Effects of practice style in managing back pain

Transcultural Adaptation and Psychometric Validation of the Spanish Version of the Pain Attitudes and Beliefs Scale for Physiotherapists

Low back pain (LBP) is one of the main musculoskeletal pain conditions, and it affects 23-28% of the global population. Strong evidence supports the absence of a direct relationship between the intensity of pain and tissue damage, with psychosocial factors also playing a crucial role. In this context, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) is a useful tool for evaluating physiotherapists' treatment orientations and beliefs regarding the management of low back pain (LBP). It helps identify practitioners who may benefit from additional education in modern pain neuroscience. However, there is not a Spanish validation of this scale for physiotherapists. Thus, the aims of this study were to translate and culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) into Spanish and to evaluate its psychometric properties. This validation study used three convenience samples of physiotherapists (PTs) (n = 22 for the pilot study, n = 529 for the validity study and n = 53 for assessing the instrument's responsiveness). The process of translating and adapting the PABS-PT into Spanish followed international guidelines and produced a satisfactory pre-final version of the questionnaire. Factor analysis confirmed the two-factor structure of the original version, with the biomedical (BM) factor explaining 39.4% of the variance and the biopsychosocial (BPS) factor explaining 13.8% of the variance. Cronbach's alpha values were excellent for the BM factor (0.86) and good for the BPS factor (0.77), indicating good internal consistency. Test-retest reliability was excellent for both factors, with intraclass correlation coefficients (ICCs) of 0.84 for BM and 0.82 for BPS. The standard error of measurement (SEM) was acceptable for both factors (3.9 points for BM and 2.4 points for BPS). Concurrent validity was moderate and in the expected direction and had significant correlations with the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and Revised Neurophysiology Pain Questionnaire (R-NPQ). Sensitivity to change was demonstrated by significant improvements in both factors after an educational intervention, with medium-to-large effect sizes. The PABS-PT also showed good discriminative ability, as it was able to distinguish between physiotherapists with and without pain education. Cut-off values for the BM and BPS factors were determined. In conclusion, the translated and adapted Spanish version of the PABS-PT demonstrated good psychometric properties and can be reliably used to assess the attitudes and beliefs of Spanish-speaking physiotherapists regarding LBP. The questionnaire is recommended for use in clinical and educational research in the Spanish language context.

Effects of Pelvic-Tilt Imbalance on Disability, Muscle Performance, and Range of Motion in Office Workers with Non-Specific Low-Back Pain

Imbalance in the pelvic tilt is considered to be a major variable in low back pain. The purpose of this study was to investigate the effects of pelvic-tilt imbalance on trunk- and hip-muscle performance, range of motion, low-back pain, and the degree of disability in office workers. This was a cross-sectional study conducted in a physical therapy clinic on forty-one office workers diagnosed with non-specific low-back pain. Among the office workers with non-specific low-back pain, 25 were assigned to the pelvic-tilt-imbalance group and 16 to the normal group without pelvic-tilt imbalance. In order to determine the differences according to the imbalance in pelvic tilt, the pain intensity and disability indices were compared between the groups. In addition, the muscle performance and range of motion of the trunk and hip joints and foot pressure were measured and compared. There were differences between the groups in the disability indices and the ratio of internal and external rotation of the hip joint. However, there were no differences in the other variables. Pelvic-tilt imbalance in office workers with non-specific chronic low-back pain may exacerbate the degree of disability and be related to hip-joint rotational range of motion.

Cost comparison of osteopathic manipulative treatment for patients with chronic low back pain

CONTEXT

Chronic low back pain (cLBP) is the second leading cause of disability in the United States, with significant physical and financial implications. Development of a multifaceted treatment plan that is cost effective and optimizes patients' ability to function on a daily basis is critical. To date, there have been no published prospective studies comparing the cost of osteopathic manipulative treatment to that of standard care for patients with cLBP.

OBJECTIVES

To contrast the cost for standard of care treatment (SCT) for cLBP with standard of care plus osteopathic manipulative treatment (SCT + OMT).

METHODS

This prospective, observational study was conducted over the course of 4 months with two groups of patients with a diagnosis of cLBP. Once consent was obtained, patients were assigned to the SCT or the SCT + OMT group based on the specialty practice of their physician. At enrollment and after 4 months of treatment, all patients in both groups completed two questionnaires: the 11 point pain intensity numerical scale (PI-NRS) and the Roland Morris Disability Questionnaire (RMDQ). Cost data was collected from the electronic medical record of each patient enrolled in the study. Chi-square (χ ² _Yates) tests for independence using Yates' correction for continuity were performed to compare the results for each group.

RESULTS

There was a total of 146 patients: 71 (48.6%) in the SCT + OMT group and 75 (51.4%) in the SCT group. The results showed no significant differences between the mean total costs for the SCT + OMT ($831.48 ± $553.59) and SCT ($997.90 ± $1,053.22) groups. However, the utilization of interventional therapies (2; 2.8%) and radiology (4; 5.6%) services were significantly less for the SCT + OMT group than the utilization of interventional (31; 41.3%) and radiology (17; 22.7%) therapies were for the SCT group (p<0.001). Additionally, the patients in the SCT + OMT group were prescribed fewer opioid medications (15; 21.1) than the SCT (37; 49.3%) patients (p.001). Patients in the SCT group were approximately 14.7 times more likely to have received interventional therapies than patients in the SCT + OMT group. Likewise, the patients in the SCT group were approximately four times more likely to have received radiological services. Paired t tests comparing the mean pre- and 4 month self reported pain severity scores on the RMDQ for 68 SCT + OMT patients (9.91 ± 5.88 vs. 6.40 ± 5.24) and 66 SCT patients (11.44 ± 6.10 vs. 8.52 ± 6.14) found highly significant decreases in pain for both group (<0.001).

CONCLUSIONS

The mean total costs for the SCT and SCT + OMT patients were statistically comparable across 4 months of treatment. SCT + OMT was comparable to SCT alone in reducing pain and improving function in patients with chronic low back pain; however, there was less utilization of opioid analgesics, physical therapy, interventional therapies, radiologic, and diagnostic services for patients in the SCT + OMT group.

Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis

INTRODUCTION

Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome.

METHODS

This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5 years' follow-up (FU).

RESULTS

In total, 448 patients (69.8 ± 9.6 years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients.

CONCLUSIONS

The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.

Validation of CARE Scale-7 in treatment-seeking patients with chronic pain: measurement of sex invariance

Supplemental Digital Content is Available in the Text.

The CARE Scale-7 is the first validated instrument to assess self-care difficulty in both sexes and may promote individualized care planning among chronic pain patients.

Objectives:

Social and interpersonal factors impact the trajectory of chronic pain. We previously developed and validated a 2-factor, 7-item measure to assess interpersonal factors, including relationship guilt and worry and difficulty prioritizing self-care in chronic pain. Here, we confirm the factor structure and examine the sex invariance of the two-factor structure of the CARE Scale-7.

Methods:

Data were collected as part of routine clinical care at a tertiary pain clinic using the Collaborative Health Outcomes Information Registry. Patient participants (67% women) were predominantly middle-aged (M = 50.9 years, SD = 17.8), married (55.2%), and White/non-Hispanic (55.7%). Data included demographics, pain characteristics, CARE Scale-7, pain catastrophizing, and Patient-Reported Outcomes Measurement Information System psychological and physical function measures. Confirmatory factor analysis was conducted to validate the factor structure of the CARE Scale, and a stepwise approach to measurement invariances by sex examined configural, metric, and scalar invariance.

Results:

Internal consistency of the scale items ensured suitability for factor analyses. Confirmatory factor analysis findings revealed an overall good fit of the 2-factor model among males and females and that CARE Scale-7 is in fact sex invariant. Finally, CARE Scale-7 showed convergent validity with pain-related outcomes.

Discussion:

The CARE Scale is the first validated instrument to assess self-care in both sexes among patients with chronic pain. The subscale of difficulty prioritizing self-care emerged as a potentially unique factor that should be integrated in clinical assessment. CARE Scale may facilitate standardized measurement in research and clinical contexts, which may inform a comprehensive treatment focus that integrates individualized self-care planning.

An experimental investigation of the relationships among race, prayer, and pain

Background and aims Compared to White individuals, Black individuals demonstrate a lower pain tolerance. Research suggests that differences in pain coping strategies, such as prayer, may mediate this race difference. However, previous research has been cross-sectional and has not determined whether prayer in and of itself or rather the passive nature of prayer is driving the effects on pain tolerance. The aim of this study was to clarify the relationships among race, prayer (both active and passive), and pain tolerance. Methods We randomly assigned 208 pain-free participants (47% Black, 53% White) to one of three groups: active prayer ("God, help me endure the pain"), passive prayer ("God, take the pain away"), or no prayer ("The sky is blue"). Participants first completed a series of questionnaires including the Duke University Religion Index, the Coping Strategies Questionnaire-Revised (CSQ-R), and the Pain Catastrophizing Scale. Participants were then instructed to repeat a specified prayer or distractor coping statement while undergoing a cold pressor task. Cold pain tolerance was measured by the number of seconds that had elapsed while the participant's hand remained in the cold water bath (maximum 180 s). Results Results of independent samples t-tests indicated that Black participants scored higher on the CSQ-R prayer/hoping subscale. However, there were no race differences among other coping strategies, religiosity, or catastrophizing. Results of a 2 (Race: White vs. Black)×3 (Prayer: active vs. passive vs. no prayer) ANCOVA controlling for a general tendency to pray and catastrophizing in response to prayer indicated a main effect of prayer that approached significance (p=0.06). Pairwise comparisons indicated that those in the active prayer condition demonstrated greater pain tolerance than those in the passive (p=0.06) and no prayer (p=0.03) conditions. Those in the passive and no prayer distractor conditions did not significantly differ (p=0.70). There was also a trending main effect of race [p=0.08], with White participants demonstrating greater pain tolerance than Black participants. Conclusions Taken together, these results indicate that Black participants demonstrated a lower pain tolerance than White participants, and those in the active prayer condition demonstrated greater tolerance than those in the passive and no prayer conditions. Furthermore, Black participants in the passive prayer group demonstrated the lowest pain tolerance, while White participants in the active prayer group exhibited the greatest tolerance. Results of this study suggest that passive prayer, like other passive coping strategies, may be related to lower pain tolerance and thus poorer pain outcomes, perhaps especially for Black individuals. On the other hand, results suggest active prayer is associated with greater pain tolerance, especially for White individuals. Implications These results suggest that understanding the influence of prayer on pain may require differentiation between active versus passive prayer strategies. Like other active coping strategies for pain, active prayer may facilitate self-management of pain and thus enhance pain outcomes independent of race. Psychosocial interventions may help religiously-oriented individuals, regardless of race, cultivate a more active style of prayer to improve their quality of life.

Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)

Background and aim

There is evidence that clinicians’ pain attitudes and beliefs are associated with the pain beliefs and illness perceptions of their patients and furthermore influence their recommendations for activity and work to patients with back pain. The Pain Attitudes and Beliefs Scale (PABS) is a questionnaire designed to differentiate between biomedical and biopsychosocial pain attitudes among health care providers regarding common low back pain. The original version had 36 items, and several shorter versions have been developed. Concern has been raised over the PABS’ internal construct validity because of low internal consistency and low explained variance. The aim of this study was to examine and improve the scale’s measurement properties and item performance.

Methods

A convenience sample of 667 Norwegian physiotherapists provided data for Rasch analysis. The biomedical and biopsychosocial subscales of the PABS were examined for unidimensionality, local response independency, invariance, response category function and targeting of persons and items. Reliability was measured with the person separation index (PSI). Items originally excluded by the developers of the scale because of skewness were re-introduced in a second analysis.

Results

Our analysis suggested that both subscales required removal of several psychometrically redundant and misfitting items to satisfy the requirements of the Rasch measurement model. Most biopsychosocial items needed revision of their scoring structure. Furthermore, we identified two items originally excluded because of skewness that improved the reliability of the subscales after reintroduction. The ultimate result was two strictly unidimensional subscales, each consisting of seven items, with invariant item ordering and free from any form of misfit. The unidimensionality implies that summation of items to valid total scores is justified. Transformation tables are provided to convert raw ordinal scores to unbiased interval-level scores. Both subscales were adequately targeted at the ability level of our physiotherapist population. Reliability of the biomedical subscale as measured with the PSI was 0.69. A low PSI of 0.64 for the biopsychosocial subscale indicated limitations with regard to its discriminative ability.

Conclusions

Rasch analysis produced an improved Norwegian version of the PABS which represents true (fundamental) measurement of clinicians’ biomedical and biopsychosocial treatment orientation. However, researchers should be aware of the low discriminative ability of the biopsychosocial subscale when analyzing differences and effect changes.

Implications

The study presents a revised PABS that provides interval-level measurement of clinicians’ pain beliefs. The revision allows for confident use of parametric statistical analysis. Further examination of discriminative validity is required.

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

The establishment of a primary spine care practitioner and its benefits to health care reform in the United States

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.

Conversations on psoriasis--what patients want and what physicians can provide: a qualitative look at patient and physician expectations

BACKGROUND

The role of the patient-physician relationship is a key issue in the management of lifelong, chronic conditions such as psoriasis, with each side bringing different perspectives.

OBJECTIVE

To explore areas of congruence and disconnection in the relationship between psoriasis patients and dermatologists, with a focus on communication issues.

METHODS

Three discussion group sessions were held in four centers across the United States with dermatologists, patients, and a follow-up of the dermatologists after watching the patient discussion.

RESULTS

Patients want more information on psoriasis, fast treatments, clear expectations from the onset of therapy, and recognition of the emotional burden. Dermatologists found that patients do not receive or internalize adequate information and need further explanation of treatment regimens to increase compliance and patient satisfaction.

LIMITATIONS

This was a qualitative study assessing the range of responses and was not a quantitative study designed to test specific hypotheses. The study may not be informative about the experiences of people with psoriasis not actively seeing a physician.

CONCLUSIONS

Encounters between physicians and psoriasis patients can be enhanced by providing information on what psoriasis is, choosing fast-acting treatments that patients are willing to use, and providing written materials about the disease and treatment plan.

Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study

Escolar-Reina P, Medina-Mirapeix F, Gascón-Cánovas JJ, Montilla-Herrador J, Valera-Garrido JF, Collins SM. Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study.

OBJECTIVE

To assess the relative influence of information provided during physical therapy on a patient's adherence to self-management strategies in relation to other predictors of adherence (patient and pain characteristics, use of self-management strategies before intervention).

DESIGN

A longitudinal observational study of the relationship between the information provided during physical therapy and adherence to self-management strategies.

SETTING

Data came from a clinical-based population in 8 primary health care centers.

PARTICIPANTS

Patients (N=184) with chronic neck or low back pain (77% under the age of 59y) were surveyed at the beginning and 1 month after completion of physical therapy.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Specific and overall adherence to 2 types of strategies: (1) nonpharmacologic pain management strategies, and (2) neck/back care in activities of daily life.

RESULTS

Adherence to strategies of nonpharmacologic self-management of pain was more probable when patients received information explaining the effectiveness of the self-management strategies (adjusted odds ratio [AOR]=10.1; P<.05) and information about their illness (AOR=3.4; P<.05) during clinical encounters. Information provided by the physical therapist did not have any influence on the adherence to neck/back care in activity of daily life (P>.05).

CONCLUSIONS

Information provided during clinical encounters is associated with adherence to different kinds of self-management strategies. While further study is required, it is suggested that more attention be given to clinical practice strategies for improving adherence to self-management of chronic pain.

Orthopaedists' and family practitioners' knowledge of simple low back pain management

STUDY DESIGN

Comparative knowledge survey.

OBJECTIVE

This study compared the knowledge of orthopaedic surgeons and family practitioners in managing simple low back pain (LBP) with reference to currently published guidelines.

SUMMARY OF BACKGROUND DATA

LBP is the most prevalent of musculoskeletal conditions. It affects nearly everyone at some point in time and about 4% to 33% of the population at any given point. Treatment guidelines for LBP should be based on evidence-based medicine and updated to improve patient management and outcome. Studies in various fields have assessed the impact of publishing guidelines on patient management, but little is known about the physicians' knowledge of the guidelines.

METHODS

Orthopedic surgeons and family practitioners participating in their annual professional meetings were requested to answer a questionnaire regarding the management of simple low back pain. Answers were scored based on the national guidelines for management of low back pain.

RESULTS

One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs. Significantly less importance was attributed to patient encouragement and reassurance by the orthopaedists as compared with family physicians.

CONCLUSION

Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice.

General practitioners' treatment orientations towards low back pain: influence on treatment behaviour and patient outcome

BACKGROUND

In low back pain (LBP) treatment and research attention has shifted from a biomedical towards a biopsychosocial approach. Patients' LBP beliefs and attitudes were found to predict long-term outcome, and recently it has been suggested that the health care providers' ideas about LBP are also important predictors of treatment behaviour and outcome.

AIMS

In the present study we examined whether (1) differences in General Practitioners' (GP) LBP treatment orientation are associated with differences in actual treatment behaviour and (2) whether treatment orientation is related to LBP outcome in patients.

METHODS

Two hundred twenty two patients consulting their GP with a new episode of LBP were recruited and completed questionnaires on (among others) LBP outcome (graded chronic pain scale) at baseline, during 12 months of follow-up and at the end of the study. Data on treatment were collected from the GPs. The GPs also completed a set of questionnaires on LBP treatment orientation. Associations between measures of treatment orientation, treatment recommendations, treatment behaviour and LBP outcome were analysed.

RESULTS

A biomedical treatment orientation was found to be associated with more concern about tissue damage and the effect of physical activity on pain and recovery in vignettes. No associations were found between treatment orientation measures, actual treatment behaviour and LBP outcome.

CONCLUSIONS

Associations were not found as expected. Still these findings are relevant and may feed a clinically important debate on widely accepted assumptions about the role and influence of health care providers in changing patients' pain behaviours.

Patterns of sick-leave and health outcomes in injured workers with back pain

Little is known about the sick-leave experiences of workers who make a workers' compensation claim for back pain. Our objective is to describe the 1-year patterns of sick-leave and the health outcomes of a cohort of workers who make a workers' compensation claim for back pain. We studied a cohort of 1,831 workers from five large US firms who made incident workers' compensation claims for back pain between January 1, 1999 and June 30, 2002. Injured workers were interviewed 1 month (n = 1,321), 6 months (n = 810) and 1 year (n = 462) following the onset of their pain. We described the course of back pain using four patterns of sick-leave: (1) no sick-leave, (2) returned to worked and stayed, (3) multiple episodes of sick-leave and (4) not yet returned to work. We described the health outcomes as back and/or leg pain intensity, functional limitations and health-related quality of life. We analyzed data from participants who completed all follow-up interviews (n = 457) to compute the probabilities of transition between patterns of sick-leave. A significant proportion of workers experienced multiple episodes of sick-leave (30.2%; 95% CI 25.0-35.1) during the 1-year follow-up. The proportion of workers who did not report sick-leave declined from 42.4% (95% CI 39.0-46.1) at 1 month to 33.6% (28.0-38.7) at 1 year. One year after the injury, 2.9% (1.6-4.9) of workers had not yet returned to work. Workers who did not report sick-leave and those who returned and stayed at work reported better health outcomes than workers who experienced multiple episodes of sick-leave or workers who had not returned to work. Almost a third of workers with an incident episode of back pain experience recurrent spells of work absenteeism during the following year. Our data suggest that stable patterns of sick-leave are associated with better health.

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

BACKGROUND AND PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Determinants of "return to work in good health" among workers with back pain who consult in primary care settings: a 2-year prospective study

Many factors have been linked to return to work after a back pain episode, but our understanding of this phenomenon is limited and cross-sectional dichotomous indices of return to work are not valid measures of this construct. To describe the course of "return to work in good health" (RWGH--a composite index of back pain outcome) among workers who consulted in primary care settings for back pain and identify its determinants, a 2-year prospective study was conducted. Subjects (n = 1,007, 68.4%) were workers who consulted in primary care settings of the Quebec City area for a nonspecific back pain. They completed five telephone interviews over 2 years (follow-up = 86%). Analyses linking baseline variables with 2-year outcome were conducted with polytomous logistic regression. The proportion of "success" in RWGH increased from 18% at 6 weeks to 57% at 2 years. In women, persistent pain, pain radiating to extremities, increasing job seniority, not having a unionized job, feeling that the physician did listen carefully and increasing fear-avoidance beliefs towards work and activity were determinants of "failure" in RWGH. In men, decreasing age, cigarette smoking, poor self-reported health status, pain in the thoracic area, previous back surgeries, a non-compensated injury, high pain levels, belief that job is below qualifications, likelihood of losing job, job status, satisfaction with health services and fear-avoidance beliefs towards work were all significant. RWGH among workers with back pain receives multiple influences, especially among men. In both genders, however, fear-avoidance beliefs about work are associated with failure and high self-efficacy is associated with success.

The physician as disability advisor for patients with musculoskeletal complaints

STUDY DESIGN

Literature review.

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

Medical literature search.

RESULTS

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

CONCLUSIONS

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

Cost-effectiveness of interventions to support self-care: A systematic review

Objectives: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness.

Methods: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions.

Results: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods.

Conclusions: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.

BRIEF REPORT: Patient-physician agreement as a predictor of outcomes in patients with back pain

OBJECTIVE

To determine whether a patient-physician agreement instrument predicts important health outcomes.

DESIGN

Three hundred eighty patients with back pain were enrolled in a comparison of rapid magnetic resonance imaging with standard x-rays. One month later, patients rated agreement with their physician in the following areas: diagnosis, diagnostic plan, and treatment plan. Outcomes included patient satisfaction with care at 1 and 12 months and functional and health status at 12 months.

SETTING

Urban academic and community primary care and specialty clinics.

MEASUREMENTS AND MAIN RESULTS

Higher agreement at 1 month (using a composite sum of scores on the 3 agreement questions) was correlated in univariate analysis with higher patient satisfaction at 1 month (R=.637, P<.001). In multivariate analysis, controlling for 1-month satisfaction and other potential confounders, higher agreement independently predicted better 12-month patient satisfaction (beta=0.188, P=.003), mental health (beta=1.080, P<.001), social function (beta=1.124, P=.001), and vitality (beta=1.190, P<.001).

CONCLUSION

Agreement between physicians and patients regarding diagnosis, diagnostic plan, and treatment plan is associated with higher patient satisfaction and better health status outcomes in patients with back pain. Additional research is required to clarify the relationship between physician communication skills, agreement, and patient outcomes.

A prognostic approach to defining chronic pain

This paper develops a prognostic approach to defining chronic back pain. Possible and probable chronic back pain were defined, respectively, by a 50% and an 80% (or greater) probability of future clinically significant back pain. We assessed whether an empirically derived chronic pain classification satisfied these validating criteria among 1213 primary care back pain patients assessed at baseline and at 1, 2 and 5 year follow-ups. From multiple measures of back pain intensity and dysfunction, Latent Transition Regression Analysis empirically identified four pain severity latent classes: no pain; mild pain; moderate pain and limitation; and severe, limiting pain. From one observation point to the next, patients were most likely to remain in the same pain severity class, but chronic pain was better characterized as a dynamic state than a static trait. Among persons with severe, limiting pain, prognostic variables (depression, diffuse pain, pain persistence) improved prediction of future severe, limiting pain. A risk score developed from pain severity and prognostic measures identified risk levels corresponding to 50 and 80% probability thresholds for predicting future clinically significant back pain. At baseline and 1 year, 6.1 and 4.4% of study patients met or exceeded the 80% risk threshold for probable chronic back pain. An additional 20.3% at baseline and 12.5% at 1 year met or exceeded the 50% risk threshold for possible chronic back pain. Defining chronic pain prospectively, by risk thresholds for future clinically significant pain, provides an empirically grounded approach to chronic pain assessment.

Evidence-Based Medicine and the Challenge of Low Back Pain: Where Are We Now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

How to identify patients with a poor prognosis in daily clinical practice

Predicting poor outcomes in daily practice is challenging. As well as prior episodes of low back pain and pain intensity, various psychosocial risk factors have been identified, although the independent prognostic value of these is rather low. This supports the necessity for a multidimensional view of the transition from acute to chronic pain and/or the development of disability. Psychological distress has been found to increase the risk of such a transition. Patients' beliefs and expectations about their pain seem to influence the recovery process; pain-related fear and fear avoidance can be influential psychological variables, from pain inception to its chronic stage. The influence of occupational factors such as job satisfaction, low workplace support or physical workload has also been emphasized. Treatment provider factors and the relationship between patients and care providers also contribute to the realistic or unrealistic expectations and meaningful or acceptable outcomes.

The epidemiology of low back pain in primary care

This descriptive review provides a summary of the prevalence, activity limitation (disability), care-seeking, natural history and clinical course, treatment outcome, and costs of low back pain (LBP) in primary care. LBP is a common problem affecting both genders and most ages, for which about one in four adults seeks care in a six-month period. It results in considerable direct and indirect costs, and these costs are financial, workforce and social. Care-seeking behaviour varies depending on cultural factors, the intensity of the pain, the extent of activity limitation and the presence of co-morbidity. Care-seeking for LBP is a significant proportion of caseload for some primary-contact disciplines. Most recent-onset LBP episodes settle but only about one in three resolves completely over a 12-month period. About three in five will recur in an on-going relapsing pattern and about one in 10 do not resolve at all. The cases that do not resolve at all form a persistent LBP group that consume the bulk of LBP compensable care resources and for whom positive outcomes are possible but not frequent or substantial.

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

A clinical return-to-work rule for patients with back pain

BACKGROUND

Tools for early identification of workers with back pain who are at high risk of adverse occupational outcome would help concentrate clinical attention on the patients who need it most, while helping reduce unnecessary interventions (and costs) among the others. This study was conducted to develop and validate clinical rules to predict the 2-year work disability status of people consulting for nonspecific back pain in primary care settings.

METHODS

This was a 2-year prospective cohort study conducted in 7 primary care settings in the Quebec City area. The study enrolled 1007 workers (participation, 68.4% of potential participants expected to be eligible) aged 18-64 years who consulted for nonspecific back pain associated with at least 1 day's absence from work. The majority (86%) completed 5 telephone interviews documenting a large array of variables. Clinical information was abstracted from the medical files. The outcome measure was "return to work in good health" at 2 years, a variable that combined patients' occupational status, functional limitations and recurrences of work absence. Predictive models of 2-year outcome were developed with a recursive partitioning approach on a 40% random sample of our study subjects, then validated on the rest.

RESULTS

The best predictive model included 7 baseline variables (patient's recovery expectations, radiating pain, previous back surgery, pain intensity, frequent change of position because of back pain, irritability and bad temper, and difficulty sleeping) and was particularly efficient at identifying patients with no adverse occupational outcome (negative predictive value 78%- 94%).

INTERPRETATION

A clinical prediction rule accurately identified a large proportion of workers with back pain consulting in a primary care setting who were at a low risk of an adverse occupational outcome.

Are patients' ratings of their physicians related to health outcomes?

PURPOSE

Observational studies using patient reports suggest associations between physician interpersonal styles and patient outcomes. Possible confounding of these associations has not been carefully examined.

METHODS

Approximately 4,700 patients of 96 physicians completed a survey instrument that included reported health status changes during the previous year, perceptions of their physician (satisfaction, trust, knowledge of patient, and autonomy support), and sociodemographic and clinical covariates. We examined the adjusted relationship between patient perceptions of their physicians and reported health status changes. Using multilevel analyses, we then explored differences among physicians in patient perceptions of their physicians and whether these differences were explained by the relationship between patient perceptions and reported health status changes.

RESULTS

There were significant adjusted relationships between patient perceptions of their physician and reported health status changes: better perceptions were associated with a smaller risk of health status decline (adjusted odds ratio = 1.14; 95% confidence interval [CI], 1.05-1.24; P <.01). Multilevel analysis showed significant differences between physicians in patient perceptions of their physicians (rho = 0.10; 95% CI, 0.07-0.13; P <.01), but these physician differences were unrelated to reported health status decline (rho = 0; P >.99).

CONCLUSIONS

Using methods similar to those of previous studies, we found a relationship between patient perceptions of their physicians and reported health status declines. Multilevel analysis, however, suggested that this relationship is not a physician effect; it may reflect unmeasured patient confounding. Multilevel analyses may help to examine the relationships between physician styles and outcomes.

What advice do patients with infectious mononucleosis report being given by their general practitioner?

OBJECTIVE

The aim of this study was to describe the advice that patients with acute infectious mononucleosis recall having been given by their general practitioner (GP; family or primary care doctor).

METHODS

Individuals with a recent diagnosis of infectious mononucleosis were recruited for a randomised controlled trial assessing the effectiveness of a brief educational intervention on recovery. All participants were asked at their initial assessment what advice that they had been given by their GP. They were not given any prompts and were free to give several responses. Responses were grouped into various themes.

RESULTS

Seventy-one patients took part. Of these, 11 (15%) recalled being given no specific advice. Of the remaining 60 participants, 70% recalled being given advice to rest, or to "take it easy", usually without any qualification; 10% recalled being given dietary advice, and 17% advice on simple symptom management.

CONCLUSION

The majority of individuals with recent onset infectious mononucleosis recall being given advice to rest by their GPs. This finding is discussed in relation to evidence suggesting that rest may be unhelpful.

Self-management of chronic pain: a population-based study

While effective self-management of chronic pain is important, clinic-based studies exclude the more typical pattern of self-management that occurs in the community, often without reference to health professionals. We examined specific hypotheses about the use of self-management strategies in a population-based study of chronic pain subjects. Data came from an Australian population-based random digit dialling computer-assisted telephone survey and included 474 adults aged 18 or over with chronic pain (response rate 73.4%). Passive strategies were more often reported than active ones: passive strategies such as taking medication (47%), resting (31.5%), and using hot/cold packs (23.4%) were most commonly reported, while the most commonly reported active strategy was exercising (25.8%). Only 33.5% of those who used active behavioural and/or cognitive strategies used them exclusively, while 67.7% of those who used passive behavioural and/or conventional medical strategies did so exclusively. Self-management strategies were associated with both pain-related disability and use of health services in multiple logistic regression models. Using passive strategies increased the likelihood of having high levels of pain-related disability (adjusted OR 2.59) and more pain-related health care visits (adjusted OR 2.9); using active strategies substantially reduced the likelihood of having high levels of pain-related disability (adjusted OR 0.2). In conclusion, we have shown in a population-based study that clinical findings regarding self-management strategies apply to the broader population and advocate that more attention be given to community-based strategies for improving awareness and uptake of active self-management strategies for chronic pain.

Back pain and health policy research: the what, why, how, who, and when

STUDY DESIGN

A background literature, supported by discussion and outcomes on the subject of Health Policy and Back Pain, from the Fifth International Forum on Low Back Pain Research in Primary Care, in Montreal in May 2002.

SUMMARY OF BACKGROUND DATA

A multitude of randomized controlled trials and systematic reviews have been completed in the field of back pain research. There has been limited health policy research in the field of back pain but a greater amount of health policy research in other medical fields.

METHODS

The focus of the workshop was on the contribution health policy could make in the area of back pain, the methodologies that are appropriate to research in back pain, and the barriers to back pain health policy research. The workshop was supported by the workshop coordinators' literature review.

RESULTS

There was consensus about the lack of improved outcomes from randomized controlled trials and individual treatments and general agreement on the importance supporting current research initiatives with health policy research. That policy-makers were developing policy in this area was agreed, and study methodology to support evidence based policy development was explored.

CONCLUSIONS

Health policy research is a relatively underdeveloped area of research in back pain. Back pain as a public health problem may be supported by a broader research approach and a collaborative association with policy-makers in this area.

Survey of general practitioner, family physician, and chiropractor's beliefs regarding the management of acute whiplash patients

STUDY DESIGN

Questionnaire Survey.

OBJECTIVE

The purpose of this study was to survey the whiplash management beliefs for practicing general practitioners, family physicians, and chiropractors.

SUMMARY OF BACKGROUND DATA

Many treatments are prescribed by general practitioners, family physicians, and chiropractors for acute whiplash, but to date no survey of management beliefs for acute whiplash has been reported.

METHODS

A total of 483 physicians and 123 chiropractors in the urban setting of Edmonton, Alberta, Canada were asked to participate by completing a questionnaire with 24 items designed to assess management beliefs regarding acute whiplash.

RESULTS

A total of 362 physicians (75%) and 88 chiropractors (72%) completed the survey. Only 1% of physicians and none of the chiropractors believed that whiplash patients should be prescribed bed rest until almost all their pain goes away. As well, only 1% of physicians and none of the chiropractors believed that patients with acute whiplash should not return to work until almost all their pain goes away. More than 89% of physicians and 76% of chiropractors believed that encouragement of maintaining normal activities, even if they hurt, is important in the recovery from whiplash. Also, 91% of physicians and 84% of chiropractors agreed that exercise therapy was effective in acute whiplash patients. Physicians are more likely to have negative feelings about treating patients who have whiplash, were more likely to believe there was nothing physically wrong with many patients with chronic whiplash, and agree that nonsteroidal anti-inflammatory drugs and muscle relaxants are effective in acute whiplash. Chiropractors are more likely to agree that traction, transcutaneous electrical nerve stimulation, manipulation, massage, and acupuncture are effective in acute whiplash.

CONCLUSIONS

Physicians and chiropractors generally hold beliefs that are consistent with the current evidence regarding the most helpful approaches to acute whiplash, although chiropractors were more likely to be supportive of passive therapy methods.

Chronic pain and frequent use of health care

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

Effects of Provider Practice on Functional Independence in Older Adults

OBJECTIVES

To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly.

DESIGN

Observational study.

SETTING

King County, Washington.

PARTICIPANTS

A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population.

MEASUREMENTS

Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider.

RESULTS

Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75).

CONCLUSION

Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.

Latent transition regression for mixed outcomes

Health status is a complex outcome, often characterized by multiple measures. When assessing changes in health status over time, multiple measures are typically collected longitudinally. Analytic challenges posed by these multivariate longitudinal data are further complicated when the outcomes are combinations of continuous, categorical, and count data. To address these challenges, we propose a fully Bayesian latent transition regression approach for jointly analyzing a mixture of longitudinal outcomes from any distribution. Health status is assumed to be a categorical latent variable, and the multiple outcomes are treated as surrogate measures of the latent health state, observed with error. Using this approach, both baseline latent health state prevalences and the probabilities of transitioning between the health states over time are modeled as functions of covariates. The observed outcomes are related to the latent health states through regression models that include subject-specific effects to account for residual correlation among repeated measures over time, and covariate effects to account for differential measurement of the latent health states. We illustrate our approach with data from a longitudinal study of back pain.

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

INTERVENTIONS

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

MAIN RESULTS

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

CONCLUSIONS

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

Integrated case management for work-related upper-extremity disorders: impact of patient satisfaction on health and work status

An integrated case management (ICM) approach (ergonomic and problem-solving intervention) to work-related upper-extremity disorders was examined in relation to patient satisfaction, future symptom severity, function, and return to work (RTW). Federal workers with work-related upper-extremity disorder workers' compensation claims (n = 205) were randomly assigned to usual care or ICM intervention. Patient satisfaction was assessed after the 4-month intervention period. Questionnaires on clinical outcomes and ergonomic exposure were administered at baseline and at 6- and 12-months postintervention. Time from intervention to RTW was obtained from an administrative database. ICM group assignment was significantly associated with greater patient satisfaction. Regression analyses found higher patient satisfaction levels predicted decreased symptom severity and functional limitations at 6 months and a shorter RTW. At 12 months, predictors of positive outcomes included male gender, lower distress, lower levels of reported ergonomic exposure, and receipt of ICM. Findings highlight the utility of targeting workplace ergonomic and problem solving skills.

Barriers to patient information provision in primary care: patients' and general practitioners' experiences and expectations of information for low back pain

BACKGROUND

As patient involvement in health-care increases, the role of information is crucial, especially in conditions where self-management is considered an integral part of care. However, the suitability and applicability of much patient information has not been appraised in terms of how far it meets patients' information needs.

AIMS

To ascertain patients' and clinicians' experiences and expectations of information in low back pain in order to suggest a suitable 'patient-centred' content for a patient information pack to be used in a primary care setting.

METHODS

A qualitative study using semi-structured interviews with General Practitioners (GPs) (n = 15) and focus groups comprising patients with low back pain (n = 37).

RESULTS

Barriers to information-giving for low back pain in primary care exist. Patients are dissatisfied with the information they receive from their GPs, especially regarding diagnosis and treatment. Patients tend to access information from a variety of other sources, which is often contradictory, conflicts with research evidence and leads to unreasonable expectations. GPs have varying views regarding the value of patient information and are equivocal about their roles as information providers. Although The Back Book is generally acceptable as a patient information leaflet for low back pain, attention to the tone of the text is required.

CONCLUSIONS

Barriers exist to patient information provision, both generally and for low back pain, which need to be addressed in order to close the gap between strategy and implementation. Improving clinician communication skills and involving patients in developing information materials which meet their needs are crucial to this process.

Dissatisfaction with medical services among Medicare beneficiaries with disabilities

OBJECTIVE

To test the hypothesis that Medicare beneficiaries who have difficulties performing activities of daily living (ADLs) are more likely to report dissatisfaction with their health care than those without ADL difficulties.

DESIGN

Cross-sectional study.

SETTING

Sample from the 1998 Medicare Current Beneficiaries Survey.

PARTICIPANTS

A population-based sample (N=19,650) of noninstitutionalized Medicare beneficiaries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction with overall quality and 9 specific aspects of medical services received in the last year.

RESULTS

After adjusting for sociodemographic, behavioral, and system characteristics and compared with those without ADL difficulties, Medicare enrollees were more likely to report dissatisfaction with the overall quality of their health care as their number of activity restrictions increased (1-2 ADLs: odds ratio [OR]=1.5; 95% confidence interval [CI], 1.2-2.0; 3-4 ADLs: OR=1.7; 95% CI, 1.2-2.4; 5-6 ADLs: OR=1.9; 95% CI, 1.4-2.8). Analysis of satisfaction with the 9 specific aspects of care yielded similar results.

CONCLUSION

Disability is a significant independent risk factor for dissatisfaction with health care in the Medicare population. Efforts should be made to identify individuals with ADL difficulties and to improve their ease and convenience of getting to a doctor, the availability of care off hours, the access to specialists, and the follow-up care received.

Disseminating and implementing the results of back pain research in primary care

STUDY DESIGN

Description of a workshop entitled "Implementation and Dissemination: Getting Research into Practice," that was held at the Fourth International Forum on Low Back Pain Research in Primary Care, in Israel in March 2000.

SUMMARY OF BACKGROUND DATA

A gap exists between research endeavors and the dissemination and implementation of new research findings.

OBJECTIVES

To describe the outcomes of a workshop on implementation and dissemination of research findings.

METHODS

The Fourth International Forum on Low Back Pain Research in Primary Care aimed to encourage open discussion and consensus building among leading experts in the field, and to develop a research agenda. The workshop on implementation and dissemination focused on issues surrounding the gap between research results and actual practice. These issues were introduced by several presentations. The broad conclusions of the subsequent debate are summarized in this paper as a series of responses to key questions: 1) who should do the implementation?, 2) what should researchers do to help implementation?, 3) what are the key outcomes?, and 4) what are important ingredients for successful implementation?

RESULTS

There was consensus about the importance of implementation of research findings, about the ineffectiveness of merely publishing or disseminating research findings, and about the need for prospective randomized trials evaluating the cost-effectiveness of different implementation strategies. The majority view is that the health provider professions and the professional bodies are the central organizations to implement guidelines, rather than the researchers themselves. Success in getting guidelines or research results into practice is dependent on involving local health service groups, experts, and opinion leaders (both local and national). Patient-centered outcomes and cost-effectiveness of guideline implementation were considered important. It was acknowledged that there are many potentially effective ingredients for successful implementation, but a clear indication of the contents of an effective implementation strategy is still lacking.

CONCLUSIONS

The plenary and workshops focused on closing the gap between research results and actual practice. As long as we do not fully understand how best to influence and change physician behavior, the choice of implementation strategies should be based on the present knowledge of potentially effective interventions and should include considerations of available resources for, and potential barriers to, implementation.