Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community

OBJECTIVE: To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP). DESIGN: A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community. SETTING: Two communities in southern Ontario. DATA SOURCE: Mailed survey data on the management of acute LBP.Outcome Measures Plain radiography use rates for acute LBP based on responses to mailed surveys. RESULTS: Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P <.025) and a 50% reduction for patients with acute LBP < 1 month (P <.025) in the intervention community. There was no significant change in the self-report need for plain radiography in the control community (P >.05). CONCLUSIONS: The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP.     

Determinants of return-to-work among low back pain patients

This prospective study identifies physical, behavioral, and psychosocial correlates of subsequent employment status in a sample of low back pain patients. The sample of 150 subjects was drawn from 2 populations of persons with chronic low back pain: 87 individuals who were receiving care at a university low back pain clinic, and 63 individuals who had applied for (but not yet received) Social Security compensation on the basis of low back pain. All subjects had worked at least 3 months prior to their latest unemployment period and were currently out of work. Initial assessment included a medical history, physical examination, biomechanical testing, psychiatric interview, and MMPI testing. All subjects were followed up 6 months later to determine whether they had returned to work. Cross-sectional group comparisons at the time of initial assessment showed that, after controlling for the effects of age, the two samples differed on several physical and biomechanical measures, the Social Security group reflecting a more chronic picture. Group differences on physical variables were found, but most significant differences disappeared when adjusted for length of time out-of-work. Longitudinal analyses showed that few objective physical or biomechanical measures were associated with return-to-work at 6 months, while a number of psychosocial variables were significant predictors of 6-month work status. The data suggest that exclusive reliance on the physical examination to determine level of disability, without consideration of psychosocial conditions, and without adjusting for the confounding effects of age and length of time out-of-work, is not empirically justified. Logistic regression analysis was used to ascertain the relative contribution of each predictor to outcome and to illustrate the hypothetical effects of changes in the levels of selected risk factors on the likelihood of return-to-work. Implications for interventions with low back pain patients are discussed and future research directions suggested.     

Avoidance of affective pain stimuli predicts chronicity in patients with acute low back pain

This prospective study of acute and sub-acute low back pain (LBP) patients was conducted to assess whether attentional biases predicted chronic pain status 3 and 6 months later. The attentional biases of 100 LBP patients were assessed within 3 months of developing pain and 6 months later. Participants also completed measures associated with outcome at 3 assessment points: baseline, 3 and 6 months later. Current pain status was assessed at follow-ups. Patients were classified as those that met standard criteria for chronic pain or those who did not (i.e., the comparison group). At baseline, participants demonstrated a bias toward sensory pain words. However, biases toward sensory pain words did not differentiate those who subsequently developed chronic pain and those who did not at either follow-up. The same bias was observed 6 months later, but again it failed to distinguish between the chronic pain and comparison groups. However, subjects who developed chronic pain at both 3 (n = 22) and 6 (n = 21) months demonstrated biases away from affective pain words at baseline but not 6 months later, in comparison to other participants. These results remained significant in multivariate analyses. These findings are consistent with patterns observed in the previous research, and suggest that avoidance of emotionally laden pain-related stimuli (i.e., affective pain words) is associated with negative outcomes for LBP patients in the acute and sub-acute phase. This research suggests that attentional biases in relation to pain-related stimuli are important for the development of chronic pain, but are more complex than initially thought.     

Characteristics and frequency of malingering among patients with low back pain

Information on the clinical characteristics and frequency of malingering among patients with low back pain was obtained in a survey mailed to orthopedic surgeons and neurosurgeons in 6 geographic regions of the United States. Working on the assumption that orthopedic surgeons and neurosurgeons are untapped historians of this clinical information, data from 105 respondents were analyzed to determine if a consensus of opinion underlies clinical judgment concerning malingering. The results indicated that agreement increases with clinical symptoms reflecting exaggeration and incongruous behavior. 70% or more of the physicians were in agreement on 6 symptoms fitting these 2 patterns. 60% of the surgeons were also in agreement that malingering is a relatively infrequent condition, occurring in 5% or less of patients with low back pain.     

Outcomes measurement for patients with low back pain

Outcomes tracking provides a systematic method of monitoring treatment effectiveness and efficiency. A familiarity with outcome measures for the patient with low back pain is very important for clinicians working in orthopaedic settings, where patients with lumbar pain are prevalent. The clinician must be able to evaluate and choose appropriate measurement tools, and understand the clinical meaning of measurements to successfully employ these instruments. The purposes of this article are to review measurement instruments and to offer practical guidelines for selection and use of outcome measures for this population. The reliability, validity, sensitivity to change, and utility of common outcome measures are discussed. An overview of generic, disease-specific, and patient-specific tools is provided, with specific commentary on the use of the SF-36, SF-12, Oswestry, Roland Morris, and patient-specific tools. Practical guidelines for utilizing outcome measures in clinical practice and the overall benefits of outcomes tracking are highlighted.     

Correlates of compliance among chiropractic patients treated for low back pain

To test Becker's revision of the Health Belief Model in predicting adherence to a chiropractic regimen, 50 patients diagnosed with recurrent acute lumbago were interviewed regarding health beliefs. All subjects had initiated treatment 12 months before the onset of research. This enabled the calculation of a compliance score for each patient, expressed as the percentage of appointments kept to appointments recommended over a 1-yr period. Posttreatment health beliefs were correlated with the compliance measure. From the four dimensions of the model tested, two categories showed variables having significant associations with appointment keeping. Intention to comply was strongly correlated with compliance (P less than 0.01). However, contrary to the model, subjects' estimates of disability were negatively related with adherence to the program (P less than 0.05). It was suggested that patients reporting high levels of disability showed forced compliance. Clinical applications derived from these results are included to aid chiropractors in the prediction and management of compliance.     

A clinical contrast: physical therapists with low back pain treating patients with low back pain

Abstract

Patients with low back pain (LBP) often display faulty beliefs and cognitions regarding their pain experience. Pain neuroscience education (PNE) aims to alter the pain experience by targeting these faulty beliefs and cognitions. One PNE strategy aims specifically to reframe commonly held beliefs about tissues by patients with LBP as the single source of pain. In line with this reasoning, it is hypothesized that physical therapists (PT) treating patients with LBP may indeed experience similar, if not worse, pain experiences while treating a patient with LBP. To date, this assumption has never been studied. A PT LBP questionnaire was developed, validated and distributed to a convenience sample of attendees of an international PT conference. One-hundred and ten PTs completed the questionnaire for a 71% response rate. Ninety percent of the PTs reported having experienced LBP, with 27% at the conference experiencing LBP at the time. Of the PTs that have experienced LBP 75% reported not having received any imaging; 81% no formal diagnoses, 58% no treatment and 86% not having missed work due to LBP. Eighty-six percent of therapists reported having experienced LBP while treating a patient with LBP, with 50% convinced their LBP was higher than the LBP experienced by the patient they were treating. The results from this study indicate PTs often treat patients with LBP while suffering LBP. It is suggested that this knowledge may potentially help patients with LBP reconceptualize their LBP experience leading to expedited recovery.     

Appraisal and coping processes among chronic low back pain patients

OBJECTIVES: Appraisals and coping play important roles in musculoskeletal disorders, but how these aspects develop over time remains unknown. The aim of the current study was to examine the development of pain-related appraisals, coping and well behaviours among chronic low back pain (CLBP) patients. METHODS: Twenty-two outpatients (15 women, 7 men) of working age were interviewed about past and present experiences of CLBP. The interviews were analysed using Grounded theory. RESULTS: The majority of the participants used disregarding processes in response to CLBP. The disregarding process developed from a psychological defence into a conscious coping strategy, the transition mediated by a crisis. This defence seemed to protect the participants' self-concept and reduce emotional discomfort, although it did not promote rehabilitation. The disregarding strategy was usually employed in later phases of the disorder and was consistent with active attempts at changing pain-related behaviours. Study limitation: Most of the participants had experienced CLBP for several years, thus the risk of memory bias cannot be ruled out. Furthermore, the sample was composed of relatively healthy subjects, thus the findings may not apply to chronic low back patients in general. CONCLUSION: Acceptance of CLBP favoured rehabilitation and helped participants change pain-related behaviours.     

Health literacy and beliefs among a community cohort with and without chronic low back pain

Health literacy, the ability to seek, understand and utilise health information, is important for good health. Suboptimal health literacy has been associated with poorer health outcomes in many chronic conditions although this has not been studied in chronic low back pain (CLBP). We examined the health literacy of individuals with CLBP using a mixed methods approach. One-hundred and seventeen adults, comprising 61 with no history of CLBP and 56 with CLBP (28 with low and high disability, respectively, as determined by a median split in Oswestry scores) participated. Data regarding severity of pain, LBP-related disability, fear avoidance, beliefs about LBP and pain catastrophizing were collected using questionnaires. Health literacy was measured using the Short-form Test of Functional Health Literacy in Adults (S-TOFHLA). A sub-sample of 36 participants with CLBP also participated in in-depth interviews to qualitatively explore their beliefs about LBP and experiences in seeking, understanding and using information related to LBP. LBP-related beliefs and behaviours, rather than pain intensity and health literacy skills, were found to be important correlates of disability related to LBP. Individuals with CLBP-high disability had poorer back pain beliefs and increased fear avoidance behaviours relating to physical activity. Health literacy (S-TOFHLA) was not related to LBP beliefs and attitudes. Qualitatively, individuals with CLBP-high disability adopted a more passive coping style and had a pathoanatomic view of their disorder compared to individuals with CLBP-low disability. While all participants with CLBP had adequate health literacy scores (S-TOFHLA), qualitative data highlighted difficulties in seeking, understanding and utilising LBP information.     

Differences in activity‐related behaviour among patients with chronic low back pain

The aim of the present study was to compare the subjectively reported and objectively assessed activity‐related characteristics of patients with Chronic Low Back Pain (CLBP) who were classified according to their scores on the Patterns of Activity Measure‐Pain (POAM‐P) into avoiders, persisters, mixed performers (i.e. high scores on both avoidance and persistence behaviour) or functional performers (i.e. low scores on avoidance and persistence behaviour). Patients carried an electronic diary during 14 days to assess the self‐reported activity and pain intensity levels in daily life. An accelerometer was used to objectively assess their activity level during the same time period. Results were available for 79 patients. Avoiders, persisters and mixed performers showed a higher level of self‐reported disability than functional performers. Avoiders were characterized by a low level of self‐reported habitual activities and persisters by long objectively measured daily uptime. The objectively assessed level of physical activity did not differ between the four groups. A further analysis tested the association between pain intensity levels and self‐reported and objectively assessed daily life activity levels in avoiders and persisters. In persisters, a higher level of self‐reported activities in daily life was related to increased pain. The objectively assessed activity level was not associated with pain intensity.     

Determinants of pain behaviour in patients with chronic low back pain

Experience of pain is manifested by a subject's behaviour, i.e. by verbalization, movements, facial expressions etc. Experience of pain is a latent construct, and the question of whether the pain is "real" becomes secondary when the behavioural aspect is emphasised: "When the patient communicates pain, then there is a pain problem". The task of the clinician and the researcher is to find out what is behind a person's response to pain. The pain behaviour is determined by many factors. These include psychological suffering due to emotional distress; learning processes regulating pain behaviour; anticipated pain and fear of pain as a cause of passivity and avoidance behaviour in chronic low back pain patients; the influence of cognitive factors, particularly the relationship between negative expectations, cognitive distortion and activity; and finally, the role of psychological distress in chronic pain. These factors are discussed in this paper. Some empirical studies are briefly reviewed to illustrate the topic. Implication of these conceptualizations for treatment of and outcome research in chronic low back pain will be briefly discussed.