Outcome of general practitioner referrals to specialist outpatient clinics for back pain.

In 1983-84 general practitioners in the Oxford region kept records of their referrals to outpatient clinics over a period of six months. Five years later in 1988-89 the general practice notes of 182 patients referred for back pain were studied to determine the outcomes of their referral. The actions initiated in the outpatient clinics were compared with the general practitioners' main reason for referral recorded at the time of referral. Of the 182 patients 136 (74.7%) received specialist treatment following the outpatient referral despite the fact that general practitioners had given treatment as the main reason for referral in only 28.6% of cases. Patients' mean consultation rate for back pain declined from 4.2 consultations per annum to 0.9 (P less than 0.001) over the five year period, but there was a small but significant increase in consultations for other problems. Five years after the referral 33.3% of patients were still consulting their general practitioner for back pain. The referral system for patients with chronic back pain could be rationalized to reduce the need for re-referrals and multiple follow-up outpatient consultations. There is a need to improve communications between general practitioners, specialists and patients about the purpose of referral, the likely effects of treatment and the scope for prevention. A survey of the outcome of referrals for common conditions, such as back pain, is a useful first step in the development of referral guidelines.     

Prognostic indicators in low back pain

Nearly four per cent of the population over the age of 15 years in a Danish general practice reported episodes of low back pain at least once a year. A one-year follow-up of 72 patients provided data regarding symptoms, length of absence from work, use of analgesics and bed rest. An indication of the prognosis was reached by relating these data to the history (including occupation), symptoms and signs noted at the initial interview. The following factors indicated a long or relapsing course:

1. More than three previous episodes of low back pain.

2. Gradual onset of symptoms.

3. Pain referred distal to the femur.

4. More than four weeks' delay in reporting symptoms.

Other factors of prognostic significance were difficulty in moving, onset in relation to work, absence from work, positive straight leg raising test and unilateral pain in the loin.

     

Predicting persistent disabling low back pain in general practice: a prospective cohort study

BACKGROUND: Patients may adopt active and/or passive coping strategies in response to pain. However, it is not known whether these strategies may also precede the onset of chronic symptoms and, if so, whether they are independent predictors of prognosis. AIM: To examine, in patients with low back pain in general practice, the prognostic value of active and passive coping styles, in the context of baseline levels of pain, disability and pain duration. DESIGN OF STUDY: Prospective cohort study. SETTING: Nine general practices in north west England. METHOD: Patients consulting their GP with a new episode of low back pain were recruited to the study. Information on coping styles, pain severity, disability, duration, and a brief history of other chronic pain symptoms was recorded using a self-completion postal questionnaire. Participants were then sent a follow-up questionnaire, 3 months after their initial consultation, to assess the occurrence of low back pain. The primary outcome was persistent disabling low back pain, that is, low back pain at 3-month follow-up self-rated as >or=20 mm on a 100 mm visual analogue scale, and >or=5 on the Roland and Morris Disability Questionnaire. RESULTS: A total of 974 patients took part in the baseline survey, of whom 922 (95%) completed a follow-up questionnaire; 363 individuals (39%) reported persistent disabling pain at follow-up. Persons who reported high levels of passive coping experienced a threefold increase in the risk of persistent disabling low back pain (relative risk [RR] = 3.0; 95% confidence interval [CI] = 2.3 to 4.0). In contrast, active coping was associated with neither an increase nor a decrease in the risk of a poor prognosis. After adjusting for baseline pain severity, disability, and other measures of pain and pain history, persons who reported a high passive coping score were still at 50% increased risk of a poor outcome (RR = 1.5; 95% CI = 1.1 to 2.0). CONCLUSION: Patients who report passive coping strategies experience a significant increase in the risk of persistent symptoms. Further, this risk persists after controlling for initial pain severity and disability. The identification of this low back pain subgroup may help target future treatments to those at greatest risk of a poor outcome.     

Radiography for low back pain: a randomised controlled trial and observational study in primary care.

BACKGROUND: Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain. Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely. However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care. AIM: To compare short and long-term physical, social, and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice. DESIGN OF STUDY: A randomised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial. SETTING: Ninety-four general practices in south London and the South Thames region. METHOD: Patients consulting their general practitioner (GP) with low back pain at first presentation were recruited to a randomised controlled trial (RCT) or to an observational group. Patients in the trial were randomly allocated to immediate referral for x-ray or to no referral. All patients were asked to complete questionnaires initially, and then at six weeks and one year after recruitment. RESULTS: Six hundred and fifty-nine patients were recruited over 26 months: 153 to the randomised trial and 506 to the observational arm. In the RCT referral for x-ray had no effect on physical functioning, pain or disability, but was associated with a small improvement in psychological wellbeing at six weeks and one year. These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation; however, those referred for x-ray had lower depression scores. CONCLUSIONS: Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.     

Patients'' views of low back pain and its management in general practice.

BACKGROUND: Low back pain is a common and persistent problem. Research studies seeking to improve the quality of management of this condition have tended to ignore the opinions of patients. There is a growing acceptance of the importance of taking patients' views into account in developing management and educational programmes for a variety of conditions. AIM: This study set out to elicit the views of patients concerning low back pain and its management in general practice. METHOD: Fifty-two in-depth interviews were conducted with patients selected from a broad range of 12 general practices. RESULTS: Analysis of the interviews identified seven themes relating to: quality of life, prognosis, secondary prevention, help-seeking behaviour, explanation of underlying pathology, satisfaction with general practitioner management, and complementary therapy. Different patient viewpoints or perspectives were expressed within each of these themes. Patients adapted to the progress of their low back pain and were not seeking a 'magical cure' from either conventional or complementary therapies. CONCLUSION: Patients' views on low back pain are heterogeneous. The dissatisfaction expressed with medical explanations for the pain may be related to superficial clinical management and the constraints of general practice. Good management of low back pain needs to take patients' complex views of the condition into account.     

Transdermal fentanyl for chronic low back pain

Purpose

Chronic low back pain is a common clinical problem. As medication, non-steroidal anti-inflammatory drugs are generally used; however, they are sometimes non-effective. Recently, opioids have been used for the treatment of chronic low back pain, and since 2010, transdermal fentanyl has been used to treat chronic non-cancer pain in Japan. The purpose of the current study was to examine the efficacy of transdermal fentanyl in the treatment of chronic low back pain.

Materials and Methods

This study included patients (n=62) that suffered from chronic low back pain and were non-responsive to non-steroidal anti-inflammatory drugs. Their conditions consisted of non-specific low back pain, multiple back operations, and specific low back pain awaiting surgery. Patients were given transdermal fentanyl for chronic low back pain. Scores of the visual analogue scale and the Oswestry Disability Index, as well as adverse events were evaluated before and after therapy.

Results

Overall, visual analogue scale scores and Oswestry Disability Index scores improved significantly after treatment. Transdermal fentanyl (12.5 to 50 µg/h) was effective in reducing low back pain in 45 of 62 patients; however, it was not effective in 17 patients. Patients who experienced the most improvement were those with specific low back pain awaiting surgery. Adverse events were seen in 40% of patients (constipation, 29%; nausea, 24%; itching, 24%).

Conclusion

Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations.     

Use of complementary and alternative medicine by mid-age women with back pain: a national crosssectional survey

ABSTRACT: BACKGROUND: The use of complementary and alternative medicine (CAM) has increased significantly in Australia over the past decade. Back pain represents a common context for CAM use, with increasing utilisation of a wide range of therapies provided within and outside conventional medical facilities. We examine the relationship between back pain and use of CAM and conventional medicine in a national cohort of mid-aged Australian women. METHODS: Data is taken from a cross-sectional survey (n=10492) of the mid-aged cohort of the Australian Longitudinal Study on Women's health, surveyed in 2007. The main outcome measures were: incidence of back pain the previous 12 months, and frequency of use of conventional or CAM treatments in the previous 12 months. RESULTS: Back pain was experienced by 77% (n=8063) of the cohort in the previous twelve month period. The majority of women with back pain only consulted with a conventional care provider (51.3%), 44.2% of women with back pain consulted with both a conventional care provider and a CAM practitioner. Women with more frequent back pain were more likely to consult a CAM practitioner, as well as seek conventional care. The most commonly utilised CAM practitioners were massage therapy (26.5% of those with back pain) and chiropractic (16.1% of those with back pain). Only 1.7% of women with back pain consulted with a CAM practitioner exclusively. CONCLUSIONS: Mid-aged women with back pain utilise a range of conventional and CAM treatments. Consultation with CAM practitioners or self-prescribed CAM was predominantly in addition to, rather than a replacement for, conventional care. It is important that health professionals are aware of potential multiple practitioner usage in the context of back pain and are prepared to discuss such behaviours and practices with their patients.     

Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands.

BACKGROUND: Although guidelines for the management of low back pain have been published in the past decade, there is potential for further improvement in back pain care. AIM: To document the management of non-specific low back pain by general practitioners (GPs) in the Netherlands, to determine how this management of care is related to patient and physician factors, and to explore possible reasons for not adhering to the guidelines. METHOD: A prospective study was set up in which 57 GPs in 30 general practices completed a computerised questionnaire after each consultation for low back pain during a four-month period. RESULTS: Of 1640 back pain contacts, 1180 referred to non-specific low back pain. Diagnostic tests were ordered in 2% of first consultations and in 7% of follow-up consultations within one episode. The advice to stay active despite pain was given in 76% and 69% of these cases respectively. Patients were prescribed an analgesic in 53% and 41% of cases respectively (mainly NSAIDs [80%]). Patients were referred to a physiotherapist in 22% of first and in 50% of follow-up consultations. Older patients were physically examined less often, prescribed analgesics more often, and were told less often that staying active could benefit them. The advice to remain active was omitted more often when symptoms lasted longer. Only a small part of the variance in management was accounted for by patient characteristics or by differences between practices. CONCLUSION: The management of low back pain met the guidelines to a large extent. Management decisions were often related to characteristics in which the guidelines lack differentiation. Important reasons for non-adherence were perceived patients' preferences. Further implementation of guidelines will be difficult unless doctors' and patients' views are more explicitly known.     

The lives of patients before presentation with pain in the neck or back

More significant events occurred in the lives of patients during the three months before presentation in general practice with pain in the neck or back than in a control group of symptomless patients.

These findings were obtained by the completion by patients of a short questionnaire and their significance is discussed.

     

Comparison of the work of a nurse practitioner with that of a general practitioner

The work of a nurse practitioner was compared with that of a general practitioner. Both were equally available to the same patient population over the same period. The nurse practitioner saw a similar age and sex distribution of patients to the doctor but saw different types of problems. More of the patients she saw were for followup of chronic diseases, health advice and screening measures while fewer were acutely ill. The doctor dealt with four times as many patients. The nurse practitioner managed 78% of her consultations without referral to a doctor, and 89% without resorting to prescribed drugs. There was a high level of patient satisfaction with her work and 97% of the patients who saw the nurse would choose to consult her again. The role of the nurse practitioner in our practice has developed differently from a similar post in another setting, thus emphasizing the need for flexibility when defining the role.

Nurse practitioners are a valuable extra resource for the development of new areas of care, rather than a cheaper substitute for a general practitioner.

     

Is biliary pain exclusively related to gallbladder stones? A controlled prospective study.

BACKGROUND: The uncertainty around true clinical manifestations of gallbladder stone disease is in contrast with the unanimous recommendation that only symptomatic gallstones should be treated. AIM: To evaluate the relationship between biliary pain, other gastrointestinal symptoms and gallstones. DESIGN OF STUDY: A pragmatic, prospective cohort questionnaire study. SETTING: Seventy-five general practices in Rotterdam, The Netherlands. METHOD: All patients suspected by their general practitioner (GP) to have gallstone disease underwent ultrasound examination of the upper abdomen. Using a self-administered questionnaire, the presence of 11 gastrointestinal symptoms was assessed at inclusion and after 1 year. Likelihood ratios (LRs) for the presence of gallstones and symptom relief rates after 1 year were calculated. The mean difference in health status at inclusion and after follow-up was calculated for patients without gallstones, for patients with gallstones who were operated on and for patients with gallstones who were not operated on. RESULTS: In total, 61% of the patients with gallstones diagnosed by ultrasound scan reported biliary pain, as did 45% of the patients without gallstones (LR = 1.34, 95% confidence interval [CI] = 1.05 to 1.71). Patients operated on for gallstone disease did not show significant relief of biliary pain compared to patients not operated on for gallstones or patients without gallstones (87%, 63% and 83%, respectively). Health status improved in all patients. The mean improvement in health status did not differ between the three patient groups. GPs were able to discriminate between patients with high and low probability of gallbladder stones by ultrasound examination (53% versus 23%). This selection, however, did not predict the outcome of cholecystectomy. CONCLUSION: Neither biliary pain nor any other gastrointestinal symptom was consistently related to gallstone disease. Therefore, the indication for elective cholecystectomy cannot be based on the presence of biliary pain alone. Relief of biliary pain in patients operated on for gallstones should not simply be attributed to a successful cholecystectomy.     

Physical loading and performance as predictors of back pain in healthy adults A 5-year prospective study

We investigated muscle strength, aerobic power, and occupational and leisure-time physical loading as predictors of back pain in a 5-year follow-up study. A cohort of 456 adults aged 25, 35, 45 and 55 years, free of back pain, participated in measurements of anthropometric characteristics, aerobic power and muscle strength characteristics at baseline. The subjects' levels and types of physical activity and occupational physical loading were also determined. At 5 years after the baseline examinations 356 of these subjects (78.1 %) were reached by mail, and 262 of them (73.6%) properly completed and returned a questionnaire including a detailed back pain history for the 5 years following the baseline measurements. Of this number 56 subjects (21 %) who reported back pain ( > 30 on a scale from 0 to 100) and functional impairment during the 5-year follow-up composed the marked back pain group. Other subjects (n = 71, 27%) noting lesser symptoms were included in the mild back pain group; 135 subjects (52%) reported having had no back pain. The subjects with marked back pain were on average taller than the subjects without back pain, while no such difference was found in body mass. Heavy occupational musculoskeletal loading (P = 0.005) and high general occupational physical demands (P = 0.036) predicted future back pain. Leisuretime physical activity, aerobic power or muscle strength characteristics were not predictive of future back pain.     

The inter-observer reproducibility of Lasègue''s sign in patients with low back pain in general practice.

BACKGROUND: The spectrum of low back pain patients in general practice differs significantly from that in an orthopaedic clinic. The most frequent specific cause of low back pain is nerve-root irritation or compression caused by intervertebral protrusion, and the diagnosis is still problematic. Testing for Lasègue's sign could be a useful way of detecting high-risk patients, but so far the reproducibility of the test has been measured only in hospital-based studies. AIM: To assess the inter-observer reproducibility of Lasègue's sign in general practice. METHOD: Fifteen General practitioners from Amsterdam and the surrounding areas tested all consecutive low back pain patients who visited them during a period of two years for Lasègue's sign. The test was repeated within two weeks in two samples: sample I consisted of 50 consecutive low back pain patients; sample II consisted of all patients who had pelvic tilt, scoliosis, or positive Lasègue's sign. RESULTS: In sample I, the observation was repeated in 49 patients. The Kappa coefficient was 0.33, and the proportions of positive and negative agreement were 33% and 96%, respectively. In sample II, the observation was repeated in 48 patients. The Kappa coefficient was 0.56, whereas the proportion of positive agreement was 67% and the proportion of negative agreement was 91%. CONCLUSIONS: The reproducibility of Lasègue's sign in routine general practice seems to be low, but may be similar to the reproducibility observed in hospital settings in selected patients who have a high chance of low back pain owing to a specific disease.     

Acute myocardial infarction: an easy diagnosis in general practice?

In the imminent myocardial infarction Rotterdam (IMIR) study, contacts by patients with their general practitioners for symptoms of potential coronary artery disease were registered. Those who had acute myocardial infarction were diagnosed on the basis of the modified World Health Organization criteria, and those with this definite diagnosis were then compared with the initial diagnosis made by the general practitioner at the moment of contact without laboratory assistance.

Of the 1,343 patients included in the study, 93 (seven per cent) had `definite' acute myocardial infarction and another 37 (three per cent) had `possible' acute myocardial infarction according to the diagnostic criteria used.

At the time of contact with the general practitioner 41 (44 per cent) of the 93 patients with definite myocardial infarction were recognized as such by the general practitioner, while in another 31 (33 per cent) the general practitioner diagnosed `imminent' myocardial infarction.

Of the 1,213 patients free of acute myocardial infarction at the time, 40 (three per cent) were incorrectly diagnosed by the general practitioner as having `acute' myocardial infarction.

In the 22 patients who in fact had acute myocardial infarction but in whom the general practitioner did not make this diagnosis at the time, it was found that there was an absence of physical signs and, similarly, in patients who subsequently did not have infarction the presence of physical signs was related to a falsepositive general practitioner diagnosis of myocardial infarction.

In view of the inaccuracy of the general practitioner's provisional diagnosis of acute myocardial infarction, we believe that electrocardiogram and enzyme tests should be carried out systematically in all patients who present to general practitioners with symptoms of potential coronary artery disease. Laboratory support should be readily available and we support the idea of having a special diagnostic service.

     

Prediction of an unfavourable course of low back pain in general practice: comparison of four instruments

BACKGROUND: Several instruments can be used to identify patients with an unfavourable course of low back pain in general practice. However, it is unclear which instrument is the predictor of outcome. AIM: To compare the predictive performance (that is, calibration and discrimination) of risk estimation by GPs with assessments using the Orebro Musculoskeletal Pain Screening Questionnaire, the Low Back Pain Perception Scale (LBPPS), and a prediction rule developed for this purpose. Design of study: A prospective cohort study with 1-year follow-up. SETTING: General practice in The Netherlands. METHOD: The outcome 'unfavourable course of low back pain' was defined as having no clinically important improvement at minimally 50% of the measurements at 6, 13, 26, and 52 weeks. Logistic regression analyses were used to study associations between potential predictors and outcome. RESULTS: In total, 60 GPs recruited 314 patients to the study (16 patients were excluded from analysis due to missing data on the course of low back pain). Over a third of patients (112/298) showed an unfavourable course of low back pain on follow-up. Risk estimation by GPs, the Orebro questionnaire, the LBPPS, and the prediction rule had discriminative ability (area under the curve) of 0.59 (95% CI [confidence intervals] = 0.52 to 0.66); 0.61 (95% CI = 0.54 to 0.67); 0.59 (95% CI = 0.52 to 0.66); and 0.75 (95% CI = 0.69 to 0.81) respectively. The prediction rule included history of low back pain, self-perceived risk to develop chronic low back pain, no solicitous responses of the patient's partner (as reported by the patient), frequent walking at work, and 'pain catastrophising'. CONCLUSION: Although the prediction rule performed best with regard to calibration and discrimination, it needs to be externally validated. Risk estimation by GPs performs as well as other instruments and, at present, seems to be the best available option.     

COOP-WONCA charts: a suitable functional status screening instrument in acute low back pain?

BACKGROUND: Functional status is considered an important measure of health status in primary care. The COOP-WONCA charts, which comprise six single-item scales, have mainly been used to determine functional ability in chronically ill patients. AIM: A study was carried out to determine whether the charts are able to measure the degree of functional impairment associated with acute illness and the improvement in functional ability accompanying the process of recovery. METHOD: A total of 95 patients presenting with acute low back pain were recruited from 15 single-handed general practices in northern Germany. At presentation and at two-week follow up, these patients completed self-administered questionnaires which included the COOP-WONCA charts. The charts ask patients to use the timescale of the past two weeks when rating their condition. Baseline and follow-up measurements of the charts were compared and correlations of chart scores with patients' measurements of pain intensity on a visual analogue scale, general practitioners' ratings of impairment and patients' measurements of recovery were analysed. RESULTS: Only the chart measuring change in health revealed a deterioration in functional ability associated with the onset of pain and an improvement in functional status at follow up. Two of the other charts indicated a deterioration at follow up. Only the chart measuring change in health was correlated with ratings of pain and impairment at baseline. At follow up, strong correlations were found between general practitioners' assessments of impairment, patients' ratings of pain and patients' ratings of recovery for all scales except for those measuring social activities and daily activities. The patients interpreted the instructions for using the COOP-WONCA charts differently; some included the period of acute back pain while others did not. CONCLUSION: Of the six charts only the change in health chart proved to be a suitable scale for measuring short-term changes in functional ability among general practice patients with acute low back pain. This may partly be a result of patients misunderstanding the instructions. If the COOP-WONCA charts are used with acutely ill patients, the fixed two-weeks timescale is not appropriate. It is suggested that patients consider their present complaints when rating their condition.     

Influence of low back pain on total knee arthroplasty outcome

BackgroundPreoperative pain and functional status are strong determinants of postsurgical success in total knee arthroplasty. Patients suffering chronic pain from other coexistent musculoskeletal problems may respond differently postoperatively, with potentially poorer outcomes after surgery. The aim of the study was to determine the influence of low back pain on the outcome of total knee replacement surgery.MethodsAll patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 (both physical and mental components). Patients were divided into those with (n = 40) and without a documented history of low back pain (n = 305).ResultsOKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24 months following surgery. The mental component of the SF-12 measure demonstrated a significant improvement in median mental health post-operatively for patients with no current history of low back pain. In contrast the group with low back pain showed no improvement in mental health scores post-operatively.ConclusionThis study demonstrates that symptomatic low back pain influences functional outcome after total knee arthroplasty surgery and that patients with low back pain show limited or no improvement in mental health post-operatively.Level of evidence II.     

Patients with suspected myocardial infarction: effect of mode of referral on admission time to a coronary care unit.

The aim of this prospective study was to determine the delay between the onset of symptoms and arrival in the coronary care unit of patients with suspected acute myocardial infarction, and the relative contribution to the total delay of patient delay, method of referral (self referral or general practitioner referral) and delay in the hospital before reaching the coronary care unit. All patients admitted with chest pain to the coronary care unit at Dudley Road Hospital, Birmingham, over the six month period April-September 1989 were included in the study. Ninety five patients were referred by their general practitioner and 107 patients attended the accident and emergency department directly or arrived by ambulance without contacting their general practitioner. The proportion of self referred and general practitioner referred patients with acute myocardial infarction, angina and non-cardiac chest pain were not significantly different. The total delay was significantly longer for patients who had been referred by their general practitioner (median 5.3 hours) than for self referrals (3.2 hours, P less than 0.001), with a significantly higher proportion of self referrals arriving at the coronary care unit within six hours of the onset of symptoms (77% versus 54%, P less than 0.01). Among general practitioner referrals, initial patient delay accounted for a median of 2.5 hours and the general practitioner's response time for a median of 1.1 hours. The delay in hospital was similar for both groups of patients. In inner city areas, self referral may result in considerably less delay than general practitioner referral allowing a greater proportion of patients to receive effective thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

One practice's review of its use of a general practitioner hospital

For a period of six months a record was kept of every attendance at a general practitioner hospital by a patient from a four-partner practice with a list of 10,500 patients.

During the six-month period one in 17 of the practice population was x-rayed; one in 50 attended the physiotherapy department, and the rate for general practitioner surgery consultations was one per person.

I believe that in semi-rural North Yorkshire the general practitioner hospital has a continuing role to play and such a hospital can provide a better and more comprehensive service to patients, and give professional satisfaction and stimulation to the primary health care team.