The StarT back screening tool and a pain mannequin improve triage in individuals with low back pain at risk of a worse prognosis - a population based cohort study

Digital mapping of shoulder pain in patients with shoulder disorders: a reliability study

INTRODUCTION

Digital body mapping can be used to document and quantify the area and location (distribution) of pain and discomfort and support assessment, monitoring, and treatment in clinical populations. This study determines the test-retest reliability of drawings detailing pain and pins and needles using digital body charts and their relationship to pain intensity and patient-reported shoulder function.

METHODS

Sixty-two participants with shoulder disorder completed pain and pins and needles drawings with test-retest interval of 30 minutes. Pain intensity in the last week and the patient-reported shoulder function questionnaires were completed. Area and radiating extent were determined using customized software. To assess relative and absolute test-retest reliability, the intraclass correlation coefficient (ICC3,1), standard error of measurement (SEM) and minimal detectable change (MDC95) were calculated. Regression analysis evaluated relation between area and radiating extent of pain and pins and needles with patient-reported function questionnaires.

RESULTS

Relative reliability for pain area and radiating extent was excellent (>0.90). Absolute reliability (SEM and MDC95) values for the pain area and radiating extent were 0.20%/34 pixels and 0.57%/94 pixels. Absolute reliability improves for smaller pain areas. Regression analysis revealed the area and radiation extent for both pain and pins and needles are independent constructs to the patient-reported function outcome when adjusted for pain intensity.

CONCLUSIONS

Digital body mapping assessing pain area and radiation extent in patients with shoulder disorders are reliable. The magnitude of absolute reliability suggests other sources of variability on repeat testing in this population. Pain area and radiation extent appear to be independent constructs.

Improving adherence to guidelines for spine pain care: what tools could support primary care clinicians in conforming to guidelines?

Background

Spine pain is one of the most common conditions seen in primary care and is often treated with ineffective, aggressive interventions, such as prescription pain medications, imagery and referrals to surgery. Aggressive treatments are associated with negative side effects and high costs while conservative care has lower risks and costs and equivalent or better outcomes. Despite multiple well-publicised treatment guidelines and educational efforts recommending conservative care, primary care clinicians (PCCs) widely continue to prescribe aggressive, low-value care for spine pain.

Methods

In this qualitative study semistructured interviews were conducted with PCCs treating spine pain patients to learn what prevents clinicians from following guidelines and what tools or support could promote conservative care. Interviews were conducted by telephone, transcribed and coded for thematic analysis.

Results

Forty PCCs in academic and private practice were interviewed. Key reflections included that while familiar with guidelines recommending conservative treatment, they did not find guidelines useful or relevant to care decisions for individual patients. They believed that there is an insufficient body of real-world evidence supporting positive outcomes for conservative care and guidance recommendations. They indicated that spine pain patients frequently request aggressive care. These requests, combined with the PCCs’ commitment to reaching shared treatment decisions with patients, formed a key reason for pursuing aggressive care. PCCs reported not being familiar with risk-screening tools for spine patients but indicated that such screens might increase their confidence to recommend conservative care to low-risk patients.

Conclusions

PCCs may be more willing to give conservative, guideline-consistent care for spine pain if they had tools to assist in making patient-specific evaluations and in countering requests for unneeded aggressive care. Such tools would include both patient risk screens and shared decision-making aids that include elements for resolving patient demands for inappropriate care.

Spatiotemporal patterns of pain distribution and recall accuracy: a dose-response study

OBJECTIVES

Clinical decisions rely on a patient's ability to recall and report their pain experience. Monitoring pain in real-time (momentary pain) may reduce recall errors and optimize the clinical decision-making process. Tracking momentary pain can provide insights into detailed changes in pain intensity and distribution (area and location) over time. The primary aims of this study were (i) to measure the temporal changes of pain intensity, area, and location in a dose-response fashion and (ii) to assess recall accuracy of the peak pain intensity and distribution seven days later, using a digital pain mapping application. The secondary aims were to (i) evaluate the influence of repeated momentary pain drawings on pain recall accuracy and (ii) explore the associations among momentary and recall pain with psychological variables (pain catastrophizing and perceived stress).

METHODS

Healthy participants (N=57) received a low (0.5 ml) or a high (1.0 ml) dose of hypertonic saline (5.8%) injection into the right gluteus medius muscle and, subsequently, were randomized into a non-drawing or a drawing group. The non-drawing groups reported momentary pain intensity every 30-s. Whereas the drawing groups reported momentary pain intensity and distribution on a digital body chart every 30-s. The pain intensity, area (pixels), and distribution metrics (compound area, location, radiating extent) were compared at peak pain and over time to explore dose-response differences and spatiotemporal patterns. All participants recalled the peak pain intensity and the peak (most extensive) distribution seven days later. The peak pain intensity and area recall error was calculated. Pain distribution similarity was determined using a Jaccard index which compares pain drawings representing peak distribution at baseline and recall. The relationships were explored among peak intensity and area at baseline and recall, catastrophizing, and perceived stress.

RESULTS

The pain intensity, area, distribution metrics, and the duration of pain were lower for the 0.5 mL than the 1.0 mL dose over time (p<0.05). However, the pain intensity and area were similar between doses at peak pain (p>0.05). The pain area and distribution between momentary and recall pain drawings were similar (p>0.05), as reflected in the Jaccard index. Additionally, peak pain intensity did not correlate with the peak pain area. Further, peak pain intensity, but not area, was correlated with catastrophizing (p<0.01).

CONCLUSIONS

This study showed differences in spatiotemporal patterns of pain intensity and distribution in a dose-response fashion to experimental acute low back pain. Unlike pain intensity, pain distribution and area may be less susceptible in an experimental setting. Higher intensities of momentary pain do not appear to influence the ability to recall the pain intensity or distribution in healthy participants.

IMPLICATIONS

The recall of pain distribution in experimental settings does not appear to be influenced by the intensity despite differences in the pain experience. Pain distribution may add additional value to mechanism-based studies as the distribution reports do not vary with pain catastrophizing. REC# N-20150052.

Consistencia interna, validez convergente, discriminante y de criterio del Start Back Screening Tool en una muestra colombiana

Introducción. El dolor lumbar (DL) es una causa frecuente de consulta y una de las principales causas de incapacidad laboral permanente. La estratificación del riesgo de discapacidad por DL permite desarrollar intervenciones terapéuticas específicas; sin embargo, dicha estratificación requiere instrumentos válidos y confiables. Objetivo. Determinar la consistencia interna y la validez convergente, discriminante y de criterio del cuestionario Start Back Screening Tool (SBST) en una muestra colombiana. Materiales y métodos. Estudio cuantitativo de validación de pruebas realizado en 68 pacientes adultos con DL que recibieron una intervención fisioterapéutica (10 sesiones) entre 2019 y 2020 en una clínica de Chía, Colombia. Los participantes diligenciaron el SBST, la escala numérica de clasificación del dolor (ENCD) y el cuestionario Roland Morris Disability (RMD) en tres momentos: pre-, post-intervención y luego de 6 semanas de seguimiento (sin tratamiento). La consistencia interna del SBST se determinó mediante los coeficientes Alfa de Cronbach, Omega, λ6 y Greatest lower bound (GLB). En cuanto a la validez de criterio y de constructo, se evaluaron las correlaciones entre el instrumento y la ENCD y el RMD mediante el coeficiente de correlación de Pearson. Finalmente, se realizó un ANOVA de medidas repetidas entre las medias de puntaje del SBST obtenidas en los tres momentos para estimar su validez discriminante. Resultados. La consistencia interna del instrumento, según los diferentes coeficientes, varió entre aceptable y alta (Alfa= 0.634; Omega=0.648; λ6=0.664; GLB = 0.780). Se observaron correlaciones positivas entre el puntaje promedio en el SBST y los puntajes promedio en la ENCD (r=0.257; p=0.035) y la RMD (r=0.475; p<0.0010), así como diferencias significativas entre los puntajes promedio del SBST pre, post-intervención y seguimiento (ANOVA: F=33.722; p <0.001). Conclusión. El SBST es un instrumento válido y confiable para el clasificar el nivel de riesgo de mal pronóstico en pacientes colombianos con DL.

Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment

Introduction

There is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures.

Purpose and importance to practice

The aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations.

Clinical implications

This Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions.

Future research priorities

Some steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

Prognostic factors for pain chronicity in low back pain: a systematic review

Supplemental Digital Content is Available in the Text.

Several prognostic factors are related to low back pain chronicity, and these should be taken into account when planning more comprehensive models in its prevention.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.