Criteria for inclusion in programs of functional restoration for chronic low back pain: Pragmatic Study

BackgroundIndividuals with chronic low back pain (cLBP) may benefit from multimodal functional restoration programs (FRPs).ObjectiveThe aim of this study was to analyze characteristics of individuals with cLBP who were referred or not to an FRP. Because cLBP is a bio-psycho-social disorder, medical and social parameters were analysed.MethodsThis was an observational cross-sectional study performed in 2017 in 6 tertiary centres in France. Consecutive individuals with cLBP visiting a rheumatologist or physical medicine and rehabilitation physician were included. Individuals referred or not to an FRP were compared by demographic characteristics, duration of sick leave over the past year, self-reported physical activity > 1 h/week, pain (numeric rating scale 0–10), anxiety/depression (Hospital Anxiety and Depression Scale), disability (Oswestry Disability Index) and kinesiophobia (Tampa Kinesiophobia Scale). Univariate and multivariate logistic regression analyses were performed, estimating odds ratios (ORs) and 95% confidence intervals (CIs).ResultsWe included 147 individuals with cLBP. The mean (SD) age was 49 (12) years and 88 (60%) were women; 58 (38%) were referred to an FRP. On multivariate analysis, referral to an FRP was associated with reduced pain level (OR: 0.95, 95% CI: 0.91–0.99, for each 1-point increase in pain score), self-reported lack of physical activity (OR: 0.84, 95% CI: 0.72–0.98) and longer sick leave (OR: 1.03, 95% CI: 1.01–1.05, for 30 more days of sick leave).ConclusionIn this multicentric observational study, referral to an FRP was linked to pain, self-reported physical activity and sick leave but not medical characteristics assessed. These findings confirm the bio-psycho-social approach of FRPs for cLBP.     

Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care

Many psychological factors have been suggested to be important obstacles to recovery from low back pain, yet most studies focus on a limited number of factors. We compared a more comprehensive range of 20 factors in predicting outcome in primary care. Consecutive patients consulting 8 general practices were eligible to take part in a prospective cohort study; 1591 provided data at baseline and 810 at 6 months. Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ). The relative strength of the baseline psychological measures to predict outcome was investigated using adjusted multiple linear regression techniques. The sample was similar to other primary care cohorts (mean age 44 years, 59% women, mean baseline RMDQ 8.6). The 20 factors each accounted for between 0.04% and 33.3% of the variance in baseline RMDQ score. A multivariate model including all 11 scales that were associated with outcome in the univariate analysis accounted for 47.7% of the variance in 6 months RMDQ score; rising to 55.8% following adjustment. Four scales remained significantly associated with outcome in the multivariate model explaining 56.6% of the variance: perceptions of personal control, acute/chronic timeline, illness identify and pain self-efficacy. When all independent factors were included, depression, catastrophising and fear avoidance were no longer significant. Thus, a small number of psychological factors are strongly predictive of outcome in primary care low back pain patients. There is clear redundancy in the measurement of psychological factors. These findings should help to focus targeted interventions for back pain in the future.     

The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study

Guidelines portray low back pain (LBP) as a benign self‐limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease‐related and socio‐demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.     

Management of chronic pain among older patients: Inside primary care in the US

Under-treatment of pain is a worldwide problem. We examine how often pain was addressed and the factors that influence how much time was spent on treating pain.We analyzed 385 videotapes of routine office visits in several primary care practices in the Southwest and Midwest regions of the United States. We coded the visit contents and the time spent on pain and other topics. Logistic regression and survival analyses examined the effects of time constraint, physician’s supportiveness, patient’s health, and demographic concordance. We found that discussion of pain occurred in 48% of visits. A median of 2.3 min was spent on addressing pain. The level of pain, physician’s supportiveness, and gender concordance were significantly associated with the odds of having a pain discussion. Time constraints and racial concordance significantly influenced the length of discussion.We conclude that despite repeated calls for addressing under-treatment for pain, only a limited amount of time is used to address pain among elderly patients. This phenomenon could contribute to the under-treatment of pain.     

No association between level of vitamin D and chronic low back pain in Swedish primary care: a cross-sectional case-control study

Objective: Assessment of vitamin D levels and deficiency status in individuals with chronic low back pain (CLBP) in a Swedish general population, compared with controls matched for sex and age.

Design: Cross-sectional case-control study.

Setting: Primary care, southern Sweden.

Subjects: Participants (n?=?44) with self-reported low back pain for at least 3 months and individually sex- and age-matched controls without a chronic pain condition (n?=?44), recruited from the general population by random letter of invitation.

Main outcome measure: Association between vitamin D level and CLBP when adjusting for possible confounders in a multivariate forward conditional logistic regression model.

Results: Mean S-25-hydroxyvitamin D levels were 81 and 80?nmol/L in the CLBP and control group, respectively. The prevalence of vitamin D deficiency was low and similar in the CLBP group and the control group. Vitamin D level was not associated with CLBP when potential confounders were taken into account.

Conclusions: No difference in vitamin D levels between participants with CLBP and matched controls could be demonstrated in the present sample. Assessment of vitamin D level and deficiency status may be of questionable value in the management of CLBP in primary care settings at similar latitudes, unless there are additional risk factors for deficiency or specific indicators of osteomalacia.

• Key Points

• Vitamin D deficiency is common and reported in many chronic pain conditions, including chronic low back pain (CLBP), but evidence for an association and causality is insufficient.

• The present study found no association between vitamin D levels and CLBP in a case-control sample of 44?+?44 individuals from the Swedish general population.

• Prevalence of vitamin D deficiency was low and comparable in individuals with CLBP and controls without chronic pain, matched for sex and age.

• Assessment of vitamin D status, for the purpose of finding and treating an underlying cause of pain, may be of limited value in the management of CLBP in primary care settings at similar latitudes.

     

The impact of chronic low back pain on older adults: a comparative study of patients and controls

Chronic low back pain (CLBP) is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free. Three hundred twenty cognitively intact participants (162 with moderate pain for 3 months, and 158 pain-free) underwent comprehensive assessment of pain severity, medical comorbidity (illnesses, body mass index, medications), severity of degenerative disc and facet disease, lumbar flexion, psychological constructs (self-efficacy, mood, overall mental health), and self-reported as well as performance-based physical function. Significant differences were ascertained for all 22 measures. Discriminant function analysis revealed that eight measures uniquely maximized the separation between the two groups (self-reported function with the Functional Status Index and the SF-36, performance-based function with repetitive trunk rotation and functional reach, mood with the Geriatric Depression Scale, comorbidity with the Cumulative Illness Rating Scale and BMI, and severity of degenerative disc disease). These results should help to guide investigators that perform studies of CLBP in older adults and practitioners that want an easily adaptable battery for use in clinical settings.     

Contributions of prognostic factors for poor outcome in primary care low back pain patients

Background: Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone. Aims: To determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors. Methods: Prospective cohort study of back pain patients (30–59 years) at five general practices in Staffordshire, UK (n =389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear‐avoidance; self‐rated health) were assessed for their association with disabling and limiting pain after 12‐months. The proportion of those with persistent problems whose outcome was related to each factor was calculated. Results: Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment (adjusted relative risk (RR) 4.2; 95% CI 2.0, 8.5) and high pain intensity (4.1; 1.7, 9.9). The largest proportions of persistent problems were related to high pain intensity (68%; 95% CI 27, 87%) and unemployment (64%; 33, 82%). Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self‐rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems. Conclusions: Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub‐groups for intervention.     

Listening to the body and talking to myself - the impact of chronic lower back pain: A qualitative study

Aims

The aim was to investigate peoples’ experiences of the impact of chronic low back pain.

Background

Chronic low back pain is a complex disorder with wide-ranging adverse consequences that can impact on people's lifestyles and self-image. It is also a condition that can sometimes be treated with some scepticism by health care providers and other people in the person's life. It has been suggested that further research into the subjective experience of chronic blow back pain is needed to develop a better understanding of its impact.

Design

This study is a qualitative analysis of semi-structured interviews with 64 participants identified as having chronic low back pain who were interviewed about the impact of the condition on their lives. The data were analysed using a method of inductive thematic analysis.

Findings

Four main themes were identified: the unpredictability of the pain, the need for vigilance, the externalization/objectification of the body and the alteration to sense of self.

Conclusion

Nurses have an important role to play in working with patients experiencing chronic low back pain to identify any patterns associated with exacerbations of the condition, validating their experiences of chronic low back pain and facilitating the accommodation of chronic low back pain into a more satisfying sense of self.     

Electromyography-biofeedback for chronic low back pain: A qualitative cohort study

Background and AimsSurface electromyography-biofeedback (sEMG-BF) may reduce the burden of CLBP by improving physical functioning, sleep, pain catastrophizing, anxiety, and depression. This qualitative study investigated the impact of weekly EMG-BF sessions on adults with CLBP.MethodsTwenty-six individuals with CLBP participated in telephone interviews after completing an 8-week virtual sEMG-BF intervention. Trained interviewers conducted the 10-to-15-minute semi-structured interviews to understand participants’ experience with the intervention. Common themes and subthemes were identified and analyzed using MAXQDA 2022 software.ResultsParticipants were predominantly middle-aged females (M = 45, range of 19 – 66) who have had exposure to utilizing conventional therapies such as physical therapy, chiropractor, and massage for the treatment of CLBP. This study focused on participants who reported their experience of the main outcome study which included perceived reductions in CLBP symptoms, including pain and stress, and positive effects on self-awareness and sleep. Three overarching themes emerged and were further divided into subthemes: participants’ involvement (virtual experience, accessibility of device, and future recommendations) perceived benefits (participants gained awareness, recommendations for future treatment, met expectations, and implementation), and desire for flexibility (obstacles and COVID-19 Impact). No adverse effects were reported by any of the participants within the study.ConclusionsBoth physical and psychological improvements were reported by participants following an sEMG-BF intervention. Specific implementation procedures and critical barriers were identified. In particular, the ability to receive care for CLBP during the COVID-19 pandemic was important to participants.     

The impact of low back pain on work: A study in primary care consulters

Background: The cost of low back pain (LBP) to employers is high, with an estimated £9090 million lost in the United Kingdom in 1998. Economic analysis of LBP has focused on work absence among the employed. There is little research characterising individuals who report reduced duties or who are not in employment because of LBP. Aims: To compare the health related characteristics of primary care LBP consulters reporting usual employment, reduced duties, sick leave and non‐employment as a result of LBP. Methods: Prospective cohort study recruiting LBP consulters aged 30–59 years of age from five general practices in North Staffordshire. Results: Nine hundred and thirty‐five participants completed the baseline phase, 65% were in employment and 35% were not in employment. Of the employed participants over 1 in 10 (11%) were undertaking reduced duties and almost one‐fifth were reporting sick leave (22%). Furthermore, 37% of non‐employed consulters reported that LBP was the reason for non‐employment. Significant differences at baseline in socioeconomic status, self‐rated health, anxiety, depression and disability were found between those undertaking their usual job, those on reduced duties and those on sickness absence due to LBP, with those participants further removed from the work force reporting worse health across all measures. Significant differences were also found in self‐rated health between those not working due to LBP and those not working for other reasons, with participants not working due to LBP reporting worse self‐rated health. At follow‐up, work status was found to be relatively stable. Conclusion: These findings indicate that the economic impact of LBP may be higher than previously estimated when data on reduced duties is combined with work absence. The additional impact of unemployment due to LBP should also be included in future assessments of the impact of LBP on the workforce.     

Conceptual overlap of psychological constructs in low back pain

The biopsychosocial model is increasingly accepted in low back pain (LBP) research and clinical practice. In order to assess the role of psychological factors in the development and persistence of pain, a wide array of measures has been developed. Yet there is likely to be considerable conceptual overlap between such measures, and consequently, a lack of clarity about the importance of psychological factors. The aims of this study were to investigate the extent of any such overlap. An observational cohort study of 1591 LBP patients consulting in primary care completed data on a range of psychological instruments. Exploratory and confirmatory factor analyses (EFA and CFA, respectively) were carried out at the subscale level (n = 20) to investigate factor structure. The influences of the derived factors on clinical outcomes (pain intensity and self-reported disability) were then tested using linear regression. EFA yielded 4 factors, termed “Pain-related distress,” “Cognitive coping,” “Causal beliefs,” and “Perceptions of the future,” which accounted for 65.5% of the variance. CFA confirmed the validity of these factors models. The pain-related distress factor was found to have the strongest association to LBP patients’ outcomes, accounting for 34.6% of the variance in pain intensity, and 51.1% of the variance in disability. Results confirmed that considerable overlap exists in psychological measures commonly used in LBP research. Most measures tap into patients’ emotional distress. These findings help us to understand how psychological constructs relate together; implications for future research and clinical practice are discussed.     

Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines?

ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence‐based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non‐spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Intersegmental kinematic analysis of lumbar spine by functional radiography between two subgroups of patients with chronic low back pain

IntroductionKinematic deficits such as fault in joint accessory motion is one of the most important contributing factors for developing the movement impairment in the lumbar spine. Functional radiography is accessible method for detecting the artherokinematic disorders. The aim of this study was to compare lumbar spine intersegmental motion between low back pain (LBP) subgroups of movement system impairment (MSI) model by functional radiography.Materials and methods20 subjects with chronic LBP in two subgroups of the MSI model (Rotation with Flexion and Rotation with Extension) participated in this study. Five x-rays were taken in different positions. Intersegmental linear translation and angular rotation of the lumbar segments were calculated.ResultsIn the Rotation with Extension subgroup, the translation and rotation values of the L3-4 segment from full to full position were significantly more than their values in the Rotation with Flexion subgroup ((mean difference = −1.69 (mm) P = 0.01), (mean difference = −3.80 (mm) P = 0.02) respectively). The translation of L2-3 segment from the neutral to the mid-flexion position was significantly greater in the Rotation with Flexion subgroup compared to the Rotation with Extension subgroup (mean difference = 1.12 (mm) P = 0.04). cumulative intersegmental angular rotation of all lumbar segments from mid to mid position was greater in the Rotation with Flexion subgroup compared to the Rotation with Extension subgroup (P = 0.03).ConclusionChanges in intersegmental translation and angular rotation of lumbar segments in subgroups of patients with LBP may be important contributing factors that induce direction specific lumbar spine loads and contribute to the development or persistence of LBP problems.     

Superficial temperature and pain tolerance in patients with chronic low back pain

IntroductionLow back pain is a common and very prevalent disease and can impose limitations that negatively impact patients. The objective of this study was to verify and compare the association between lumbar superficial temperature and pressure pain tolerance thresholds in individuals with chronic nonspecific low back pain and healthy controls.MethodsThis was a cross-sectional observational study involving 38 individuals with nonspecific chronic low back pain and 19 healthy controls. Volunteers underwent thermographic (infrared sensor), pain perception (visual analog scale), and pressure pain tolerance thresholds (algometry) evaluations in the right and left paravertebral muscles and L4-L5 ligament.ResultsA lower tolerance to pressure pain was found in patients compared to controls at all evaluated sites (p ≤ 0.003). Superficial temperature was significantly higher in the sites evaluated in the low back pain group (p < 0.001). In patients with low back pain, pain perception was weakly and inversely correlated with pressure pain tolerance (r = -0.31; p = 0.05) and moderately correlated to the temperature of the evaluated sites (r = 0.51 to 0.59, p ≤ 0.001). Also, an inverse and weak to moderate association was observed between pressure pain tolerance thresholds and temperature in patients only (r = -0.36 to −0.49; p ≤ 0.02).ConclusionIndividuals with low back pain have lower pressure pain tolerance thresholds and higher superficial temperature in the lumbar region when compared to healthy individuals. The associations observed show that the higher the pain perception, the lower the pain tolerance and the higher the superficial temperature in the lumbar region. Also, the higher the temperature, the lower the pain tolerance.     

慢性腰背痛病变的相关CT影像分析

目的探讨慢性腰背痛病变的相关CT影像的临床应用价值。方法对164例慢性腰背痛患者经CT诊断或手术证实或随访后查明病因者的CT资料进行回顾性分析。结果164例中椎间盘退变致椎间盘程度不等膨出148例,占90.24%:椎间盘突出129例,占78.66%;骨性椎管狭窄33例,占20.12%;退行性腰椎滑脱14例,占8.5%;后纵韧带骨化或钙化26例,占15.85%;黄韧带肥厚22例,占13.41%。结论腰椎间盘病变是引起慢性腰背痛的主要原因,具有典型的CT影像改变,椎管狭窄或侧隐窝狭窄,后纵韧带骨化或钙化也是引起慢性腰背痛的原因之一,正确分析其CT影像特征,对于指导临床治疗,具有重要的意义。     

Using discrete choice experiments to inform randomised controlled trials: an application to chronic low back pain management in primary care

Pain Management Programmes (PMPs) are a multi‐disciplinary approach to the management of chronic low back pain (CLBP). Notwithstanding evidence of effectiveness, successful take‐up of programmes requires acceptability to patients. We used a discrete choice experiment to investigate patient preferences for alternative PMPs for managing CLBP in primary care. Specifically, we estimated the probability of uptake of alternative configurations of PMPs. Potential attributes and associated levels influencing take‐up were identified through a systematic literature review, survey of current PMPs, expert consultation, and focus groups. Five attributes were included: content; provider; schedule; group size; and travel time to clinic. Four hundred and fourteen questionnaires were mailed to patients attending clinics and 124 questionnaires were returned suitable for analysis. Method of delivery influenced probability of take‐up, with small group sizes and low intensity programmes over a prolonged period increasing the probabilities. Travel time was also important. However, providers and contents of PMPs were not main drivers of preferences, though those with more severe pain did prefer PMPs provided by more specialists. Probability of take‐up increases when PMPs better reflect patient preferences. Given preferences, resource constraints, and evidence on clinical outcomes of alternative configurations it is suggested more resource‐intensive PMPs be reserved for those with the most severe and disabling pain and less intensive programmes delivered over a longer time period in smaller groups for those with less severe pain. These findings can inform future randomised trials to evaluate acceptable PMPs in primary care.     

Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurse-led service in general practice

OBJECTIVES: (1) To determine the acceptability of the Royal College of General Practitioner Guidelines to small samples of nurses, General Practitioners and acute back pain patients, (2) to determine what additional roles for nurses in the management of acute back pain in primary care might be acceptable to these samples, (3) to evaluate the responses of General Practitioners, nurses and patients to a suggested service model based on the RCGP Guidelines, (4) to identify opportunities for and barriers to the further development of such models and to obtain the appraisal of the above by an external group of assessors. METHODOLOGY: Using a qualitative design the pilot study included Primary Care (General Practitioners, Practice Nurses and Patients) with the main outcome measures as: appraisal questionnaires (for RCGP Guideline), qualitative content analysis of focus group narratives, and appraisal of process and outcomes by an external panel. RESULTS: Attitudes towards the RCGP guidelines were positive, but professionals and patients alike did not think their recommendations could be implemented with the current service provision in primary care. There was criticism by professionals of the capacity for a nurse-led service within practices. Access to chiropractors, osteopaths and/or specialist physiotherapists in National Health Service primary care was raised as a need by both groups. All members of the Advisory Panel approved the processes for the recruitment of participants, focus group questions and analysis. DISCUSSION: Barriers to implementation of the RCGP Guideline and to a nurse-led acute back pain service in general practice, were illustrated. These mainly relate to grossly inadequate capacity to deal with multidimensional patient needs, allowing progression to chronic pain states and much higher health care costs. There was a strong desire to include a different group of professionals in primary care. We recommend a local needs assessment and consideration of a national strategy for the implementation of the RCGP Guideline in primary care.