 (95% CI 18-26) at 26 weeks and 21 (95% CI 17-25) at 52 weeks (moderate-certainty evidence). For the subacute pain cohort, the mean pain score was 63 (95% CI 55-71) at baseline, 29 (95% CI 22-37) at 6 weeks, 29 (95% CI 22-36) at 26 weeks and 31 (95% 23-39) at 52 weeks (moderate-certainty evidence). For the persistent pain cohort, the mean pain score was 56 (95% CI 37-74) at baseline, 48 (95% CI 32-64) at 6 weeks, 43 (95% CI 29-57) at 26 weeks and 40 (95% CI 27-54) at 52 weeks (very low-certainty evidence). The clinical course of disability was slightly more favourable than the clinical course of pain. INTERPRETATION Participants with acute and subacute low back pain had substantial improvements in levels of pain and disability within the first 6 weeks ( moderate-certainty evidence); however, participants with persistent low back pain had high levels of pain and disability with minimal improvements over time (very low-certainty evidence). Identifying and escalating care in individuals with subacute low back pain who are recovering slowly could be a focus of intervention to reduce the likelihood of transition into persistent low back pain. PROTOCOL REGISTRATION PROSPERO - CRD42020207442.
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Affiliation(s)
- Sarah B Wallwork
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Felicity A Braithwaite
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Mary O'Keeffe
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Mervyn J Travers
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Simon J Summers
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Belinda Lange
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Dana A Hince
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Leonardo O P Costa
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Luciola da C Menezes Costa
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - Belinda Chiera
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
| | - G Lorimer Moseley
- IIMPACT in Health (Wallwork, Braithwaite, Moseley), University of South Australia, Kaurna Country, Adelaide, Australia; Persistent Pain Research Group, Hopwood Centre for Neurobiology (Braithwaite), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Institute for Musculoskeletal Health (O'Keeffe), School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences and Physiotherapy (Travers), University of Notre Dame Australia, Fremantle, Australia; School of Biomedical Science (Summers), Queensland University of Technology, Queensland, Australia; Caring Futures Institute (Lange), College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; Institute for Health Research (Hince), Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame, Fremantle, Australia; Masters and Doctoral Programs in Physical Therapy (Costa, Menezes Costa), Universidade Cidade de São Paulo, São Paulo, Brazil; UniSA STEM (Chiera), University of South Australia, Kaurna Country, Adelaide, Australia
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Toews I, Anglemyer A, Nyirenda JL, Alsaid D, Balduzzi S, Grummich K, Schwingshackl L, Bero L. Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials: a meta-epidemiological study. Cochrane Database Syst Rev 2024; 1:MR000034. [PMID: 38174786 PMCID: PMC10765475 DOI: 10.1002/14651858.mr000034.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Researchers and decision-makers often use evidence from randomised controlled trials (RCTs) to determine the efficacy or effectiveness of a treatment or intervention. Studies with observational designs are often used to measure the effectiveness of an intervention in 'real world' scenarios. Numerous study designs and their modifications (including both randomised and observational designs) are used for comparative effectiveness research in an attempt to give an unbiased estimate of whether one treatment is more effective or safer than another for a particular population. An up-to-date systematic analysis is needed to identify differences in effect estimates from RCTs and observational studies. This updated review summarises the results of methodological reviews that compared the effect estimates of observational studies with RCTs from evidence syntheses that addressed the same health research question. OBJECTIVES To assess and compare synthesised effect estimates by study type, contrasting RCTs with observational studies. To explore factors that might explain differences in synthesised effect estimates from RCTs versus observational studies (e.g. heterogeneity, type of observational study design, type of intervention, and use of propensity score adjustment). To identify gaps in the existing research comparing effect estimates across different study types. SEARCH METHODS We searched MEDLINE, the Cochrane Database of Systematic Reviews, Web of Science databases, and Epistemonikos to May 2022. We checked references, conducted citation searches, and contacted review authors to identify additional reviews. SELECTION CRITERIA We included systematic methodological reviews that compared quantitative effect estimates measuring the efficacy or effectiveness of interventions tested in RCTs versus in observational studies. The included reviews compared RCTs to observational studies (including retrospective and prospective cohort, case-control and cross-sectional designs). Reviews were not eligible if they compared RCTs with studies that had used some form of concurrent allocation. DATA COLLECTION AND ANALYSIS Using results from observational studies as the reference group, we examined the relative summary effect estimates (risk ratios (RRs), odds ratios (ORs), hazard ratios (HRs), mean differences (MDs), and standardised mean differences (SMDs)) to evaluate whether there was a relatively larger or smaller effect in the ratio of odds ratios (ROR) or ratio of risk ratios (RRR), ratio of hazard ratios (RHR), and difference in (standardised) mean differences (D(S)MD). If an included review did not provide an estimate comparing results from RCTs with observational studies, we generated one by pooling the estimates for observational studies and RCTs, respectively. Across all reviews, we synthesised these ratios to produce a pooled ratio of ratios comparing effect estimates from RCTs with those from observational studies. In overviews of reviews, we estimated the ROR or RRR for each overview using observational studies as the reference category. We appraised the risk of bias in the included reviews (using nine criteria in total). To receive an overall low risk of bias rating, an included review needed: explicit criteria for study selection, a complete sample of studies, and to have controlled for study methodological differences and study heterogeneity. We assessed reviews/overviews not meeting these four criteria as having an overall high risk of bias. We assessed the certainty of the evidence, consisting of multiple evidence syntheses, with the GRADE approach. MAIN RESULTS We included 39 systematic reviews and eight overviews of reviews, for a total of 47. Thirty-four of these contributed data to our primary analysis. Based on the available data, we found that the reviews/overviews included 2869 RCTs involving 3,882,115 participants, and 3924 observational studies with 19,499,970 participants. We rated 11 reviews/overviews as having an overall low risk of bias, and 36 as having an unclear or high risk of bias. Our main concerns with the included reviews/overviews were that some did not assess the quality of their included studies, and some failed to account appropriately for differences between study designs - for example, they conducted aggregate analyses of all observational studies rather than separate analyses of cohort and case-control studies. When pooling RORs and RRRs, the ratio of ratios indicated no difference or a very small difference between the effect estimates from RCTs versus from observational studies (ratio of ratios 1.08, 95% confidence interval (CI) 1.01 to 1.15). We rated the certainty of the evidence as low. Twenty-three of 34 reviews reported effect estimates of RCTs and observational studies that were on average in agreement. In a number of subgroup analyses, small differences in the effect estimates were detected: - pharmaceutical interventions only (ratio of ratios 1.12, 95% CI 1.04 to 1.21); - RCTs and observational studies with substantial or high heterogeneity; that is, I2 ≥ 50% (ratio of ratios 1.11, 95% CI 1.04 to 1.18); - no use (ratio of ratios 1.07, 95% CI 1.03 to 1.11) or unclear use (ratio of ratios 1.13, 95% CI 1.03 to 1.25) of propensity score adjustment in observational studies; and - observational studies without further specification of the study design (ratio of ratios 1.06, 95% CI 0.96 to 1.18). We detected no clear difference in other subgroup analyses. AUTHORS' CONCLUSIONS We found no difference or a very small difference between effect estimates from RCTs and observational studies. These findings are largely consistent with findings from recently published research. Factors other than study design need to be considered when exploring reasons for a lack of agreement between results of RCTs and observational studies, such as differences in the population, intervention, comparator, and outcomes investigated in the respective studies. Our results underscore that it is important for review authors to consider not only study design, but the level of heterogeneity in meta-analyses of RCTs or observational studies. A better understanding is needed of how these factors might yield estimates reflective of true effectiveness.
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Affiliation(s)
- Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Andrew Anglemyer
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John Lz Nyirenda
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Dima Alsaid
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Sara Balduzzi
- Biometrics Department, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Kathrin Grummich
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Lisa Bero
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, Australia
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7
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Webers C, Grimm S, van Tubergen A, van Gaalen F, van der Heijde D, Joore M, Boonen A. The value of correctly diagnosing axial spondyloarthritis for patients and society. Semin Arthritis Rheum 2023; 62:152242. [PMID: 37451047 DOI: 10.1016/j.semarthrit.2023.152242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/30/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To demonstrate the value of diagnosing axSpA, by comparing health and costs associated with available diagnostic algorithms and perfect diagnosis. METHODS Using data from SPACE and other cohorts, a model was developed to estimate health (quality-adjusted life-years, QALYs) and costs (healthcare consumption and work productivity losses) of different diagnostic algorithms for axSpA amongst patients with low back pain referred to a rheumatologist, over a 60-year horizon. The model combined a decision-tree (diagnosis) with a state-transition model (treatment). The three algorithms (Berlin [BER, highest specificity], Modification 1 [M1; less strict inflammatory back pain (IBP) criterion] and Modification 2 [M2; IBP not mandatory as entry criterion, highest sensitivity]) were compared. Changes in sensitivity/specificity were explored and the value of perfect diagnosis was investigated. RESULTS For each correctly diagnosed axSpA patient, up to 4.7 QALYs and €60,000 could be gained/saved, considering a societal perspective. Algorithm M2 resulted in more health and lower costs per patient (24.23 QALYs; €157,469), compared to BER (23.96 QALYs; €159,423) and M1 (24.15 QALYs; €158,417). Hypothetical improvements in M2 sensitivity resulted in slightly more value compared to improvements in specificity. Perfect diagnosis can cost €7,500 per patient and still provide enough value. CONCLUSION Correct diagnosis of axSpA results in substantial health and cost benefits for patients and society. Not requiring IBP as mandatory for diagnosis of axSpA (algorithm M2) provides more value and would be preferable. A considerably more expensive diagnostic algorithm with better accuracy than M2 would still be considered good value for money.
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Affiliation(s)
- Casper Webers
- Department of Internal Medicine, Department of Rheumatology, Maastricht University Medical Centre, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Astrid van Tubergen
- Department of Internal Medicine, Department of Rheumatology, Maastricht University Medical Centre, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Floris van Gaalen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Annelies Boonen
- Department of Internal Medicine, Department of Rheumatology, Maastricht University Medical Centre, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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8
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Lyng KD, Djurtoft C, Bruun MK, Christensen MN, Lauritsen RE, Larsen JB, Birnie KA, Stinson J, Hoegh MS, Palsson TS, Olesen AE, Arendt-Nielsen L, Ehlers LH, Fonager K, Jensen MB, Würtzen H, Poulin PA, Handberg G, Ziegler C, Moeller LB, Olsen J, Heise L, Rathleff MS. What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map. Pain 2023; 164:1406-1415. [PMID: 36602421 DOI: 10.1097/j.pain.0000000000002855] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/01/2022] [Indexed: 01/06/2023]
Abstract
ABSTRACT Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.
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Affiliation(s)
- Kristian D Lyng
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
| | - Chris Djurtoft
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
| | - Malene K Bruun
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
| | - Mads N Christensen
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
| | - Rikke E Lauritsen
- Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper B Larsen
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Kathryn A Birnie
- Departments of Anesthesiology, Perioperative, and Pain Medicine and
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Jennifer Stinson
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Morten S Hoegh
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Thorvaldur S Palsson
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
| | - Anne E Olesen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Lars H Ehlers
- Denmark & Nordic Institute of Health Economics, Aarhus, Denmark
| | - Kirsten Fonager
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Social Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Martin B Jensen
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
| | - Hanne Würtzen
- Department of Neuroanaesthesiology, The Multidisciplinary Pain Centre, Rigshospitalet, Copenhagen, Denmark
| | - Patricia A Poulin
- Department of Psychology, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gitte Handberg
- Pain Research Group, Pain Center, Odense University Hospital, Odense, Denmark
- Pain Center, Odense University Hospital, Odense, Denmark
| | - Connie Ziegler
- Gigtforeningen/Danish Rheumatism Association, Copenhagen, Denmark
| | - Lars B Moeller
- Foreningen af Kroniske Smerteramte og Pårørende (FAKS)/The Association for Chronic Pain Patients and Relatives, Copenhagen, Denmark
| | - Judi Olsen
- Fibromyalgi & Smerteforeningen/the Danish Fibromyalgia & Pain Association, Copenhagen, Denmark
| | - Lotte Heise
- Danish Broadcasting Corporation, Copenhagen, Denmark
| | - Michael S Rathleff
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Center for General Practice at Aalborg University, Aalborg University, Aalborg, Denmark
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9
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Budtz CR, Rønnow MM, Stæhr TAB, Andersen NBDV, Christiansen DH. The usefulness of the STarT back screening tool and single-item general health measures when predicting future disability in patients with low back pain treated in Danish primary care physiotherapy. Musculoskelet Sci Pract 2023; 65:102767. [PMID: 37116370 DOI: 10.1016/j.msksp.2023.102767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/13/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The extent to which disease specific screening tools or other health measures add to the predictive value of common clinical factors (pain, disability and socio-demographics) has been sparsely investigated. The aim of this study was to investigate whether a disease specific screening tool and a single-item general health measure adds predictive value to basic information collected in primary physiotherapy care when predicting future disability in patients with low back pain. MATERIAL AND METHODS This longitudinal cohort study included 354 patients with low back pain from Danish primary care physiotherapy. Information was collected on socio-demographics, common clinical factors, The STarT Back Screening Tool (SBT) and general health perceptions measured as a single item from the SF-36 (GH-1). Disability at 6-month follow-up, measured by the Roland-Morris Disability Questionnaire, was predicted using multiple linear regression models. RESULTS Clinical factors and baseline disability level explained 28.3% of the variance in 6-month disability scores. With SBT and GH-1 added separately to the baseline model, the explained variance increased by 2.1% (p = 0.01) and 3.6% (p < 0.001), respectively. CONCLUSION The added value of the disease specific screening tools or the single-item general measure when predicting disability in patients with low back pain was generally small. Moreover, the predictive value of the single-item general measure seems comparable to and slightly better than the disease specific screening tool. Overall these findings may question the clinical utility of such measures.
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Affiliation(s)
- Cecilie Rud Budtz
- Elective Surgery Centre, Silkeborg Regional Hospital, Falkevej 1, 8600, Silkeborg, Denmark.
| | - Mathias Moselund Rønnow
- Department of Occupational Medicine, University Research Clinic, Goedstrup Hospital, Hospitalsparken 15, 7400, Herning, Denmark
| | - Thor Andre Brøndberg Stæhr
- Department of Occupational Medicine, University Research Clinic, Goedstrup Hospital, Hospitalsparken 15, 7400, Herning, Denmark
| | - Nils-Bo de Vos Andersen
- Central Denmark Region, Primary Health Care and Quality Improvement, Skottenborg 26, 8800, Viborg, Denmark
| | - David Høyrup Christiansen
- Elective Surgery Centre, Silkeborg Regional Hospital, Falkevej 1, 8600, Silkeborg, Denmark; Regional Hospital Central Jutland, Heibergs Allé 2K, 8000, Viborg, Denmark; Deartment of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark
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10
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Wilson AT, Riley JL, Bishop MD, Beneciuk JM, Cruz-Almeida Y, Markut K, Redd C, LeBlond N, Pham PH, Shirey D, Bialosky JE. Pain phenotyping and investigation of outcomes in physical therapy: An exploratory study in patients with low back pain. PLoS One 2023; 18:e0281517. [PMID: 36787322 PMCID: PMC9928110 DOI: 10.1371/journal.pone.0281517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023] Open
Abstract
Phenotypes have been proposed as a method of characterizing subgroups based on biopsychosocial factors to identify responders to analgesic treatments. This study aimed to, first, confirm phenotypes in patients with low back pain receiving physical therapy based on an a priori set of factors used to derive subgroups in other pain populations. Second, an exploratory analysis examined if phenotypes differentiated pain and disability outcomes at four weeks of physical therapy. Fifty-five participants completed psychological questionnaires and pressure pain threshold (PPT). Somatization, anxiety, and depression domains of the Symptom-Checklist-90-Revised, and PPT, were entered into a hierarchical agglomerative cluster analysis with Ward's method to identify phenotypes. Repeated measures ANOVAs assessed pain ratings and disability by phenotype at four weeks. Three clusters emerged: 1) high emotional distress and pain sensitivity (n = 10), 2) low emotional distress (n = 34), 3) low pain sensitivity (n = 11). As an exploratory study, clusters did not differentiate pain ratings or disability after four weeks of physical therapy (p's>0.05). However, trends were observed as magnitude of change for pain varied by phenotype. This supports the characterization of homogenous subgroups based on a protocol conducted in the clinical setting with varying effect sizes noted by phenotype for short-term changes in pain. As an exploratory study, future studies should aim to repeat this trial in a larger sample of patients.
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Affiliation(s)
- Abigail T. Wilson
- School of Kinesiology and Rehabilitation Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, United States of America
- * E-mail:
| | - Joseph L. Riley
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, United States of America
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Mark D. Bishop
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
| | - Jason M. Beneciuk
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - Yenisel Cruz-Almeida
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, United States of America
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Keri Markut
- University of Florida Health Rehab Center-Orthopedic and Sports Medicine Institute, Gainesville, Florida, United States of America
| | - Charlotte Redd
- University of Florida Health Rehab Center-Orthopedic and Sports Medicine Institute, Gainesville, Florida, United States of America
| | - Nicholas LeBlond
- Duke University Health System Durham, North Carolina, United States of America
| | - Patrick H. Pham
- Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - David Shirey
- Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - Joel E. Bialosky
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida, United States of America
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11
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Ahmed I, Dhaif F, Khatri C, Parsons N, Hutchinson C, Staniszewska S, Price A, Metcalfe A. The meniscal tear outcome (METRO) review: A systematic review summarising the clinical course and outcomes of patients with a meniscal tear. Knee 2022; 38:117-131. [PMID: 36041240 DOI: 10.1016/j.knee.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 06/15/2022] [Accepted: 07/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. METHOD A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. RESULTS 35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant. CONCLUSIONS Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications.
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Affiliation(s)
- Imran Ahmed
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, University Hospital Coventry and Warwickshire, Coventry CV22DX, United Kingdom.
| | - Fatema Dhaif
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, University Hospital Coventry and Warwickshire, Coventry CV22DX, United Kingdom.
| | - Chetan Khatri
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, University Hospital Coventry and Warwickshire, Coventry CV22DX, United Kingdom.
| | - Nicholas Parsons
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV47AL, United Kingdom.
| | - Charles Hutchinson
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, University Hospital Coventry and Warwickshire, Coventry CV22DX, United Kingdom.
| | - Sophie Staniszewska
- Warwick Medical School, University of Warwick, Coventry CV47AL, United Kingdom.
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Headington, Oxford OX3 7LD, United Kingdom.
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, University Hospital Coventry and Warwickshire, Coventry CV22DX, United Kingdom.
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12
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van Delft E, Lopes Barreto D, Han KH, Tchetverikov I, Evertse A, Kuijper TM, Hazes J, Weel-Koenders A. Impact of triage by a rheumatologist on appropriateness of referrals from primary to secondary care: a cluster randomized trial. Scand J Rheumatol 2022:1-9. [PMID: 36173970 DOI: 10.1080/03009742.2022.2112833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The quality of referrals is often criticized, and the effectiveness of improvement efforts remains uncertain. We assessed the impact of a rheumatologist triaging patients in primary care on the appropriateness of referrals to secondary care, healthcare utilization, and patient experience and outcomes. METHOD A cluster randomized controlled trial was conducted with patients experiencing musculoskeletal complaints. Intervention practices deployed an experienced rheumatologist triaging patients through in-person review. Usual care was performed in control practices, where practitioners referred patients based on their own judgement. The primary outcome was the proportion of inflammatory rheumatic diseases (IRDs) diagnosed by rheumatologists in referred patients. Healthcare utilization (iMTA Medical Consumption Questionnaire), quality of life (EuroQol 5 Dimensions), and experience of care (Consumer Quality Index) were determined after 3 months of follow-up. Data were analysed according to the intention-to-treat principle. RESULTS In total, 544 participants were included [mean age 51.4 (range 18-87) years; 24% were men]. Of all referred patients, 51% had an IRD in the intervention group versus 21% in the control group (p = 0.035). After 3 months of follow-up, patients from the triage intervention showed lower healthcare utilization (p = 0.006) and higher quality of life (p = 0.011), without a decline in experienced quality of care (p = 0.712), compared to controls. CONCLUSION Triage by a rheumatologist in primary care provides appropriate care and adequate experience of care, leading to a higher quality of life. Long-term evidence is needed to assess the value on cost-effectiveness before implementing this strategy nationwide.
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Affiliation(s)
- Etam van Delft
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - D Lopes Barreto
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - K H Han
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - I Tchetverikov
- Department of Rheumatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - A Evertse
- Medical Center Molenaar, Oud-Beijerland, The Netherlands
| | - T M Kuijper
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jmw Hazes
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aeam Weel-Koenders
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.,Health Technology Assessment, Erasmus University, Rotterdam, The Netherlands
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13
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Placebo administration for dry eye disease: a level I evidence based systematic review and meta-analysis. Int J Clin Pharm 2022; 44:1087-1101. [PMID: 35939178 PMCID: PMC9618542 DOI: 10.1007/s11096-022-01439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/04/2022] [Indexed: 12/05/2022]
Abstract
Background The efficacy of various common treatment options for dry eye disease (DED) has been investigated against placebo. However, the potential beneficial effect of placebo in the management of DED is still unclear. Aim This meta-analysis investigated the impact of placebo administration in DED in Ocular Surface Disease Index (OSDI), Schirmer I test (SIT), tear breakup time (TBUT), corneal staining, and complications. Method This meta-analysis and systematic review was conducted according to the 2020 PRISMA guidelines. In March 2022, Pubmed, Web of Science, Google Scholar, and Embase were accessed. All the randomised clinical trials which investigated any active treatment against a placebo control group were considered. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), corneal staining. Results Data from 56 studies (12,205 patients) were retrieved. Placebo administration is not effective in improving TBUT (P = 0.3), OSDI (P = 0.2), SIT (P = 0.1) and corneal staining (P = 0.1) from baseline to last follow-up. Active treatment led to a higher TBUT and SIT compared to placebo administration (P < 0.0001). The active treatment resulted in a lower OSDI compared to placebo administration (P = 0.0005). Five studies reported data on the corneal staining. No difference was found between placebo administration and active treatment (P = 0.8). Conclusion Placebo administration does not impact symptoms of DED and can be successfully employed to evaluate the efficacy of active treatments. Supplementary Information The online version contains supplementary material available at 10.1007/s11096-022-01439-y.
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14
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Felício DC, Elias Filho J, Pereira DS, Queiroz BZD, Leopoldino AAO, Rocha VTM, Pereira LSM. The effect of kinesiophobia in older people with acute low back pain: longitudinal data from Back Complaints in the Elders (BACE). CAD SAUDE PUBLICA 2021; 37:e00232920. [PMID: 34932682 DOI: 10.1590/0102-311x00232920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/04/2021] [Indexed: 11/22/2022] Open
Abstract
This study aimed to investigate the course of low back pain (LBP) intensity over a period of 12 months in older people with and without kinesiophobia.This was an international multicenter study. LBP intensity was examined by using the Numerical Pain Scale at baseline and over five follow-up periods. The Fear-Avoidance Beliefs Questionnaire was used to measure patients' beliefs and fears. The study included 532 older adults (non kinesiophobic = 227; kinesiophobic = 305). The individuals had moderate pain at baseline, with a significant difference observed between the groups. Participants showed a rapid improvement in the first 6 weeks, followed by minor improvements in the succeeding months. However, a significant difference between groups remained during the follow-up period. Independently, kinesiophobia is a significant prognostic factor. These findings suggest the importance of screening for psychosocial factors in the management of older patients with LBP. Practice implications: patients need to be warned that pain can be perpetuated by inappropriate avoidance behaviors that may later lead to disability.
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Lo WC, Chen YT, Chen CC. The Effects of Elgucare on Degenerated Intervertebral Disc-Induced Low Back Pain and Disc Regeneration: A Clinical Trial. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:5824956. [PMID: 34790253 PMCID: PMC8592736 DOI: 10.1155/2021/5824956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Chronic low back pain (LBP) has a wide range of causes. However, most cases are induced by degeneration of the lumbar intervertebral discs (IVDs), and the aching caused by local compression of the affected region has considerable impacts on quality of life. This clinical trial investigated the use of Elgucare, a Chinese herbal formula, as a food supplement to reduce the pain of patients with LBP induced by degeneration of the lumbar IVDs. METHODS The study assessed patient subjective quality of life, functional limitations caused by LBP, and variations in pain. The assessment was done through the visual analogue scale (VAS) and effects on lumbar IVD thickness, water content, and bone mineral density (BMD). These parameters were evaluated before and after the administration of Elgucare or a placebo, one of which was taken by each participant for a 12-month period. RESULTS Elgucare reduced the patients' mean VAS pain score by 2.25 points and improved their mean LBP-hampered mobility as assessed by the Roland-Morris Questionnaire by 5.17 points. The results of another questionnaire indicated that Elgucare slowed the LBP-induced deterioration of patients' quality of life, while objective assessment indices obtained through X-ray and magnetic resonance imaging showed that the height and water retention of their IVDs were increased. However, the BMD results showed no improvements. CONCLUSIONS Elgucare can increase the water retention and height of IVDs and reduce LBP, thereby enhancing quality of life. Therefore, Elgucare can potentially be used as a clinical supplement.
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Affiliation(s)
- Wen-Cheng Lo
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu Ting Chen
- Research and Development of DC Botanical Biotechnology CO., LTD, LDY Chinese Medicine Hospital, New Taipei City, Taiwan
| | - Chen Ching Chen
- DC Botanical Biotechnology CO., LTD, LDY Chinese Medicine Hospital, New Taipei City, Taiwan
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Rønnow MM, Stæhr TAB, Christiansen DH. Predicting change in symptoms and function in patients with persistent shoulder pain: a prognostic model development study. BMC Musculoskelet Disord 2021; 22:732. [PMID: 34452608 PMCID: PMC8401246 DOI: 10.1186/s12891-021-04612-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background Persistent shoulder pain causes considerable disruption of the individual’s life and imposes high costs on healthcare and society. Well-informed treatment and referral pathways are crucial as unsuccessful interventions and longer duration of symptoms minimizes the likelihood of success in future interventions. Although physiotherapy is generally recommended as first line treatment, no prognostic model or clinical prediction rules exists to help guide the treatment of patients with persistent shoulder pain undergoing physiotherapy. Thus, the objective of this study was to develop a prognostic model to inform clinical decision making and predict change in symptoms and function in patients with persistent shoulder pain. Methods This was a prospective cohort study of 243 patients with persistent shoulder pain referred to outpatient physiotherapy rehabilitation centres. Data was collected at baseline and six-month follow-up. The outcome was change in shoulder symptoms and function as measured by the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) from baseline to 6 months follow up. Potential predictors were included in a multivariable linear regression model which was pruned using modified stepwise backwards elimination. Results The final model consisted of seven predictors; baseline QuickDASH score, employment status, educational level, movement impairment classification, self-rated ability to cope with the pain, health-related quality of life and pain catastrophizing. Together these variables explained 33% of the variance in QuickDASH-change scores with a model root mean squared error of 17 points. Conclusion The final prediction model explained 33% of the variance in QuickDASH change-scores at 6 months. The root mean squared error (model SD) was relatively large meaning that the prediction of individual change scores was quite imprecise. Thus, the clinical utility of the prediction model is limited in its current form. Further work needs be done in order to improve the performance and precision of the model before external validity can be examined along with the potential impact of the model in clinical practice. Two of the included predictors were novel and could be examined in future studies; movement impairment classification based on diagnosis and health-related quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04612-y.
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Affiliation(s)
- Mathias Moselund Rønnow
- Department of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Gl. Landevej 61, 7400, Herning, Denmark.
| | - Thor André Brøndberg Stæhr
- Department of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Gl. Landevej 61, 7400, Herning, Denmark
| | - David Høyrup Christiansen
- Department of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Gl. Landevej 61, 7400, Herning, Denmark
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Prevalence, Characteristics, and Clinical Course of Neuropathic Pain in Primary Care Patients Consulting With Low Back-related Leg Pain. Clin J Pain 2021; 36:813-824. [PMID: 32841967 DOI: 10.1097/ajp.0000000000000879] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Little is known about the epidemiology of neuropathic pain in primary care patients consulting with low back-related leg pain. We aimed to describe prevalence, characteristics, and clinical course of low back-related leg pain patients with and without neuropathic pain, consulting with their family doctor in the United Kingdom. MATERIALS AND METHODS This was a prospective cohort study. Data were collected using a standardized baseline clinical examination and self-report questionnaires at baseline, 4, 12, and 36 months. We identified cases of neuropathic pain using 3 definitions: 2 based on clinical diagnosis (sciatica, with and without evidence of nerve root compression on magnetic resonance imaging), one on the self-report version of Leeds Assessment for Neurological Symptoms and Signs. Differences between patients with and without neuropathic pain were analyzed comparing each definition. Clinical course (mean pain intensity measured as the highest of leg or back pain intensity: mean of 3 Numerical Rating Scales, each 0 to 10) was investigated using linear mixed models over 36 months. RESULTS Prevalence of neuropathic pain varied from 48% to 74% according to definition used. At baseline, patients with neuropathic pain had more severe leg pain intensity, lower pain self-efficacy, more patients had sensory loss than those without. Distinct profiles were apparent depending on neuropathic pain definition. Mean pain intensity reduced after 4 months (6.1 to 3.9 [sciatica]), most rapidly in cases defined by clinical diagnosis. DISCUSSION This research provides new information on the clinical course of neuropathic pain and a better understanding of neuropathic pain in low back-related leg pain patients consulting in primary care.
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Brunner E, Meichtry A, Vancampfort D, Imoberdorf R, Gisi D, Dankaerts W, Graf A, Wipf Rebsamen S, Suter D, Wildi LM, Buechi S, Sieber C. Influence of weekday of admission and level of distress on length of hospital stay in patients with low back pain: a retrospective cohort study. BMC Musculoskelet Disord 2021; 22:656. [PMID: 34353298 PMCID: PMC8340547 DOI: 10.1186/s12891-021-04529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/16/2021] [Indexed: 11/22/2022] Open
Abstract
Background Low back pain (LBP) is often a complex problem requiring interdisciplinary management to address patients’ multidimensional needs. Providing inpatient care for patients with LBP in primary care hospitals is a challenge. In this setting, interdisciplinary LBP management is often unavailable during weekends. Delays in therapeutic procedures may result in a prolonged length of hospital stay (LoS). The impact of delays on LoS might be strongest in patients reporting high levels of psychological distress. Therefore, this study investigates the influence of weekday of admission and distress on LoS of inpatients with LBP. Methods This retrospective cohort study was conducted between 1 February 2019 and 31 January 2020. In part 1, a negative binomial model was fitted to LoS with weekday of admission as a predictor. In part 2, the same model included weekday of admission, distress level, and their interaction as covariates. Planned contrast was used in part 1 to estimate the difference in log-expected LoS between group 1 (admissions Friday/Saturday) and the reference group (admissions Sunday-Thursday). In part 2, the same contrast was used to estimate the corresponding difference in (per-unit) distress trends. Results We identified 173 patients with LBP. The mean LoS was 7.8 days (SD = 5.59). Patients admitted on Friday (mean LoS = 10.3) and Saturday (LoS = 10.6) had longer stays, but not those admitted on Sunday (LoS = 7.1). Analysis of the weekday effect and planned contrast showed that admission on Friday or Saturday was associated with a significant increase in LoS (log ratio = 0.42, 95% CI = 0.21 to 0.63). A total of 101 patients (58%) returned questionnaires, and complete data on distress were available from 86 patients (49%). According to the negative binomial model for LoS and the planned contrast, the distress effect on LoS was significantly influenced (difference in slopes = 0.816, 95% CI = 0.03 to 1.60) by dichotomic weekdays of admission (Friday/Saturday vs. Sunday-Thursday). Conclusions Delays in interdisciplinary LBP management over the weekend may prolong LoS. This may particularly affect patients reporting high levels of distress. Our study provides a platform to further explore whether interdisciplinary LBP management addressing patients’ multidimensional needs reduces LoS in primary care hospitals.
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Affiliation(s)
- Emanuel Brunner
- Department of Physiotherapy and Rehabilitation, Winterthur Cantonal Hospital, Brauerstrasse 15, CH-801, Winterthur, Switzerland. .,Department of Health, OST - Eastern Swiss University of Applied Sciences, St. Gallen, Switzerland. .,Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.
| | - André Meichtry
- School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Davy Vancampfort
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Reinhard Imoberdorf
- Department of Internal Medicine, Winterthur Cantonal Hospital, Winterthur, Switzerland
| | - David Gisi
- Department of Physiotherapy and Rehabilitation, Winterthur Cantonal Hospital, Brauerstrasse 15, CH-801, Winterthur, Switzerland
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Anita Graf
- Department of Physiotherapy and Rehabilitation, Winterthur Cantonal Hospital, Brauerstrasse 15, CH-801, Winterthur, Switzerland
| | - Stefanie Wipf Rebsamen
- Department of Physiotherapy and Rehabilitation, Winterthur Cantonal Hospital, Brauerstrasse 15, CH-801, Winterthur, Switzerland
| | - Daniela Suter
- Department of Medicine, Nursing, Winterthur Cantonal Hospital, Winterthur, Switzerland
| | - Lukas Martin Wildi
- Department of Medicine, Institute of Rheumatology, Winterthur Cantonal Hospital, Winterthur, Switzerland
| | - Stefan Buechi
- Clinic for Psychotherapy and Psychosomatics "Hohenegg", Meilen, Switzerland
| | - Cornel Sieber
- Department of Internal Medicine, Winterthur Cantonal Hospital, Winterthur, Switzerland.,Institute for Biomedicine of Ageing, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany
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van der Gaag WH, Chiarotto A, Heymans MW, Enthoven WT, van Rijckevorsel-Scheele J, Bierma-Zeinstra SM, Bohnen AM, Koes BW. Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study. Pain 2021; 162:1632-1640. [PMID: 33394879 PMCID: PMC8120685 DOI: 10.1097/j.pain.0000000000002161] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/23/2022]
Abstract
ABSTRACT Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.
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Affiliation(s)
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Martijn W. Heymans
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
- Department of Epidemiology & Biostatistics, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Wendy T.M. Enthoven
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Sita M.A. Bierma-Zeinstra
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Orthopedics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Arthur M. Bohnen
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Bart W. Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Center for Muscle and Health, University of Southern Denmark, Odense, Denmark
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20
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Hayden JA, Ellis J, Ogilvie R, Boulos L, Stanojevic S. Meta-epidemiological study of publication integrity, and quality of conduct and reporting of randomized trials included in a systematic review of low back pain. J Clin Epidemiol 2021; 134:65-78. [PMID: 33545270 DOI: 10.1016/j.jclinepi.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/07/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To comprehensively describe the quality of conduct, reporting, and publication integrity characteristics for all trials included in a large Cochrane review, comparing those published by presumed predatory publishers with those published by nonpredatory publishers. DESIGN Cross-sectional meta-epidemiological study. STUDY SELECTION Two hundred seventy-nine studies (25,704 participants) eligible for the recent update of the "Exercise therapy for chronic low back pain" Cochrane review were included. DATA EXTRACTION Study and manuscript characteristics, including predatory publication status and other quality and integrity characteristics were extracted along with treatment effect. RESULTS Nine percent of trials included were in presumed predatory publications; 12% in the period since 2010. We found frequency of other concerning characteristics to range from low (eg, plagiarism, 5%) to common (eg, lack of evidence of trial registration or protocol publication [75%]; insufficient sample size [84%]) in included studies. Studies published by presumed predatory publishers consistently had inferior conduct, reporting and publication integrity characteristics. Presumed predatory publication was associated with missing conflict of interest statement (OR 7.6, 95% CI 3.0-19.1), inadequate follow-up duration (OR 11.2, 95% CI 3.7-33.7), incomplete study methods (OR 12.1, 95% CI 2.8-52.2) and baseline reporting (OR 4.3, 95% CI 1.6-11.7), and high risk of bias (OR 2.7, 95% CI 1.2-6.3). All (100%) presumed predatory publications were missing trial registrations (vs. 72%) and had inadequate sample sizes (vs. 82%). Trials published in presumed predatory journals did not appear to have inflated effect sizes. CONCLUSIONS Predatory publishers pose a distinct challenge to the consumption and synthesis of randomized controlled trials. More work is needed in other clinical areas to understand the potential impact of randomized controlled trials published in predatory publications, and as a result, the potential impact on evidence from systematic reviews that include these studies.
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Affiliation(s)
- J A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - J Ellis
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R Ogilvie
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - L Boulos
- Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
| | - S Stanojevic
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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21
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Galve Villa M, S Palsson T, Cid Royo A, R Bjarkam C, Boudreau SA. Digital Pain Mapping and Tracking in Patients With Chronic Pain: Longitudinal Study. J Med Internet Res 2020; 22:e21475. [PMID: 33104012 PMCID: PMC7652695 DOI: 10.2196/21475] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023] Open
Abstract
Background Digital pain mapping allows for remote and ecological momentary assessment in patients over multiple time points spanning days to months. Frequent ecological assessments may reveal tendencies and fluctuations more clearly and provide insights into the trajectory of a patient’s pain. Objective The primary aim of this study is to remotely map and track the intensity and distribution of pain and discomfort (eg, burning, aching, and tingling) in patients with nonmalignant spinal referred pain over 12 weeks using a web-based app for digital pain mapping. The secondary aim is to explore the barriers of use by determining the differences in clinical and user characteristics between patients with good (regular users) and poor (nonregular users) reporting compliance. Methods Patients (N=91; n=53 women) with spinal referred pain were recruited using web-based and traditional in-house strategies. Patients were asked to submit weekly digital pain reports for 12 weeks. Each pain report consisted of digital pain drawings on a pseudo–three-dimensional body chart and pain intensity ratings. The pain drawings captured the distribution of pain and discomfort (pain quality descriptors) expressed as the total extent and location. Differences in weekly pain reports were explored using the total extent (pixels), current and usual pain intensity ratings, frequency of quality descriptor selection, and Jaccard similarity index. Validated e-questionnaires were completed at baseline to determine the patients’ characteristics (adapted Danish National Spine Register), disability (Oswestry Disability Index and Neck Disability Index), and pain catastrophizing (Pain Catastrophizing Scale) profiles. Barriers of use were assessed at 6 weeks using a health care–related usability and acceptance e-questionnaire and a self-developed technology-specific e-questionnaire to assess the accessibility and ease of access of the pain mapping app. Associations between total extent, pain intensity, disability, and catastrophizing were explored to further understand pain. Differences between regular and nonregular users were assessed to understand the pain mapping app reporting compliance. Results Fluctuations were identified in pain reports for total extent and pain intensity ratings (P<.001). However, quality descriptor selection (P=.99) and pain drawing (P=.49), compared using the Jaccard index, were similar over time. Interestingly, current pain intensity was greater than usual pain intensity (P<.001), suggesting that the timing of pain reporting coincided with a more intense pain experience than usual. Usability and acceptance were similar between regular and nonregular users. Regular users were younger (P<.001) and reported a larger total extent of pain than nonregular users (P<.001). Conclusions This is the first study to examine digital reports of pain intensity and distribution in patients with nonmalignant spinal referred pain remotely for a sustained period and barriers of use and compliance using a digital pain mapping app. Differences in age, pain distribution, and current pain intensity may influence reporting behavior and compliance.
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Affiliation(s)
- Maria Galve Villa
- Center for Neuroplasticity and Pain, Center for Sensory Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Thorvaldur S Palsson
- Center for Sensory Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Albert Cid Royo
- Center for Neuroplasticity and Pain, Center for Sensory Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Carsten R Bjarkam
- Department of Neurosurgery, Institute of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Shellie A Boudreau
- Center for Neuroplasticity and Pain, Center for Sensory Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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22
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Ampiah PK, Hendrick P, Moffatt F. Implementation of a biopsychosocial physiotherapy management approach for patients with non-specific chronic low back pain in Ghana: a study protocol for a mixed-methods, sequential, feasibility, pretest-posttest quasi-experimental study. PHYSICAL THERAPY REVIEWS 2020. [DOI: 10.1080/10833196.2020.1832721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Paapa Kwesi Ampiah
- Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Hendrick
- Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Fiona Moffatt
- Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
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Irgens P, Kongsted A, Myhrvold BL, Waagan K, Engebretsen KB, Natvig B, Vøllestad NK, Robinson HS. Neck pain patterns and subgrouping based on weekly SMS-derived trajectories. BMC Musculoskelet Disord 2020; 21:678. [PMID: 33054732 PMCID: PMC7559200 DOI: 10.1186/s12891-020-03660-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/20/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Neck and low back pain represent dynamic conditions that change over time, often with an initial improvement after the onset of a new episode, followed by flare-ups or variations in intensity. Pain trajectories were previously defined based on longitudinal studies of temporal patterns and pain intensity of individuals with low back pain. In this study, we aimed to 1) investigate if the defined patterns and subgroups for low back pain were applicable to neck pain patients in chiropractic practice, 2) explore the robustness of the defined patterns, and 3) investigate if patients within the various patterns differ concerning characteristics and clinical findings. METHODS Prospective cohort study including 1208 neck pain patients from chiropractic practice. Patients responded to weekly SMS-questions about pain intensity and frequency over 43 weeks. We categorized individual responses into four main patterns based on number of days with pain and variations in pain intensity, and subdivided each into four subgroups based on pain intensity, resulting in 16 trajectory subgroups. We compared baseline characteristics and clinical findings between patterns and between Persistent fluctuating and Episodic subgroups. RESULTS All but two patients could be classified into one of the 16 subgroups, with 94% in the Persistent fluctuating or Episodic patterns. In the largest subgroup, "Mild Persistent fluctuating" (25%), mean (SD) pain intensity was 3.4 (0.6) and mean days with pain 130. Patients grouped as "Moderate Episodic" (24%) reported a mean pain intensity of 2.7 (0.6) and 39 days with pain. Eight of the 16 subgroups each contained less than 1% of the cohort. Patients in the Persistent fluctuating pattern scored higher than the other patterns in terms of reduced function and psychosocial factors. CONCLUSIONS The same subgroups seem to fit neck and low back pain patients, with pain that typically persists and varies in intensity or is episodic. Patients in a Persistent fluctuating pattern are more bothered by their pain than those in other patterns. The low back pain definitions can be used on patients with neck pain, but with the majority of patients classified into 8 subgroups, there seems to be a redundancy in the original model.
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Affiliation(s)
- P Irgens
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway.
| | - A Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - B L Myhrvold
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway
| | - K Waagan
- Department for Data Capture and Collections Management, University Center for Information Technology, University of Oslo, Oslo, Norway
| | - K B Engebretsen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - B Natvig
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - N K Vøllestad
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway
| | - H S Robinson
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway
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Coombs DM, Machado GC, Richards B, Oliveira CB, Herbert RD, Maher CG. Clinical course of patients with low back pain following an emergency department presentation: a systematic review and meta-analysis. Emerg Med J 2020; 38:834-841. [DOI: 10.1136/emermed-2019-209294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 07/15/2020] [Accepted: 07/25/2020] [Indexed: 11/04/2022]
Abstract
IntroductionLow back pain, and especially non-specific low back pain, is a common cause of presentation to the emergency department (ED). Although these patients typically report relatively high pain intensity, the clinical course of their pain and disability remains unclear. Our objective was to review the literature and describe the clinical course of non-specific low back pain after an ED visit.MethodsElectronic searches were conducted using MEDLINE, CINAHL and EMBASE from inception to March 2019. We screened for cohort studies or randomised trials investigating pain or disability in patients with non-specific low back pain presenting to EDs. We excluded studies that enrolled participants with minimal pain or disability scores at baseline. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias and quality of evidence. Estimates of pain and disability were converted to a common 0–100 scale. We estimated pooled means and 95% CIs of pain and disability as a function of time since ED presentation.ResultsEight studies (nine publications) with a total of 1994 patients provided moderate overall quality evidence of the expected clinical course of low back pain after an ED visit. Seven of the eight studies were assessed to have a low risk of bias. At the time of the ED presentation, the pooled estimate of the mean pain score on a 0–100 scale was 71.0 (95% CI 64.2–77.9). This reduced to 46.1 (95% CI 37.2–55.0) after 1 day, 41.8 (95% CI 34.7 to 49.0) after 1 week and 13.5 (95% CI 5.8–21.3) after 26 weeks. The course of disability followed a similar pattern.ConclusionsPatients presenting to EDs with non-specific low back pain experience rapid reductions in pain intensity, but on average symptoms persisted 6 months later. This review can be used to educate patients so they can have realistic expectations of their recovery.
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25
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Prognostic indicators for poor outcomes in low back pain patients consulted in primary care. PLoS One 2020; 15:e0229265. [PMID: 32218561 PMCID: PMC7100970 DOI: 10.1371/journal.pone.0229265] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/02/2020] [Indexed: 12/19/2022] Open
Abstract
Background Non-specific low back pain (NSLBP) is the most prevalent musculoskeletal condition in western countries and is associated with persistent disability and high consumption of health care resources. NSLBP patients first seek primary health care services but the outcomes are often uncertain. This study aimed to examine the clinical course of the outcomes and to identify prognostic indicators for poor outcomes in NSLBP patients who consulted primary care. Methods A prospective cohort study of 115 patients seeking treatment for NSLBP in primary care was conducted. Participants were consecutively recruited by their General Practitioners (GPs) and then assessed at baseline and 2 and 6 months later. Baseline assessment included socio-demographic and clinical data, psychosocial factors, pain, disability, and health related quality of life (HRQoL). Pain, disability, HRQoL and global perception of change were also assessed at 2 and 6-months’ follow-up. In addition, information regarding the GP’ practice was collected. Poor outcomes were determined according to the cut-off point used to define a persistent disabling condition and the minimal important change established for disability, pain and for global perception of change. The relationship between variables on baseline and poor outcomes was modulated through binary logistic regression analysis. The significance of associations was evaluated at ≤ 0.05 p-value with 95% confidence intervals (CI) and adjusted odds ratios (AOR). Results 110 (94.8%) and 104 (89.7%) participants completed the follow-up assessment at 2 and 6 months, respectively. The mean age (±SD) was 48.06 ± 11.41, with 53.9%, (N = 62) reporting an acute presentation of NSLBP. Six months after GP consultation, 53.8% (N = 56) of the participants reported a persistent disabling condition. An “LBP episode of less than 12 weeks” [AOR: 0.26; 95% CI (0.10, 0.65); AOR: 0.34; 95% CI (0.14, 0.81); AOR: 0.21; 95% CI (0.09, 0.53)],”maladaptive psychosocial factors” [AOR: 2.06; 95% CI (1.40, 3.04); AOR: 1.82; 95% CI (1.27, 2.59); AOR: 1.72; 95% CI (1.20, 2.47)] were significantly associated with poor outcomes on disability, pain and global perception of change, respectively. Besides these factors, being employed reduces the chances of poor outcomes on disability [AOR 0.31; 95% CI (0.11, 0.92)]. Conclusions A large proportion of LBP patients seeking primary health care reported poor outcomes 6 months after GP consultation. Patients who report chronic LBP, maladaptive psychosocial factors and are unemployed have a significant increase in the risk of poor outcome. These findings suggest the need of implementing effective models of care able to provide early screening and appropriate treatment to those at greatest risk of a poor outcome. Trial registration Current Controlled Trials NCT04046874 (August 6, 2019). Retrospectively registered.
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Budtz CR, Mose S, Christiansen DH. Socio-demographic, clinical and psychological predictors of healthcare utilization among patients with musculoskeletal disorders: a prospective cohort study. BMC Health Serv Res 2020; 20:239. [PMID: 32293420 PMCID: PMC7092455 DOI: 10.1186/s12913-020-05100-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 03/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Musculoskeletal disorders are common in the general population and a leading cause for care seeking. Despite the large number of patients with musculoskeletal disorders seeking care, little is known of the clinical course, pathways and predictors of healthcare utilization among these patients. The purposes of the study were to 1) describe the clinical course and related healthcare utilization in primary care physiotherapy and secondary healthcare among patients with neck, shoulder and low-back pain treated in physiotherapy practice, and 2) identify independent clinical, socio-demographic, psychological and general health predictors of healthcare utilization. METHODS The study was a prospective cohort study of patients seeking physiotherapy treatment for neck, shoulder, or low-back pain in physiotherapy practices across Denmark. A total of 759 physiotherapy patients completed questionnaires containing information on clinical course and potential predictors of healthcare utilization. Healthcare utilization was obtained from the Danish National Health Service Register and National Patient Register. Associations between potential predictors and low/high primary care physiotherapy utilization and hospital contacts in relation to specific neck, shoulder or low-back disorders were analysed using binomial regression analyses and adjusted for age, sex, duration of pain and comorbidity. RESULTS During 6 months follow-up, patients experienced clinically relevant improvements in pain, fear avoidance and psychological wellbeing. Patients with higher baseline pain and disability and who were on sickness leave were more likely to have high primary care physiotherapy utilization. Hospital contacts were predicted by higher levels of pain, disability and low psychological wellbeing. CONCLUSIONS Clinical factors and sickness leave seems to be the main predictors of primary care physiotherapy utilization, whereas for secondary care contacts, psychological factors may also be of importance. The study contributes to the on-going research into clinical pathways and may identify future target areas to reduce healthcare utilization in patients with musculoskeletal disorders.
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Affiliation(s)
- Cecilie Rud Budtz
- Regional Hospital West Jutland, Department of Occupational Medicine, University Research Clinic, Gl. Landevej 61, 7400, Herning, Denmark.
| | - Søren Mose
- Regional Hospital West Jutland, Department of Occupational Medicine, University Research Clinic, Gl. Landevej 61, 7400, Herning, Denmark.,VIA University College, School of Physiotherapy, Gl. Struervej 1, 7500, Holstebro, Denmark
| | - David Høyrup Christiansen
- Regional Hospital West Jutland, Department of Occupational Medicine, University Research Clinic, Gl. Landevej 61, 7400, Herning, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark
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Seitzman GD, Lietman TM. Dry Eye Research-Still Regressing? Ophthalmology 2019; 126:192-194. [PMID: 30683176 DOI: 10.1016/j.ophtha.2018.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 10/27/2022] Open
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Patient-defined outcomes for pain, fatigue, emotional distress, and interference with activities did not differ by age for individuals with musculoskeletal pain. Pain Rep 2019; 4:e798. [PMID: 31984302 PMCID: PMC6903348 DOI: 10.1097/pr9.0000000000000798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 01/21/2023] Open
Abstract
Introduction: Age impacts the prevalence and experience of musculoskeletal pain; however, it is unknown whether this factor impacts patient's anticipated outcomes after treatment. Objective: Using the Patient-Centered Outcomes Questionnaire (PCOQ), the primary purpose was to determine whether there are age-related differences in desired, successful, expected levels, and importance of improvement in pain, fatigue, emotional distress, and interference with daily activities. As a secondary purpose, anatomical location and sex were then included in the model to examine for interaction effects. Methods: A secondary analysis of the Optimal Screening for Prediction of Referral and Outcome cross-sectional and longitudinal cohorts was conducted. Included in this analysis were 572 individuals seeking physical therapy for nonsurgical neck, low back, shoulder, and knee pain who completed the PCOQ at the initial evaluation. A three-way analysis of variance examined PCOQ domains by age categories, sex, and anatomical location. Results: Interaction effects were not observed for any of the domains of interest (P > 0.01). Significant main effects were also not observed for age, sex, and anatomical location (P > 0.01). Conclusion: Musculoskeletal pain prevalence may differ across age categories but, in this cohort, neither age, nor sex, nor anatomical location impacted patient-defined outcomes for intensity, fatigue, emotional distress, and interference with daily activities.
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Maas ET, van Dongen JM, Juch JNS, Groeneweg JG, Kallewaard JW, de Boer MR, Koes B, Verhagen AP, Huygen FJPM, van Tulder MW, Ostelo RWJG. Randomized controlled trials reflected clinical practice when comparing the course of low back pain symptoms in similar populations. J Clin Epidemiol 2019; 116:122-132. [PMID: 31536786 DOI: 10.1016/j.jclinepi.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/15/2019] [Accepted: 09/10/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study compares participants in randomized controlled trials (RCTs) (the Minimal Invasive Treatment [MinT] trials) to participants in a related observational study with regard to their low back pain (LBP) symptom course. STUDY DESIGN AND SETTING Eligible patients were diagnosed with chronic LBP originating from the facet joints (N = 615) or sacroiliac (SI) joints (N = 533) and were treated with radiofrequency denervation and an exercise program. Randomized patients were compared to patients in the related observational study who fulfilled all RCT eligibility criteria (observational group 1) and to patients who did not fulfill at least one of the RCT eligibility criteria (observational group 2). Outcomes were pain intensity, treatment success, and functional status over a 3-month period. Longitudinal mixed-model analyses and linear regression models were applied to analyze the differences in outcomes between the RCT and observational study groups. RESULTS No differences in symptom course were found between patients in the RCTs and patients in observational group 1. Patients with facet joint pain in observational group 2 had overall less treatment success (odds ratios [OR], 0.67; 95% confidence interval [CI], 0.50-0.90), and less improvement in physical functioning (mean difference [MD], 5.82; 95% CI, 2.54-9.11) compared to the RCT patients. Patients with SI joint pain in observational group 2 had higher pain scores (MD, 0.40; 95% CI, 0.09-0.72), less treatment success (OR, 0.72; 95% CI, 0.54-0.96), and less improvement in physical functioning (MD, 7.16; 95% CI, 3.84-10.47) compared to the RCT patients. CONCLUSION This supports the generalizability of results from the MinT RCTs as this study suggests that these RCTs reflect clinical practice when comparing similar populations. To what extent this holds true for all RCTs in LBP should be further explored.
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Affiliation(s)
- Esther T Maas
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Science Research Institute, 1081HV, Amsterdam, the Netherlands.
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Science Research Institute, 1081HV, Amsterdam, the Netherlands
| | - Johan N S Juch
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J George Groeneweg
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Science Research Institute, 1081HV, Amsterdam, the Netherlands
| | - Bart Koes
- Department of General Practice, Erasmus Medical Centre, Rotterdam, the Netherlands; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Arianne P Verhagen
- Department of General Practice, Erasmus Medical Centre, Rotterdam, the Netherlands; University of Technology Sydney, Graduate School of Health, Discipline of Physiotherapy, Ultimo, New South Wales, 2007, Australia
| | - Frank J P M Huygen
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Science Research Institute, 1081HV, Amsterdam, the Netherlands; Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Raymond W J G Ostelo
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Science Research Institute, 1081HV, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Khatri C, Ahmed I, Parsons H, Smith NA, Lawrence TM, Modi CS, Drew SJ, Bhabra G, Parsons NR, Underwood M, Metcalfe AJ. The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis. Am J Sports Med 2019; 47:1734-1743. [PMID: 29963905 DOI: 10.1177/0363546518780694] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known. PURPOSE To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials. STUDY DESIGN Systematic review and meta-analysis. METHODS Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores. RESULTS A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms. CONCLUSION Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.
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Affiliation(s)
- Chetan Khatri
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Imran Ahmed
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Helen Parsons
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Nicholas A Smith
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Thomas M Lawrence
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Chetan S Modi
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Stephen J Drew
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Gev Bhabra
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Nicholas R Parsons
- Statistics & Epidemiology Unit, University of Warwick Medical School, Coventry, UK
| | - Martin Underwood
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Andrew J Metcalfe
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
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A critical appraisal of the quality of low back pain practice guidelines using the AGREE II tool and comparison with previous evaluations: a EuroAIM initiative. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2781-2790. [PMID: 30220040 DOI: 10.1007/s00586-018-5763-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/09/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess the methodologic quality of guidelines for the management of low back pain (LBP) and compare their recommendations. METHODS No ethics committee approval was needed for this systematic review. In March 2017, a systematic search was performed using MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence to find practice guidelines of assessment and management of LBP. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool, and the results were compared with previous appraisals performed in 2004 and 2009. RESULTS Of 114 retrieved guidelines, eight were appraised. All except one reached the level of "acceptable" in overall result, with two of them reaching the highest scores. Only two guidelines reached a level of "acceptable" in every domain; the others had at least one domain with low scores. The guidelines had the higher scores (range = 63-94%) on "Scope and purpose" and "Clarity of presentation" (47-89%). "Stakeholder Involvement" has the highest variability between the guidelines results (40-96%). "Rigor of Development" reached an intermediate mean result (34-90%), "Applicability" (42-70%), and "Editorial Independence" (38-85%). Only three guidelines had a radiologist among authors and reached higher scores compared to guidelines without a radiologist among the authors. Compared to previous assessments, low-level guidelines were 53% in 2004, 36% in 2009, and 13% in 2017. CONCLUSIONS Considering all guidelines, only one had a "low" overall score, while half of them were rated as of "high" quality. Future guidelines might take this into account to improve clinical applicability.
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The smallest worthwhile effect of primary care physiotherapy did not differ across musculoskeletal pain sites. J Clin Epidemiol 2018; 101:44-52. [DOI: 10.1016/j.jclinepi.2018.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/26/2018] [Accepted: 05/19/2018] [Indexed: 01/27/2023]
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Moiz M, Smith N, Smith TO, Chawla A, Thompson P, Metcalfe A. Clinical Outcomes After the Nonoperative Management of Lateral Patellar Dislocations: A Systematic Review. Orthop J Sports Med 2018; 6:2325967118766275. [PMID: 29942814 PMCID: PMC6009091 DOI: 10.1177/2325967118766275] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: The first-line treatment for patellar dislocations is often nonoperative and consists of physical therapy and immobilization techniques, with various adjuncts employed. However, the outcomes of nonoperative therapy are poorly described, and there is a lack of quality evidence to define the optimal intervention. Purpose: To perform a comprehensive review of the literature and assess the quality of studies presenting patient outcomes from nonoperative interventions for patellar dislocations. Study Design: Systematic review; Level of evidence, 4. Methods: The MEDLINE, AMED, Embase, CINAHL, Cochrane Library, PEDro, and SPORTDiscus electronic databases were searched through July 2017 by 3 independent reviewers. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Study quality was assessed using the CONSORT (Consolidated Standards for Reporting Trials) criteria for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies and case series. Results: A total of 25 studies met our inclusion criteria, including 12 randomized controlled trials, 7 cohort studies, and 6 case series, consisting of 1066 patients. Studies were grouped according to 4 broad categories of nonoperative interventions based on immobilization, weightbearing status, quadriceps exercise type, and alternative therapies. The most commonly used outcome measure was the Kujala score, and the pooled redislocation rate was 31%. Conclusion: This systematic review found that patient-reported outcomes consistently improved after all methods of treatment but did not return to normal. Redislocation rates were high and close to the redislocation rates reported in natural history studies. There is a lack of quality evidence to advocate the use of any particular nonoperative technique for the treatment of patellar dislocations.
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Affiliation(s)
- Munim Moiz
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nick Smith
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amit Chawla
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Thompson
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Andrew Metcalfe
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Clinical Trials Unit, University of Warwick, Coventry, UK. The views expressed in this article are those of the authors and not necessarily those of the National Institute for Human Research
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Ogollah RO, Konstantinou K, Stynes S, Dunn KM. Determining One-Year Trajectories of Low-Back-Related Leg Pain in Primary Care Patients: Growth Mixture Modeling of a Prospective Cohort Study. Arthritis Care Res (Hoboken) 2018; 70:1840-1848. [PMID: 29575673 DOI: 10.1002/acr.23556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/08/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The clinical presentation and outcome of patients with back and leg pain in primary care are heterogeneous and may be better understood by identification of homogeneous and clinically meaningful subgroups. Subgroups of patients with different back pain trajectories have been identified, but little is known about the trajectories for patients with back-related leg pain. This study sought to identify distinct leg pain trajectories, and baseline characteristics associated with membership of each group, in primary care patients. METHODS Monthly data on leg pain intensity were collected over 12 months for 609 patients participating in a prospective cohort study of adult patients seeking health care for low-back and leg pain, including sciatica, of any duration and severity, from their general practitioner. Growth mixture modeling was used to identify clusters of patients with distinct leg pain trajectories. Trajectories were characterized using baseline demographic and clinical examination data. Multinomial logistic regression was used to predict latent class membership, with a range of covariates. RESULTS Four patient clusters were identified: improving mild pain (58%), persistent moderate pain (26%), persistent severe pain (13%), and improving severe pain (3%). Clusters showed statistically significant differences in a number of baseline characteristics. CONCLUSION Four trajectories of leg pain were identified. Clusters 1, 2, and 3 were generally comparable to back pain trajectories, while cluster 4, with major improvement in pain, is infrequently identified. Awareness of such distinct patient groups improves understanding of the course of leg pain and may provide a basis of classification for intervention.
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Affiliation(s)
- Reuben O Ogollah
- Arthritis Research UK Primary Care Centre, Keele University, Keele, and School of Medicine, University of Nottingham, Nottingham, UK
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Keele University, Keele, UK
| | - Siobhán Stynes
- Arthritis Research UK Primary Care Centre, Keele University, Keele, UK
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Keele University, Keele, UK
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Green D, Lewis M, Mansell G, Artus M, Dziedzic K, Hay E, Foster N, van der Windt D. Clinical course and prognostic factors across different musculoskeletal pain sites: A secondary analysis of individual patient data from randomised clinical trials. Eur J Pain 2018; 22:1057-1070. [DOI: 10.1002/ejp.1190] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 12/19/2022]
Affiliation(s)
- D.J. Green
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - M. Lewis
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - G. Mansell
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - M. Artus
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - K.S. Dziedzic
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - E.M. Hay
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - N.E. Foster
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - D.A. van der Windt
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
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Travers MJ, Bagg MK, Gibson W, O'Sullivan K, Palsson TS. Better than what? Comparisons in low back pain clinical trials. Br J Sports Med 2018; 53:847-848. [PMID: 29420237 DOI: 10.1136/bjsports-2017-098130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Mervyn J Travers
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia, Australia
| | - Matthew K Bagg
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,New College Village, University of New South Wales, Sydney, New South Wales, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Kieran O'Sullivan
- Department of Sports Spine Centre, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Department of Clinical Therapies, University of Limerick, Limerick, Ireland
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de Vos Andersen NB, Kent P, Hjort J, Christiansen DH. Clinical course and prognosis of musculoskeletal pain in patients referred for physiotherapy: does pain site matter? BMC Musculoskelet Disord 2017; 18:130. [PMID: 28356140 PMCID: PMC5371202 DOI: 10.1186/s12891-017-1487-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Danish patients with musculoskeletal disorders are commonly referred for primary care physiotherapy treatment but little is known about their general health status, pain diagnoses, clinical course and prognosis. The objectives of this study were to 1) describe the clinical course of patients with musculoskeletal disorders referred to physiotherapy, 2) identify predictors associated with a satisfactory outcome, and 3) determine the influence of the primary pain site diagnosis relative to those predictors. Methods This was a prospective cohort study of patients (n = 2,706) newly referred because of musculoskeletal pain to 30 physiotherapy practices from January 2012 to May 2012. Data were collected via a web-based questionnaire 1–2 days prior to the first physiotherapy consultation and at 6 weeks, 3 and 6 months, from clinical records (including primary musculoskeletal symptom diagnosis based on the ICPC-2 classification system), and from national registry data. The main outcome was the Patient Acceptable Symptom State. Potential predictors were analysed using backwards step-wise selection during longitudinal Generalised Estimating Equation regression modelling. To assess the influence of pain site on these associations, primary pain site diagnosis was added to the model. Results Of the patients included, 66% were female and the mean age was 48 (SD 15). The percentage of patients reporting their symptoms as acceptable was 32% at 6 weeks, 43% at 3 months and 52% at 6 months. A higher probability of satisfactory outcome was associated with place of residence, being retired, no compensation claim, less frequent pain, shorter duration of pain, lower levels of disability and fear avoidance, better mental health and being a non-smoker. Primary pain site diagnosis had little influence on these associations, and was not predictive of a satisfactory outcome. Conclusion Only half of the patients rated their symptoms as acceptable at 6 months. Although satisfactory outcome was difficult to predict at an individual patient level, there were a number of prognostic factors that were associated with this outcome. These factors should be considered when developing generic prediction tools to assess the probability of satisfactory outcome in musculoskeletal physiotherapy patients, because the site of pain did not affect that prognostic association. Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1487-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Peter Kent
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jakob Hjort
- Department of Clinical Medicine, HEALTH, Aarhus University, Aarhus, Denmark
| | - David Høyrup Christiansen
- Department of Occupational Medicine, Regional Hospital West Jutland-University Research Clinic, Herning, Denmark.
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Sequence variant at 8q24.21 associates with sciatica caused by lumbar disc herniation. Nat Commun 2017; 8:14265. [PMID: 28223688 PMCID: PMC5322534 DOI: 10.1038/ncomms14265] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 12/14/2016] [Indexed: 12/19/2022] Open
Abstract
Lumbar disc herniation (LDH) is common and often debilitating. Microdiscectomy of herniated lumbar discs (LDHsurg) is performed on the most severe cases to resolve the resulting sciatica. Here we perform a genome-wide association study on 4,748 LDHsurg cases and 282,590 population controls and discover 37 highly correlated markers associating with LDHsurg at 8q24.21 (between CCDC26 and GSDMC), represented by rs6651255[C] (OR=0.81; P=5.6 × 10−12) with a stronger effect among younger patients than older. As rs6651255[C] also associates with height, we performed a Mendelian randomization analysis using height polygenic risk scores as instruments to estimate the effect of height on LDHsurg risk, and found that the marker's association with LDHsurg is much greater than predicted by its effect on height. In light of presented findings, we speculate that the effect of rs6651255 on LDHsurg is driven by susceptibility to developing severe and persistent sciatica upon LDH. Lumbar disc herniation (LDH) can cause persistent sciatica, and in some cases surgery is required to relieve symptoms. Here, the authors carry out a genome-wide association study using microdiscectomy as an indicator of severe LDH, and find a locus on chromosome 8 associated with this condition.
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Whittle R, Royle KL, Jordan KP, Riley RD, Mallen CD, Peat G. Prognosis research ideally should measure time-varying predictors at their intended moment of use. Diagn Progn Res 2017; 1:1. [PMID: 31093533 PMCID: PMC6457137 DOI: 10.1186/s41512-016-0006-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/21/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Prognosis research studies (e.g. those deriving prognostic models or examining potential predictors of outcome) often collect information on time-varying predictors after their intended moment of use, sometimes using a measurement method different to that which would be used. We aimed to illustrate how estimates of predictor-outcome associations and prognostic model performance obtained from such studies may differ to those at the earlier, intended moment of use. METHODS We analysed data from two primary care cohorts of patients consulting for non-inflammatory musculoskeletal conditions: the Prognostic Research Study (PROG-RES: n = 296, aged >50 years) and the Primary care Osteoarthritis Screening Trial (POST: n = 756, >45 years). Both cohorts had collected comparable information on a potentially important time-varying predictor (current pain intensity: 0-10 numerical rating scale), other predictors (age, gender, practice) and outcome (patient-perceived non-recovery at 6 months). Using logistic regression models, we compared the direction and magnitude of predictor-outcome associations and model performance measures under two scenarios: (i) current pain intensity ascertained by the treating general practitioner in the consultation (the intended moment of use) and (ii) current pain intensity ascertained by a questionnaire mailed several days after the consultation. RESULTS In both cohorts, the predictor-outcome association was substantially weaker for pain measured at the consultation (OR (95% CI): PROG-RES 1.06 (0.95, 1.18); POST 1.04 (0.96, 1.12)) than for pain measured in the questionnaire (PROG-RES 1.34 (1.20, 1.48); POST 1.26 (1.18, 1.34)). The c-statistic of the multivariable model was lower when pain was measured at the consultation (c-statistic (95% CI): PROG-RES 0.57 (0.51, 0.64); POST 0.66 (0.62, 0.70)) than when pain was measured in the questionnaire (PROG-RES 0.69 (0.63, 0.75); POST 0.72 (0.68, 0.76)), reflecting the lower OR for pain at the consultation. CONCLUSIONS Prognostic research studies ideally should measure time-varying predictors at their intended moment of use and using the intended measurement method. Otherwise, they may produce substantially different estimates of predictor-outcome associations and model performance. Researchers should report when, how and where predictors were measured and identify any significant departures from their intended use that may limit the applicability of findings in practice. TRIAL REGISTRATION The protocol for the PROG-RES cohort data collection and primary analysis has been published in an open-access journal (Mallen et al., BMC Musculoskelet Disord 7:84, 2006). The POST trial was registered (ISRCTN40721988; date of registration: 21 June 2011; date of enrolment of the first participant: 3 October 2011) and had a pre-specified protocol covering primary analysis. There was no published protocol for the current secondary analyses presented in this manuscript.
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Affiliation(s)
- Rebecca Whittle
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Kara-Louise Royle
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Kelvin P. Jordan
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Richard D. Riley
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Christian D. Mallen
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - George Peat
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
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Reimer M, Hüllemann P, Hukauf M, Keller T, Binder A, Gierthmühlen J, Baron R. Prediction of response to tapentadol in chronic low back pain. Eur J Pain 2016; 21:322-333. [PMID: 27510567 PMCID: PMC5248647 DOI: 10.1002/ejp.926] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Many chronic low back pain (cLBP) patients do not satisfactorily respond to treatment. The knowledge of responders and non-responders before initiating treatment would improve decision making and reduce health care costs. The aims of this exploratory prediction study in cLBP patients treated with tapentadol were to identify predictors of treatment outcome based on baseline characteristics, to evaluate quality-of-life and functionality as alternative outcome parameters and to develop nomograms to calculate the individual probability of response. METHODS In a retrospective analysis of an open-label phase 3b trial, 46 baseline characteristics were included into statistical prediction modelling. One hundred and twenty-one patients were followed up during the titration and treatment period and 67 patients were analysed who discontinued the trial. RESULTS Demographic data were not relevant for response prediction. Nine baseline co-variables were robust: painDETECT score, intensity of burning and painful attacks, SF36 Health Survey score (MCS, PCS), EuroQol-5, Hospital Anxiety/Depression Scale. Gender had a minor influence. Alternative outcomes (quality-of-life, functionality) were more important for response prediction than conventional pain intensity measures. Neuropathic symptoms (high painDETECT score) had a positive predictive validity. Painful attacks and classical yellow flags (depression, anxiety) negatively influenced the treatment response. High depression scores, female gender and low burning predicted discontinuation during titration. CONCLUSION In this exploratory study, predictive baseline characteristics have been identified that can be used to calculate the individual probability of tapentadol response in cLBP. The small sample size in relation to the number of initial variables is a limitation of this approach. SIGNIFICANCE Predictors for treatment response of tapentadol were identified in patients with chronic low back pain based on clinical pre-treatment characteristics that can guide personalized treatment. Quality-of-life and functionality were the most relevant outcomes for response prediction.
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Affiliation(s)
- M Reimer
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - P Hüllemann
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - M Hukauf
- StatConsult GmbH, Magdeburg, Germany
| | - T Keller
- StatConsult GmbH, Magdeburg, Germany
| | - A Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - J Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
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Swain MS, Kamper SJ, Maher CG, Latimer J, Broderick C, McKay D, Henschke N. Short-term Clinical Course of Knee Pain in Children and Adolescents: A Feasibility Study Using Electronic Methods of Data Collection. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2016; 22. [PMID: 27196524 DOI: 10.1002/pri.1669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/08/2015] [Accepted: 02/28/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE Musculoskeletal disorders, such as knee pain, are common in children and adolescents, but there is a lack of high quality research that evaluates the clinical course of these conditions. The objective of this study was to evaluate the feasibility of conducting a prospective study of children and adolescents with knee pain using electronic methods of data collection. METHODS Children and adolescents with knee pain that presented to primary care physiotherapy clinics were enrolled and followed-up on a weekly basis via short messaging service (SMS) until their knee pain had recovered (i.e. two consecutive weeks of no pain). Feasibility was assessed in terms of recruitment, retention and response rates to SMS and an online questionnaire. Baseline and 6-month follow-up measures included pain, disability, physical function, physical activity and health related quality of life. Kaplan-Meier survival analysis was used to estimate the median time to knee pain recovery. RESULTS Thirty participants (mean age 13.0 ± 2.2 years, 53% boys) were recruited over 26 months. The overall response rate to weekly SMS follow-up was 71.3% (809 received/1135 sent). One third of participants stopped responding to SMS prior to recovery, and these participants typically had a much lower response rate during the time they remained in the study. At 6-month follow-up, 80% of the cohort completed the final online questionnaire, and 29% of participants still reported current knee pain (≥1/10 VAS). The median time for knee pain recovery was 8 weeks (95%CI: 5, 10). CONCLUSION Electronic data collection alone seems insufficient to track pain recovery in young people and may need to be supplemented with more traditional data collection methods. Researchers should consider further measures to address slow recruitment rates and high attrition when designing large prospective studies of children and adolescents in the future. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Michael S Swain
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Steven J Kamper
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jane Latimer
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Carolyn Broderick
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Children's Hospital Institute of Sports Medicine, The Sydney Children's Hospitals Network, Sydney, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, Australia
| | - Damien McKay
- Children's Hospital Institute of Sports Medicine, The Sydney Children's Hospitals Network, Sydney, Australia
| | - Nicholas Henschke
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Institute for Public Health, University of Heidelberg, Heidelberg, Germany
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Johansson M, Jensen Stochkendahl M, Hartvigsen J, Boyle E, Cassidy J. Incidence and prognosis of mid-back pain in the general population: A systematic review. Eur J Pain 2016; 21:20-28. [DOI: 10.1002/ejp.884] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 11/06/2022]
Affiliation(s)
- M.S. Johansson
- Department of Sports Science and Clinical Biomechanics; Faculty of Health; University of Southern Denmark; Odense Denmark
| | | | - J. Hartvigsen
- Department of Sports Science and Clinical Biomechanics; Faculty of Health; University of Southern Denmark; Odense Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics; Odense Denmark
| | - E. Boyle
- Department of Sports Science and Clinical Biomechanics; Faculty of Health; University of Southern Denmark; Odense Denmark
- Division of Epidemiology; Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
| | - J.D. Cassidy
- Department of Sports Science and Clinical Biomechanics; Faculty of Health; University of Southern Denmark; Odense Denmark
- Division of Epidemiology; Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
- Division of Health Care and Outcomes Research; Krembil Research Institute; University Health Network; Toronto ON Canada
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Baker RM. Commentary on Classification of patients with incident non-specific low back pain: implications for research. Spine J 2016; 16:577-8. [PMID: 27261843 DOI: 10.1016/j.spinee.2016.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/12/2016] [Indexed: 02/09/2023]
Abstract
Norton G, McDonough CM, Cabral HJ, Shwartz M, Burgess JF Jr. Classification of patients with incident non-specific low back pain: implications for research. Spine J 2016;16:567-76 (in this issue).
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Affiliation(s)
- Ray M Baker
- EvergreenHealth, 12333 NE 130th Ln #400, Kirkland, WA 98034, USA.
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Rantonen J, Karppinen J, Vehtari A, Luoto S, Viikari-Juntura E, Hupli M, Malmivaara A, Taimela S. Cost-effectiveness of providing patients with information on managing mild low-back symptoms in an occupational health setting. BMC Public Health 2016; 16:316. [PMID: 27068751 PMCID: PMC4828818 DOI: 10.1186/s12889-016-2974-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence shows that low back specific patient information is effective in sub-acute low back pain (LBP), but effectiveness and cost-effectiveness (CE) of information in early phase symptoms is not clear. We assessed effectiveness and CE of patient information in mild LBP in the occupational health (OH) setting in a quasi-experimental study. METHODS A cohort of employees (N = 312, aged <57) with non-specific, mild LBP (Visual Analogue Scale between 10-34 mm) was selected from the respondents of an employee survey (N = 2480; response rate 71 %). A random sample, representing the natural course of LBP (NC, N = 83; no intervention), was extracted as a control group. Remaining employees were invited (181 included, 47 declined, one excluded) into a randomised controlled study with two 1:1 allocated parallel intervention arms ("Booklet", N = 92; "Combined", N = 89). All participants received the "Back Book" patient information booklet and the Combined also an individual verbal review of the booklet. Physical impairment (PHI), LBP, health care (HC) utilisation, and all-cause sickness absence (SA) were assessed at two years. CE of the interventions on SA days was analysed by using direct HC costs in one year, two years from baseline. Multiple imputation was used for missing values. RESULTS Compared to NC, the Booklet reduced HC costs by 196€ and SA by 3.5 days per year. In 81 % of the bootstrapped cases the Booklet was both cost saving and effective on SA. Compared to NC, in the Combined arm, the figures were 107€, 0.4 days, and 54 %, respectively. PHI decreased in both interventions. CONCLUSIONS Booklet information alone was cost-effective in comparison to natural course of mild LBP. Combined information reduced HC costs. Both interventions reduced physical impairment. Mere booklet information is beneficial for employees who report mild LBP in the OH setting, and is also cost saving for the health care system. TRIAL REGISTRATION ClinicalTrials.gov NCT00908102.
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Affiliation(s)
- J Rantonen
- Finnish Institute of Occupational Health (FIOH), P.B. 40, 00251, Helsinki, Finland.
- Hjelt Institute, Department of Public Health, University of Helsinki, Helsinki, Finland.
- South Karelian Institute, Lappeenranta University of Technology, Lappeenranta, Finland.
- University of Helsinki, Helsinki, Finland.
| | - J Karppinen
- Finnish Institute of Occupational Health (FIOH), P.B. 40, 00251, Helsinki, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - A Vehtari
- Helsinki Institute for Information Technology HIIT, Department of Computer Science, Aalto University, Espoo, Finland
| | - S Luoto
- Department of Physical Medicine and Rehabilitation, South Karelia Social and Health Care District, Lappeenranta, Finland
| | - E Viikari-Juntura
- Finnish Institute of Occupational Health (FIOH), P.B. 40, 00251, Helsinki, Finland
| | - M Hupli
- Department of Physical Medicine and Rehabilitation, South Karelia Social and Health Care District, Lappeenranta, Finland
| | - A Malmivaara
- National Institute for Health and Welfare, Centre for Health and Social Economics, Helsinki, Finland
| | - S Taimela
- Evalua International, Espoo, Finland
- Hjelt Institute, Department of Public Health, University of Helsinki, Helsinki, Finland
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Meisingset I, Stensdotter AK, Woodhouse A, Vasseljen O. Neck motion, motor control, pain and disability: A longitudinal study of associations in neck pain patients in physiotherapy treatment. ACTA ACUST UNITED AC 2016; 22:94-100. [DOI: 10.1016/j.math.2015.10.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 11/27/2022]
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The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial. J Orthop Sports Phys Ther 2016; 46:144-54. [PMID: 26813755 DOI: 10.2519/jospt.2016.6238] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Randomized clinical trial. Background The recommended initial management strategy for patients with low back pain and signs of nerve root compression is conservative treatment, but there is little evidence to guide the most appropriate management strategy. Preliminary research suggests that a treatment protocol of mechanical traction and extension-oriented exercises may be effective, particularly in a specific subgroup of patients. OBJECTIVE To examine the effectiveness of mechanical traction in patients with lumbar nerve root compression and within a predefined subgroup. METHODS One hundred twenty patients with low back pain with nerve root compression were recruited from physical therapy clinics. Using predefined subgrouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6 weeks, 6 months, and 1 year by assessors blinded to group allocation. Outcomes were examined using linear mixed-model analyses examining change over time by treatment and the interaction between treatment and subgrouping status. RESULTS The mean ± SD age of participants was 41.1 ± 11.3 years, median duration of symptoms was 62 days, and 57% were male. No significant differences in disability or pain outcomes were noted between treatment groups at any time point, nor was any interaction found between subgroup status and treatment. CONCLUSION Patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients or within a predefined subgroup of patients. The study protocol was registered with ClinicalTrials.gov (NCT00942227). Level of Evidence Therapy, level 2b.
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Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis. THE JOURNAL OF PAIN 2016; 17:755-74. [PMID: 26844416 DOI: 10.1016/j.jpain.2016.01.473] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 12/05/2015] [Accepted: 01/14/2016] [Indexed: 12/11/2022]
Abstract
UNLABELLED Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Ten electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP. PERSPECTIVE In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions.
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Field JR, Newell D. Clinical Outcomes in a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care in the United Kingdom: A Comparison of Self- and National Health Service-Referred Routes. J Manipulative Physiol Ther 2016; 39:54-62. [PMID: 26837228 DOI: 10.1016/j.jmpt.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE An innovative commissioning pathway has recently been introduced in the United Kingdom allowing chiropractic organizations to provide state-funded chiropractic care to patients through referral from National Health Service (NHS) primary care physicians. The purpose of this study was to examine the outcomes of NHS and private patient groups presenting with musculoskeletal conditions to chiropractors under the Any Qualified Provider scheme and compare the clinical outcomes of these patients with those presenting privately. METHODS A prospective cohort design monitoring patient outcomes comparing self-referring and NHS-referred patients undergoing chiropractic care was used. The primary outcome was the change in Bournemouth Questionnaire scores. Within- and between-group analyses were performed to explore differences between outcomes with additional analysis of subgroups as categorized by the STarT back tool. RESULTS A total of 8222 patients filled in baseline questionnaires. Of these, NHS patients (41%) had more adverse health measures at baseline and went on to receive more treatment. Using percent change in Bournemouth Questionnaire scores categorized at minimal clinical change cutoffs and adjusting for baseline differences, patients with low back and neck pain presenting privately are more likely to report improvement within 2 weeks and to have slightly better outcomes at 90 days. However, these patients were more likely to be attending consultations beyond 30 days. CONCLUSIONS This study supports the contention that chiropractic services as provided in United Kingdom are appropriate for both private and NHS-referred patient groups and should be considered when general medical physicians make decisions concerning referral routes and pain pathways for patients with musculoskeletal conditions.
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Affiliation(s)
| | - Dave Newell
- Director of Research, Anglo-European College of Chiropractic, Bournemouth, UK
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van Dulmen SA, van der Wees PJ, Bart Staal J, Braspenning JCC, Nijhuis-van der Sanden MWG. Patient reported outcome measures (PROMs) for goalsetting and outcome measurement in primary care physiotherapy, an explorative field study. Physiotherapy 2016; 103:66-72. [PMID: 27033783 DOI: 10.1016/j.physio.2016.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 01/05/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Routine use of patient reported outcome measures (PROMs) may provide an effective way of monitoring patient valued outcomes. In this study we explored (1) the current use of PROMs; (2) to what extent the goals correspond with the selected PROMs; (3) the health outcomes based on PROMs. DESIGN Observational clinical cohort study. SETTING Dutch primary care physiotherapy practices (n=43). PARTICIPANTS Patients (n=299) with neck pain or low back pain. MAIN OUTCOME MEASURES The number of PROMs used per patient were calculated. The International Classification of Functioning, Disability and Health was used to map the patients' goals and the percentages of PROMS selected that match the domains of the goals were calculated. Health outcomes were assessed using two approaches for estimating the minimal clinically important difference (MCID). RESULTS Repeated measurements with the Visual Analogue Scale, the Patient Specific Complaints questionnaire, the Quebec Back Pain Disability Scale, or the Neck Disability Index were completed by more than 60% of the patients. The PROMs used matched in 46% of the cases with goals for pain improvement, and in 43% with goals set at activity/participation level. The mean differences between baseline and follow up scores for all PROMs were statistically significant. Improvements of patients based on MCID varied from 57% to 90%. CONCLUSIONS PROMs were used in the majority of the patients, showed improved health outcomes and fitted moderately with goals. The results of this study can be used for future research assessing the routine use of outcome measurements with PROMs.
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Affiliation(s)
- Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
| | - Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - J Bart Staal
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands; School for Physical Therapy, University of Applied Sciences Nijmegen, The Netherlands
| | - J C C Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Rhon D, Fritz J. COMParative Early Treatment Effectiveness between physical therapy and usual care for low back pain (COMPETE): study protocol for a randomized controlled trial. Trials 2015; 16:423. [PMID: 26399603 PMCID: PMC4581511 DOI: 10.1186/s13063-015-0959-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/14/2015] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel Rhon
- Center for the Intrepid, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA.
| | - Julie Fritz
- Department of Physical Therapy, College of Health, University of Utah, 520 Wakara Way, Salt Lake City, Utah, 84108, USA.
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