Management of back and neck pain: who seeks care from physical therapists?

BACKGROUND AND PURPOSE: Little information is available on factors associated with physical therapist use by people with back or neck pain. Identifying the characteristics of people who seek care from physical therapists is a useful first step in determining whether there is appropriate use of physical therapy services. The purpose of this study was to identify factors associated with physical therapist use by people with back or neck pain. SUBJECTS: The subjects were 29,049 people who had back pain or neck pain, or both, and who were seen for an initial evaluation at 1 of 21 US spine care centers. Each subject and evaluating physician completed a written survey at the time of the initial evaluation. METHODS: Multiple logistic regression analyses were conducted to identify factors associated with physical therapist use. RESULTS: Several measures of health and illness severity were associated with physical therapist use. Age and being male were negatively associated with physical therapist use. Education level, having workers' compensation coverage, and being in litigation were positively associated with physical therapist use. Physical therapist use also varied by previous physician use and census region. DISCUSSION AND CONCLUSION: The results suggest that variations in physical therapist use are associated with factors other than health and illness severity. The results also suggest that people who would benefit from physical therapy may not be receiving it or that people who would not benefit from physical therapy are receiving it, or both.     

Advice and care for headaches: who seeks it, who gives it?

Using data from a cross-sectional survey and a prospective record linkage study the aims of this study were to: (i) determine sources of advice and care for headaches in a population survey of adults, and (ii) investigate prospectively the influences of headaches on general practice consultation in a 12-month follow-up of the responders to the population survey. A population based cross-sectional survey was mailed to 4885 adults (aged > or = 18 years) with an adjusted response rate of 56% (n = 2662). The main outcome measures of interest were (i) self-report advice and care-seeking in the survey (ii) consultation with general practitioner for headache and for other conditions in 12-month period subsequent to the survey. Reporting a recent GP consultation for headache was associated with younger age (mean: 46 vs 48 years), female gender (68% vs 60%), and greater headache severity as measured by frequency, pain, and associated disability. The commonest sources of advice and care in the past were GPs (27%), opticians (21%), and pharmacists (8%). Consultations for headache were not common in the 12-months following the survey (n = 144); however, those reporting a recent headache were almost 4 times more likely to consult subsequently with a headache than those not (relative risk; 95% CI: 3.7; 1.9, 7.0). Recent reporting of headache was also associated with an increased risk of consulting for mental disorders (1.7; 1.2, 2.6), diseases of the digestive (1.6; 1.1, 2.3) and respiratory system (1.4; 1.1, 1.8), and a decreased risk of consulting for circulatory diseases (0.8; 0.7, 1.0). Only a minority of headache sufferers consult their GP, regardless of severity, with opticians and pharmacists being other important sources of information. Headache appears to have an additional impact upon GP workload through increased rates of consultations for nonheadache conditions amongst headache sufferers. The interesting findings regarding rates of consultation for digestive and circulatory conditions amongst headache sufferers may be linked to the use of headache medication.     

Exercise and chronic low back pain: what works?

The aim of this review was to investigate current evidence for the type and quality of exercise being offered to chronic low back pain (CLBP) patients, within randomised controlled trials (RCTs), and to assess how treatment outcomes are being measured. A two-fold methodological approach was adopted: a methodological assessment identified RCTs of 'medium' or 'high' methodological quality. Exercise quality was subsequently assessed according to the predominant exercise used. Outcome measures were analysed based on current recommendations. Fifty-four relevant RCTs were identified, of which 51 were scored for methodological quality. Sixteen RCTs involving 1730 patients qualified for inclusion in this review based upon their methodological quality, and chronicity of symptoms; exercise had a positive effect in all 16 trials. Twelve out of 16 programmes incorporated strengthening exercise, of which 10 maintained their positive results at follow-up. Supervision and adequate compliance were common aspects of trials. A wide variety of outcome measures were used. Outcome measures did not adequately represent the guidelines for impairment, activity and participation, and impairment measures were over-represented at the expense of others. Despite the variety offered, exercise has a positive effect on CLBP patients, and results are largely maintained at follow-up. Strengthening is a common component of exercise programmes, however, the role of exercise co-interventions must not be overlooked. More high quality trials are needed to accurately assess the role of supervision and follow-up, together with the use of more appropriate outcome measures.     

Rational treatment of low back trouble?

The treatment of low back trouble remains, with rare exceptions, largely empirical. The scientific validation of the various available therapeutic options ultimately rests in controlled clinical trials. This paper discusses the problems inherent in the construction of such trials, and suggests that resources should be directed to the identification of clinical syndromes of predictable natural history. It is recommended that future trials of therapeutic efficacy be considered in relation to the natural history of back trouble.     

Impaired trunk muscle function in sub-acute neck pain: etiologic in the subsequent development of low back pain?

Low back pain (LBP) and neck pain are associated with dysfunction of the trunk and neck muscles, respectively, and may involve common or similar mechanisms. In both cases, dysfunction may compromise spinal control. Anecdotally, neck pain patients commonly develop LBP. This study investigated the possibility that trunk muscle function is compromised in neck pain patients and that compromised trunk muscle function is associated with increased risk of LBP. Fifty-four neck pain patients and 52 controls were assessed on an abdominal drawing-in task (ADIT) and on self-report tests. Performance on the ADIT was able to detect neck pain patients with 85% sensitivity and 73% specificity. Catastrophizing and McGill pain questionnaire (affective) scores were higher in patients with an abnormal task response than in patients with an uncertain or normal response, although the self-report data did not predict task performance. Fifty subjects from each group were contactable by telephone at 2 years. They were asked whether they had experienced persistent or recurrent LBP since the assessment. Subjects (patients and controls) who obtained an abnormal response on the ADIT were 3 to 6 times more likely to develop persistent or recurrent LBP than those who obtained an uncertain or normal response. ADIT performance was the main predictor of development of LBP in patients. The results suggest that reduced voluntary trunk muscle control in neck pain patients is associated with an increased risk of developing LBP.     

Who’s in charge? Challenges in evaluating quality of primary care treatment for low back pain

Rationale and objectives Low back pain (LBP) is a common condition with frequent health care visits and work disability. Quality improvement efforts in primary care focused on guidelines adherence, provider selection and education, and feedback on appropriateness of care. Such efforts can only succeed if a health care provider is in charge of care over a substantial period. This study was conducted to provide insights about actual patterns of provider involvement in LBP care and implications for quality evaluation. Methods Established primary care patients with occupational LBP and health care covered by a workers’ compensation insurer were selected. Primary care physician (PCP) involvement was examined relative to overall health care utilization. Four methods of classifying PCP involvement were used to assess the association between PCP involvement and health care and work disability outcomes over a 2‐year follow‐up period. Results Primary care physician was rarely the sole provider during episodes of occupational LBP. PCP was the initial non‐emergency room provider in 55% of cases, and was the most prevalent provider during at least one episode of care in 45% of cases. Different methods of classification led to different conclusions about the association between PCP involvement and work disability or number of health care visits. Multiple providers were involved throughout the clinical course of the small number of cases that accounted for most of the health care visits and work disability; in these cases, the role of PCP in care was difficult to determine. Conclusions Administrative data alone are adequate for provider comparisons only in relatively simple cases. Provider comparisons based on initial treating provider likely overstate the importance of early care, particularly in more complex cases. For LBP, quality improvement models based on PCP‐directed interventions or reinforcing guideline adherence may not impact outcomes. A patient‐centred model may be necessary to achieve outcome improvements.     

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.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose. To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods. A community-based longitudinal study. All inhabitants aged 22 - 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to 'localized LBP' and to 'LBP with additional sites of BP'. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results. Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported 'localized LBP' and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported 'Generalized BP' comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported 'localized LBP'. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions. Subjects with 'localized LBP' presented healthier lifestyle than subjects with 'Generalized BP'. The latter experienced higher degree of pain measures. It seems that 'Generalized BP' is not a different entity than 'localized LBP' but rather a more severe one.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose.?To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods.?A community-based longitudinal study. All inhabitants aged 22 – 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to ‘localized LBP’ and to ‘LBP with additional sites of BP’. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results.?Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported ‘localized LBP’ and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported ‘Generalized BP’ comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported ‘localized LBP’. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions.?Subjects with ‘localized LBP’ presented healthier lifestyle than subjects with ‘Generalized BP’. The latter experienced higher degree of pain measures. It seems that ‘Generalized BP’ is not a different entity than ‘localized LBP’ but rather a more severe one.     

Researching low back pain? An overview of the pitfalls

Abstract

Low back pain (LBP) is one of the most common causes of disability and work loss in Western society, yet there exists little consensus about its most effective management. Undoubtedly, one of the greatest contributing factors to this confusion has been the inadequate and conflicting research base upon which clinical management decisions are made. This paper is aimed at discussing the common problems inherent within low back pain research, identifying some avoidable pitfalls and many unanswered questions. Some helpful directions for further research, including improvements in the research methodology, are also included. Finally, the review considers the physiotherapist's role in research of the management of LBP.     

Can standing back extension exercise improve or prevent low back pain in Japanese care workers?

BackgroundWe suggested a standing back extension exercise ‘One Stretch’ based on the McKenzie method, to examine the ability to improve or prevent low back pain (LBP) in Japanese care workers.MethodsWe conducted a single-center, non-randomized, controlled study in Japan. Care workers in an intervention group received an exercise manual and a 30-minute seminar on LBP and were encouraged with a group approach, while care workers in a control group were given only the manual. All care workers answered questionnaires at the baseline and end of a 1-year study period. The subjective improvement of LBP and compliance with the exercise were evaluated.ResultsIn all, 64 workers in the intervention group and 72 in the control group participated in this study. More care workers in the intervention group exercised regularly and improved or prevented LBP than in the control group (P = 0·003 and P<0·0001, respectively). In the intervention group, none had a first medical consultation or were absent from disability for LBP by the end of the study period.ConclusionThe exercise ‘One Stretch’ would be effective to improve or prevent LBP in care workers. Our group approach would lead to better compliance with the exercise.