Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial.

BACKGROUND CONTEXT: The process through which new scientific developments are incorporated into clinical practice is referred to as "knowledge transfer" and is currently the subject of great interest in many areas of clinical medicine. Family physicians managing patients with acute low back pain have been shown to have a poor overall rate of concordance with clinical practice guideline-recommended treatments. New methods need to be developed to help physicians bridge the guideline implementation gap. PURPOSE: To determine the efficacy of a knowledge transfer method that communicates clinical practice guidelines to family physicians and their patients using patient-specific, physician-to-physician communications. STUDY DESIGN: A prospective randomized controlled study. PATIENT SAMPLE: 428 patients with acute mechanical low back pain and accepted Workers' Compensation Board claims were studied. OUTCOME MEASURES: Concordance with specific clinical practice guideline-derived history taking items, physical examination procedures and treatment recommendations was determined. METHODS: Patients with acute mechanical back pain of less than 4 weeks duration and accepted Workers' Compensation Board claims were randomly assigned to one of three groups. In Group 1 (control group) neither the patients nor their family physicians received any information concerning the guidelines. In Group 2, family physicians alone or as well as their patients (Group 3) received a summary of clinical practice guidelines at approximately 2 weeks postinjury. In addition, both Groups 2 and 3 received reminders summarizing the recommended guidelines for patients at three specific stages of their clinical course. All guideline correspondence was addressed to a specific family physician or patient, signed by the study physician-investigators, and specified the patient by name. RESULTS: Family physicians in the control and intervention groups demonstrated a high degree of concordance with the guideline-recommended history taking and physical examination procedures, but were generally highly discordant with guideline-recommended treatments. Significant improvement in guideline-concordant treatments was seen only with diminished recommendations of prolonged bed rest and passive therapies and an increase in recommended aerobic exercise. Concordance with guideline recommendations relating to the use of spinal manipulative therapy was poor in all study groups. CONCLUSIONS: A knowledge transfer method that involved patient-specific, physician-to-physician communication to family physicians or their patients at three stages of the patient's clinical course was largely unsuccessful in improving concordance with guideline treatment recommendations.     

Randomized open-labbel non-inferiority trial of acetaminophen or loxoprofen for patients with acute low back pain

Background

Current worldwide clinical practice guidelines recommend acetaminophen as the first option for the treatment of acute low back pain. However, there is no concrete evidence regarding whether acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) is more effective for treating acute low back pain (LBP) in Japan. The present study aimed to investigate whether acetaminophen treatment for acute musculoskeletal pain was comparable with loxoprofen (a traditional NSAID in Japan) treatment.

Limited clinical utility of pain drawing in assessing patients with low back pain

OBJECTIVE: The aim of this study was to assess the use of pain drawing by studying its ability to identify patients with low back pain and abnormal psychological profile. The intraevaluator repeatability of the penalty point method of scoring of pain drawing was also evaluated. METHODS: A total of 331 consecutive patients with low back pain were prospectively recruited. The psychologic profile was assessed using the Hospital Anxiety and Depression Scale. The pain drawings were scored with the penalty point method. The ability of pain drawing to identify patients with significant anxiety and depression was assessed by calculating the sensitivity, specificity, and positive predictive value. The intraevaluator repeatability was calculated for scoring done at an interval of 1 month using the kappa statistic. RESULTS: There were statistically significant differences in the anxiety and depression scores in patients with normal (n = 200) and abnormal (n = 131) pain drawing (anxiety: 9 +/- 4 vs 10.3 +/- 3.7; depression: 8.1 +/- 3.5 vs 8.8 +/- 3.6; P < 0.005). The pain drawing had a low sensitivity for detecting patients with any degree of anxiety (43%) or depression (40%). The positive predictive value of pain drawing for anxiety and depression was 78% and 69%, respectively. The kappa value for intraobserver assessment was 0.6 (P < 0.05). CONCLUSION: Though there are differences in anxiety and depression scores in patients with normal and abnormal pain drawing, the performance characteristics of pain drawing are less than acceptable and therefore limit its use in clinical practice.     

Nordic Walking and chronic low back pain: design of a randomized clinical trial

Background  

Low Back Pain is a major public health problem all over the western world. Active approaches including exercise in the treatment of low back pain results in better outcomes for patients, but it is not known exactly which types of back exercises are most beneficial or whether general physical activity provide similar benefits.     

Lumbar motion changes in chronic low back pain patients: a secondary analysis of data from a randomized clinical trial

Background contextSeveral therapies have been used in the treatment of chronic low back pain (LBP), including various exercise strategies and spinal manipulative therapy (SMT). A common belief is that spinal motion changes in particular ways in direct response to specific interventions, such as exercise or spinal manipulation.PurposeThe purpose of this study was to assess changes in lumbar region motion for more than 12 weeks by evaluating four motion parameters in the sagittal plane and two in the horizontal plane in LBP patients treated with either exercise therapy or spinal manipulation.Study design/settingSecondary analysis of a subset of participants from a randomized clinical trial.Patient sampleOne hundred ninety-nine study participants with LBP of more than 6 weeks' duration who had spinal motion measures obtained before and after the period of intervention.Outcome measuresLumbar region spinal kinematics sampled using a six-degree-of-freedom instrumented spatial linkage system.MethodsTrained therapists collected regional lumbar spinal motion data at baseline and 12 weeks of follow-up. The lumbar region spinal motion data were analyzed as a total cohort and relative to treatment modality (high dose, supervised low-tech trunk exercise, SMT, and a short course of home exercise and self-care advice). The study was supported by grants from Health Resources and Services Administration, Danish Agency for Science Technology and Innovation, Danish Chiropractors Research Foundation, and the University of Southern Denmark. No conflicts of interest reported.ResultsFor the cohort as a whole, lumbar region motion parameters were altered over the 12-week period, except for the jerk index parameter. The group receiving spinal manipulation changed significantly in all, and the exercise groups in half, the motion parameters included in the analysis. The spinal manipulation group changed to a smoother motion pattern (reduced jerk index), whereas the exercise groups did not.ConclusionThis study provides evidence that spinal motion changes can occur in chronic LBP patients over a 12-week period and that these changes are associated with the type of treatment.     

Osteopaths' clinical reasoning during consultation with patients experiencing acute low back pain: A qualitative case study approach

BackgroundThe clinical reasoning strategies employed in healthcare have been well established in a wide range of health professions. Currently, there is little literature pertaining to the diagnostic process of osteopaths and the clinical reasoning strategies utilised in osteopathy.AimTo investigate the processes of clinical reasoning utilised by osteopaths in the diagnostic hypothesis generation for patients with acute low back pain.MethodsTwo methods were employed: a thematic analysis in conjunction with content analysis which involved a novel ‘consultation mapping’ approach. Three osteopaths were video recorded taking a case history and performing examination procedures. Following conclusion of each consultation, participants viewed a video recording of the consultation, and provided a commentary which was audio recorded. All audio and video recordings were later transcribed for analysis.ResultsThree themes were identified from the data which broadly represented three existing clinical reasoning strategies: Implicit cognitive evaluations not apparent to an external observer (pattern recognition); Iterative processing of cues assembled through clinical interactions (hypothetico-deductive reasoning); Collaborative interaction between patient and practitioner (collaborative reasoning). Each consultation was then ‘mapped’, and content analysis showed dynamic transitioning between three levels of pattern recognition (‘light’, ‘moderate’, ‘heavy’) of hypothetico-deductive reasoning. Collaborative reasoning occurred consistently at the commencement and conclusion of each consultation.ConclusionsThe clinical reasoning strategies employed by osteopaths in this study were pattern recognition, hypothetico-deductive reasoning and collaborative reasoning. Each strategy was characterised by a theme which described its meaning.     

Significant differences of brain blood flow in patients with chronic low back pain and acute low back pain detected by brain SPECT

Background

The aim of this study was to examine and compare the areas of brain blood flow in patients with chronic low back pain (CLBP) without structural abnormality and acute low back pain (ALBP) with lumber disc herniation (LDH). Functional neuroimaging studies provide evidence of abnormalities in the regional cerebral blood flow during low back pain. Recent studies have shown that CLBP is associated with plastic, pathophysiological changes in the brain. However, there has been no report yet statistically or by neuro-images on the compared brain single photon-emission computed tomography (SPECT) findings between CLBP and ALBP patients.

Methods

The subjects comprised 14 patients, 7 CLBP and 7 ALBP patients. The CLBP group included the patients who had no or minor structural abnormality in the lumbar spine on magnetic resonance imaging (MRI) and met the criteria for a classification of “pain disorder” (chronic) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. The ALBP group included the patients who had symptoms within 3 months of onset and LDH revealed by MRI. All patients were assessed using brain SPECT. We then performed a two-tailed view analysis using the easy Z score imaging system, determined the mean Z scores, and performed vBSEE software (Fujifilm RI Pharma, Tokyo, Japan) for both CLBP and ALBP patients.

Results

The CLBP group showed significantly reduced blood flow in the bilateral prefrontal cortex of the frontal lobe and increased blood flow in the bilateral posterior lobe of the cerebellum.

Conclusions

SPECT images and statistical analyses revealed the brain blood flow alterations in the patients with ALBP and CLBP. These results may suggest that the dysfunction of the prefrontal cortex could lead to the appearance of unconscious pain behavior controlled by the cerebellum in the patients with CLBP.