How effective is the acute low back pain screening questionnaire for predicting 1-year follow-up in patients with low back pain?

OBJECTIVES: The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain. STUDY DESIGN: A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective. PATIENTS: Ninety patients (76% response rate) returned the completed questionnaire package. RESULTS: The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation). CONCLUSIONS: The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.     

Why do patients with low back pain seek care at emergency department? A cross-sectional study

BackgroundIt is unclear why patients with low back pain seek care in emergency departments.ObjectivesWe aim to describe the demographic, physical, and psychological characteristics, and reasons for seeking care at emergency departments due to an episode of low back pain.MethodsThis is a cross-sectional study conducted in an emergency department of a public hospital in São Paulo, Brazil, from September 2018 to May 2019. All patients who presented with a new episode of low back pain as the main complaint for seeking care at the emergency department on regular weekdays were invited to participate. We collected data on sociodemographic characteristics, general health characteristics, psychosocial risk factors, and reasons for visiting the emergency department.ResultsA total of 200 patients participated. We observed that most patients (68%) were women, with a mean age of 55 years, and who had previous episodes of low back pain (86%). Most patients went to the emergency department because they were worried about their pain (78%) and because they could not control their pain (73%). Patients also choose the emergency department because it is always available, it is free, and provided them good care.ConclusionsMost patients with low back pain seek care at emergency departments because they were worried about their pain and because the department is always open and does not require appointment. Understanding these reasons is an important step for the implementation of future public policies to make health care more efficient, to reduce unnecessary expenses and to avoid low-value care.     

Illness perceptions of low back pain patients in primary care: what are they, do they change and are they associated with outcome?

We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ-R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ-R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.     

Emergency department use: Is frequent use associated with a lack of primary care provider?

Objective

To determine if having a primary care provider is an important factor in frequency of emergency department (ED) use.

Design

Analysis of a central computerized health network database.

Setting

Three EDs in southern New Brunswick.

Participants

All ED visits during 1 calendar year to an urban regional hospital (URH), an urban urgent care centre (UCC), and a rural community hospital (RCH) were captured.

Main outcome measures

Patients with and without listed primary care providers were compared in terms of number of visits to the ED. A logistic regression analysis was used to determine factors predictive of frequent attendance.

Results

In total, 48 505, 41 004, and 27 900 visits were made to the URH, UCC, and RCH, respectively, in 2009. The proportion of patients with listed primary care providers was 36.6% for the URH, 37.1% for the UCC, and 89.4% for the RCH. Among ED patients at all sites, frequent attenders (4 or more visits to an ED in 1 year) were significantly more likely (59.6% vs 45.1%, P < .001) to have listed primary care providers. Other factors that predicted frequent use included attendance at a rural ED, female sex, and older age.

Conclusion

This study characterizes attendance rates for 3 EDs in southern New Brunswick. Our findings highlight interesting differences between urban and rural ED populations, and suggest that frequent use of the ED might not be related to lack of a listed primary care provider.     

Health care providers communicate less well with patients with chronic low back pain – A study of encounters at a back pain clinic in Denmark

We aimed to study the quality of communication between health care providers and patients with low back pain with emphasis on information giving in a back pain clinic, including if characteristics of patients could be associated with communication quality. We videotaped 79 encounters in which 21 providers informed patients about the results of magnetic resonance imaging of the back. Background information about the patients was collected by questionnaires and interview after the encounter. Videotapes were analysed with the Four Habits Coding Scheme (4HCS) in which higher scores mean better communication. There were strong negative correlations between 4HCS scores and the duration of back pain, and patient age. The results were significant for all professional subgroups (doctors, physiotherapists, chiropractors). Communication quality in encounters with back pain patients is worse, the longer the patient has suffered pain. Poor communication quality also seems to be associated with patients being older.     

Do illness perceptions predict pain-related disability and mood in chronic orofacial pain patients? A 6-month follow-up study

In our study, we investigated the predictive value of illness beliefs as measured by the revised illness perception questionnaire (IPQ‐R) in the context of other clinical predictors in patients with chronic orofacial pain over a 6‐month follow‐up period. Consecutive patients (152) referred to the interdisciplinary orofacial pain service at the Centre for Dental and Oral Medicine and Cranio‐Maxillofacial Surgery, University of Zurich received questionnaires to assess pain and pain‐related disability, anxiety, depression as well as physical and mental quality of life at three time points: prior to treatment, 3 and 6 months after beginning of treatment. Results: significant improvement was found over time for all outcome measures except mental quality of life. Results of the regression analysis indicated that believing pain could have serious consequences on one's life (IPQ subscale consequences) is one of the most important predictors for treatment outcome. The belief in low personal control and in a chronic timeline is also shown to be predictive for outcome, though explaining a smaller proportion of variance. These results provided evidence that beliefs about pain are important predictors for treatment outcome even when controlled for pain and mood. They therefore need to be considered in the management of patients with chronic orofacial pain. Assessing patients’ illness beliefs can provide essential information on these important psychological determinants of adjustment to chronic pain and may be specific targets for individualised treatment approaches.     

Do medical factors predict disability in older adults with persistent low back pain?

Persistent low back pain (LBP) is one of the most common and challenging persistent pain conditions in older adults. Medical comorbidity also is common in these individuals, but its impact on disability has not been examined. The purpose of this study was, using a cross-sectional design, to examine the functional impact of pain-related and general medical comorbidity on 100 community dwelling older adults (mean age 74.3) with persistent mechanical LBP. Subjects received a structured history and physical examination, lumbosacral spine X-rays, and standardized tests of physical function. Pain-related variables included intensity, duration, extent, and lumbar motion-induced pain. General medical variables included age, comorbidity, number of medications, depressive symptoms, back range of motion, body mass index, and severity of radiographic pathology. Function/disability measures included self-reported disability, gait speed, and mean number of static lifts and amount of work performed during a dynamic lifting task. Structural equation modeling was used to evaluate the influence of pain and medical variables on function/disability. The overall regression model indicated pain and medical variables were significantly associated with function/disability measures (R2=0.45, P<0.01). Individual regression coefficients, however, indicated that only pain duration (r=-0.36, P<0.05) and pain severity (r=0.37, P<0.001) were significantly associated with function/disability. Despite the prevalence of medical co-morbidities in older PLBP subjects, they appear to be of limited utility in understanding level of disability. These findings also underscore the need to optimize pain treatment in independent older adults to optimize physical function and delay the onset of dependent living status.     

Are the changes in postural control associated with low back pain caused by pain interference?

BACKGROUND: Voluntary limb movements are associated with involuntary and automatic postural adjustments of the trunk muscles. These postural adjustments occur prior to movement and prevent unwanted perturbation of the trunk. In low back pain, postural adjustments of the trunk muscles are altered such that the deep trunk muscles are consistently delayed and the superficial trunk muscles are sometimes augmented. This alteration of postural adjustments may reflect disruption of normal postural control imparted by reduced central nervous system resources available during pain, so-called "pain interference," or reflect adoption of an alternate postural adjustment strategy. METHODS: We aimed to clarify this by recording electromyographic activity of the upper (obliquus externus) and lower (transversus abdominis/obliquus internus) abdominal muscles during voluntary arm movements that were coupled with painful cutaneous stimulation at the low back. If the effect of pain on postural adjustments is caused by pain interference, it should be greatest at the onset of the stimulus, should habituate with repeated exposure, and be absent immediately when the threat of pain is removed. Sixteen patients performed 30 forward movements of the right arm in response to a visual cue (control). Seventy trials were then conducted in which arm movement was coupled with pain ("pain trials") and then a further 70 trials were conducted without the pain stimulus ("no pain trials"). RESULTS: There was a gradual and increasing delay of transversus abdominis/obliquus internus electromyograph and augmentation of obliquus externus during the pain trials, both of which gradually returned to control values during the no pain trials. CONCLUSION: The results suggest that altered postural adjustments of the trunk muscles during pain are not caused by pain interference but are likely to reflect development and adoption of an alternate postural adjustment strategy, which may serve to limit the amplitude and velocity of trunk excursion caused by arm movement.     

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 lumbar repositioning errors larger among patients with chronic low back pain compared with asymptomatic subjects?

OBJECTIVE: To resolve the debate over whether lumbar repositioning acuity is reduced in patients with chronic low back pain (CLBP) by using a study design and methodology to minimize the effects of potential confounders. DESIGN: A single-blinded, controlled, multigroup comparative study. SETTING: Vocational rehabilitation center. PARTICIPANTS: Ninety-two patients with CLBP, divided into subgroups based on severity of symptoms and diagnostic characteristics. An age- and sex-matched group (n=31) of healthy subjects were the control. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We measured repositioning errors (variable, constant) at 3 positions of the lumbar spine. Subjects were guided to a sitting target posture and asked to perform lumbar flexion before reproducing the target posture. Self-assessed pain, self-efficacy, and functional ability were addressed through questionnaires. RESULTS: There were no differences in repositioning errors between the patients with CLBP or the subgroups of patients and the control group. We found only weak correlations between the repositioning errors and the self-reported data on functional disability, self-efficacy, and pain. CONCLUSIONS: We suggest that sensorimotor dysfunctions in CLBP should be evaluated with methods other than repositioning tests in order to generate data relevant to the development of rational diagnostic methods and rehabilitation programs.     

Is physical functioning influenced by activity-related pain prediction and fear of movement in patients with subacute low back pain?

In patients with low back pain (LBP), physical functioning may be negatively influenced by both expectations on pain and pain-related fear. It is unclear whether these factors influence both physical functioning in the laboratory as well as in daily life. The aim of this study was to test if a combination of persistent overprediction of pain and fear of movement predicts lab-based performance and whether these factors are relevant for predicting daily-life functioning.One hundred and twenty four patients with subacute LBP performed a laboratory-based performance test twice. Maximum voluntary contraction, pre-test pain expectations, perceived pain during testing and fear of movement were measured. Patients were classified as correct or incorrect predictors, based on differences between expected and perceived pain on the second attempt. Next, physical activity in daily life was measured with an accelerometer.In explaining physical functioning in the laboratory and in daily life an interaction effect between fear and pain prediction was observed. In overpredictors, fear was negatively associated with lab-based performance (β = ?0.48, p < 0.01), and positively associated with daily-life functioning (β = 0.50, p < 0.05). No significant association between fear and performance or daily-life functioning were found in correct predictors.In contrast to correct predictors, in overpredictors lab-based performance and daily-life functioning was additionally explained by fear of movement. Thus it appears that fear of movement is only predictive of performance in patients with LBP who simultaneously overpredict the consequences of movements in terms of painfulness.     

Which psychosocial factors are related to severe pain and functional limitation in patients with low back pain?: Psychosocial factors related to severe low back pain

BackgroundLow back pain (LBP) is a global public health issue. Psychosocial factors are linked to LBP. However, there is a lack of knowledge about the relation of psychosocial factors to clinical outcomes of patients with severe LBP.ObjectiveTo investigate the relationship between specific psychosocial factors with severe pain and functional limitation of patients with LBP.MethodsA cross-sectional study of 472 participants with LBP was conducted. Participants completed self-reported questionnaires, including psychosocial factors, characteristics of pain, and functional limitations. Two multivariable logistic regression models were performed with severe pain intensity (≥ 7 out of 10) and functional limitation (≥ 7 out of 10) (dependent variables) and 15 psychosocial factors (independent variables).ResultsOne hundred twenty-five (26.5%) participants had severe LBP. Patients with catastrophising symptoms were 2.21 [95%Confidence Interval (CI): 1.30, 3.77] times more likely to have severe pain and 2.72 (95%CI: 1.75, 4.23) times more likely to have severe functional limitation than patients without catastrophising symptoms. Patients with maladaptive beliefs about rest were 2.75 (95%CI: 1.37, 5.52) times more likely to present with severe pain and 1.72 (95%CI: 1.04, 2.83) times more likely to have severe functional limitation. Patients with kinesiophobia were 3.34 (95%CI: 1.36, 8.24) times more likely to present with severe pain, and patients with social isolation were 1.98 (95%CI: 1.25, 3.14) times more likely to have severe functional limitation.ConclusionCatastrophising, kinesiophobia, maladaptive beliefs about rest, and social isolation are related to unfavourable clinical outcomes of patients with LBP.     

Is there evidence to use kinematic/kinetic measures clinically in low back pain patients? A systematic review

BackgroundCurrently, there is a widespread reliance on self-reported questionnaires to assess low back pain patients. However, it has been suggested that objective measures of low back pain patients' functional status should be used to aid clinical assessment. The aim of this study is to systematically review which kinematic /kinetic parameters have been used to assess low back pain patients against healthy controls and to propose clinical kinematic/kinetic measures.MethodsPubMed, Embase and Scopus databases were searched for relevant studies. Reference lists of selected studies and hand searches were performed. Studies had to compare people with and without non-specific low back pain while performing functional tasks and report body segment/joint kinematic and/or kinetic data. Two reviewers independently identified relevant papers.FindingsSixty-two studies were included. Common biases identified were lack of assessor blinding and sample size calculation, use of samples of convenience, and poor experimental protocol standardization. Studies had small sample sizes. Range of motion maneuvers were the main task performed (33/62). Kinematic/kinetic data of different individual or combination of body segments/joints were reported among the studies, commonest was to assess the hip joint and lumbar segment motion (13/62). Only one study described full body movement. The most commonly reported outcome was range of motion. Statistically significant differences between controls and low back pain groups were reported for different outcomes among the studies. Moreover, when the same outcome was reported disagreements were noted.InterpretationThe literature to date offers limited and inconsistent evidence of kinematic/kinetic measures in low back pain patients that could be used clinically.     

Do patients with low back pain and central sensitization have differences in physical fitness?

IntroductionLow back pain is one of the main musculoskeletal complaints, and may be associated with central sensitization (CS). The physical capacity of patients with low back pain and CS is not very clear.MethodsA cross-sectional study, with 92 patients divided into two groups according to their risk of CS. The patient's physical capacity ability was assessed using 6-min walking test (6MWT); timed up and go test (TUG); sit-to-stand test (STS); and trunk flexor, extensor and side-bridge endurance tests. In addition, participants completed questionnaires regarding disability, kinesiophobia, catastrophization and quality of life.ResultsThe group with a higher risk of CS had worst performance in the 6MWT (U = 1248; p < 0.001), STS (t(83) = 3.63; p < 0.001) and TUG (t(83) = −4.46; p < 0.001). Similarly, endurance in the right (U = 1453,5; p = 0,002) and left (U = 1467; p = 0,003) side-bridge tests, and the trunk extensor test (U = 1546; p = 0,003) was worse. Disability (U = 1272; p < 0.001), physical capacity kinesiophobia (t(83) = -2.21; p = 0.03) work kinesiophobia (U = 1452; p < 0.001), and pain catastrophization (t(77.57) = -5.03; p < 0.001), were also higher in the group with a higher risk of CS. Quality of life indicators were worse in the higher risk group for all domains of the EQ-5D-3L: Mobility (X²(1) = 12.92; p < 0.001), self-care (X²(1) = 16,3; p = 0,012), usual activities (X²(2) = 14.14; p = 0.001), pain (X²(2) = 27.79; p < 0.001), anxiety and depression (X²(2) = 15.05; p = 0.001).ConclusionPatients with low back pain and higher risks of CS appear to show lower performance in physical capacity tests, higher rates of disability, kinesiophobia, pain catastrophization, and lower quality of life compared to those with lower risks of CS.     

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.