Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.Design Cohort study with one year follow-up.Setting Primary care clinics in Sydney, Australia.Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.     

What lies beyond the pain? A case report

The majority of people have back pain at some point in their lives and most are cured without any intervention. However, some patients develop chronic back pain and persistent disability. There is strong evidence that psychological factors significantly correlate with the development of chronic back pain. Back pain has also emerged as the strongest predictor of major depression. Assessing and treating patients in a manner that integrates psychosocial and biological aspects of care is the essence of excellent family medicine. This case illustrates the importance for primary care physicians of screening for depression and other psychosocial factors in assessing patients with persistent back pain.     

Prevalence of myofascial pain in general internal medicine practice.

Myofascial pain is a regional pain syndrome characterized in part by a trigger point in a taut band of skeletal muscle and its associated referred pain. We examined a series of 172 patients presenting to a university primary care general internal medicine practice. Of 54 patients whose reason for a visit included pain, 16 (30%) satisfied criteria for a clinical diagnosis of myofascial pain. These patients were similar in age and sex to other patients with pain, and the frequency of pain as a primary complaint was similar for myofascial pain as compared with other reasons for pain. The usual intensity of myofascial pain as assessed by a visual analog scale was high, comparable to or possibly greater than pain due to other causes. Patients with upper body pain were more likely to have myofascial pain than patients with pain located elsewhere. Physicians rarely recognized the myofascial pain syndrome. Commonly applied therapies for myofascial pain provided substantial abrupt reduction in pain intensity. The prevalence and severity of myofascial pain in this university internal medicine setting suggest that regional myofascial pain may be an important cause of pain complaints in the practice of general internal medicine.     

Exploring How Pain Leads to Productivity Loss in Primary Care Consulters for Osteoarthritis: A Prospective Cohort Study

Objective

Osteoarthritis pain has become a leading cause of decreased productivity and work disability in older workers, a major concern in primary care. How osteoarthritis pain leads to decreased productivity at work is unclear; the aim of this study was to elucidate causal mechanisms and thus identify potential opportunities for intervention.

Methods

Population-based prospective cohort study of primary care consulters with osteoarthritis. Path analysis was used to test proposed mechanisms by examining the association between pain at baseline, and onset of work productivity loss at three years for mediation by physical limitation, depression, poor sleep and poor coping mechanisms.

Results

High pain intensity was associated with onset of work productivity loss (Adjusted Odds Ratio 2.5; 95%CI 1.3, 4.8). About half of the effect of pain on work productivity was a direct effect, and half was mediated by the impact of pain on physical function. Depression, poor sleep quality and poor coping did not mediate the association between high pain intensity and onset of work productivity loss.

Conclusions

As pain is a major cause of work productivity loss, results suggest that decreasing pain should be a major focus. However, successfully improving function may have an indirect effect by decreasing the impact of pain on work productivity, especially important as significant pain reduction is often difficult to achieve. Although depression, sleep problems, and coping strategies may be directly related to work productivity loss, addressing these issues may not have much effect on the significant impact of pain on work productivity.     

Cluster-randomised controlled trial of community mobilisation in Mumbai slums to improve care during pregnancy, delivery, postpartum and for the newborn

Background

Chronic back pain is a major public health problem and the primary reason patients seek acupuncture treatment. Therefore, an objective assessment of acupuncture efficacy is critical for making informed decisions about its appropriate role for patients with this common condition. This study addresses methodological shortcomings that have plagued previous studies evaluating acupuncture for chronic low back pain.

Methods and Design

A total of 640 participants (160 in each of four arms) between the ages of 18 and 70 years of age who have low back pain lasting at least 3 months will be recruited from integrated health care delivery systems in Seattle and Oakland. They will be randomized to one of two forms of Traditional Chinese Medical (TCM) acupuncture needling (individualized or standardized), a "control" group (simulated acupuncture), or to continued usual medical care. Ten treatments will be provided over 7 weeks. Study participants and the "Diagnostician" acupuncturists who evaluate participants and propose individualized treatments will be masked to the acupuncture treatment actually assigned each participant. The "Therapist" acupuncturists providing the treatments will not be masked but will have limited verbal interaction with participants. The primary outcomes, standard measures of dysfunction and bothersomeness of low back pain, will be assessed at baseline, and after 8, 26, and 52 weeks by telephone interviewers masked to treatment assignment. General health status, satisfaction with back care, days of back-related disability, and use and costs of healthcare services for back pain will also be measured. The primary analysis comparing outcomes by randomized treatment assignment will be analysis of covariance adjusted for baseline value. For both primary outcome measures, this trial will have 99% power to detect the presence of a minimal clinically significant difference among all four treatment groups and over 80% power for most pairwise comparisons. Secondary analyses will compare the proportions of participants in each group that improve by a clinically meaningful amount.

Conclusion

Results of this trial will help clarify the value of acupuncture needling as a treatment for chronic low back pain.

Trial registration

Clinical Trials.gov NCT00065585.     

Primary Reasons for Osteopathic Consultation: A Prospective Survey in Quebec

Background

Osteopathy is an increasingly popular health care modality to address pain and function in the musculoskeletal system, organs and the head region, as well as functional somatic syndromes. Although osteopathy is recommended principally in guidelines for management of back pain, osteopaths'' scope of practice is wide, albeit poorly defined. In order to understand better the practice of osteopathy, this study aimed to investigate the most common reasons for osteopathic consultations in clinical settings in Quebec.

Methods

A prospective survey of members of the Registre des ostéopathes du Québec was conducted to examine demographics in osteopathic practices, as well as patients'' primary reasons for consultations over a two-week period. The questionnaire was devised following a literature review and refined and verified with two stages of expert input.

Results

277 osteopaths (60.1% response rate) responded to the survey notice. 14,002 patients'' primary reasons for consultations were reported in completed questionnaires and returned by practicing osteopaths. Musculoskeletal pain located in the spine, thorax, pelvis and limbs was the most common reason for consultations (61.9%), with females consulting most commonly for cervical pain and males for lumbar pain. Perinatal and paediatric (11.8%), head (9.1%), visceral (5.0%) and general concerns (4.8%) were the other most common reasons for consultations. Preventive care represented the remaining 0.3%.

Interpretation

The nature of primary reasons for osteopathic consultations, coupled with documented satisfaction of patients with this approach, suggest a future for multidisciplinary collaborative health care including osteopathy. Results of this survey may contribute to informing physicians and others pending regulation of Quebec osteopaths, and also provide direction for future clinical research and guidelines development.     

Pain centers--organization and outcome.

Pain treatment centers have evolved at a rapid rate, but they differ in their complexity and services provided. Patients, as well as primary care physicians, have difficulty in identifying the appropriate center for a specific problem. Guidelines for pain centers have recently been proposed by the International Association for the Study of Pain, along with an attempt at their accreditation. Outcome studies from pain centers have proliferated, with a wide range of treatment programs being reported. Comprehensive multidisciplinary pain centers using the rehabilitation medicine approach are effective in decreasing disability and increasing the productivity of patients with chronic, disabling pain.     

A model of oncologic care in general medicine

The problems related to cancer and its control initially manifest in local community, and general practitioners are those who most commonly have to face them there. The aim of the study was to develop a program of comprehensive oncologic care for primary care physicians, which would be highly professional, efficient, economically justified and feasible, with the ultimate goal of upgrading the target population health and quality of life. Opinions on the priorities and intensity of work in particular activities of general practitioners in the field of oncologic care were obtained from 54 Croatian experts in oncologic care. An Expert Opinion was designed to collect oncologists' opinions by use of Delphi method. The study was performed in two runs, yielding a high rate of accordance among the oncologists. 38 of 54 participants responded in the first run, and 40 of 54 (74%) responded in the second run. The results indicated pain therapy and terminal care to be given highest priority, whereas measures of primary prevention ranked first as a group. There was a unanimous agreement that current activities of primary care physicians in the field of oncologic care were not satisfactory, and that they should take the role of a coordinator of the oncologic care of both individual patients and the population at large. The study showed that a model of oncologic care applicable throughout the country could be developed by combining data from a small health care office with the knowledge of renowned experts in the field.     

Perceived discrimination and physical activity mediate the associations between receiving a survivorship care plan and cancer pain

BackgroundSurvivorship care plan helps improve the continuity of care and manage ongoing pain that affects up to 46% of cancer survivors by promoting health behaviors, including physical activity. However, perceived discrimination may decrease the likelihood of cancer survivors participating in physical activities and negatively influence their pain status. Thus, this study aimed to examine the mediating role of physical activity and perceived discrimination in the relationship between receiving a survivorship care plan and cancer pain.MethodsThis cross-sectional, correlational study utilized data from the 2012–2019 Behavioral Risk Factor Surveillance System. Analyses accounted for the complex survey design. Logistic regression was utilized to analyze the association among survivorship care plans, discrimination, physical activity, and pain. Generalized structural equation modeling was conducted to test a hypothesized model in which survivorship care plans and discrimination affect physical activity, and subsequently influence pain status.ResultsForty-two and 81% of survivors reported receiving treatment summaries and follow-up care plans, respectively, and 8% experienced cancer pain. After controlling for covariates, the highest discrimination quintile was three times more likely to report cancer pain than the lowest quintile. While receiving follow-up care plans was positively related to cancer pain, respondents in the third- to fifth- quintiles were less likely to report cancer pain when receiving follow-up care plans than the first quintile respondents. Physical activity mediated the association between discrimination and cancer pain.ConclusionsReverse relationships between receiving follow-up care plans and cancer pain existed; however, discrimination and physical activity mediated these relationships.     

A Cost-Consequences analysis of the effect of Pregabalin in the treatment of peripheral Neuropathic Pain in routine medical practice in Primary Care settings

Background  

Neuropathic pain (NeP) is a common symptom of a group of a variety of conditions, including diabetic neuropathy, trigeminal neuralgia, or postherpetic neuralgia. Prevalence of NeP has been estimated to range between 5-7.5%, and produces up to 25% of pain clinics consultations. Due to its severity, chronic evolution, and associated co-morbidities, NeP has an important individual and social impact. The objective was to analyze the effect of pregabalin (PGB) on pain alleviation and longitudinal health and non-health resources utilization and derived costs in peripheral refractory NeP in routine medical practice in primary care settings (PCS) in Spain.     

Primary Care Physicians’ Attitudes and Beliefs towards Chronic Low Back Pain: An Asian Study

Background

Chronic low back pain is a serious global health problem. There is substantial evidence that physicians’ attitudes towards and beliefs about chronic low back pain can influence their subsequent management of the condition.

Objectives

(1) to evaluate the attitudes and beliefs towards chronic low back pain among primary care physicians in Asia; (2) to study the cultural differences and other factors that are associated with these attitudes and beliefs.

Method

A cross sectional online survey was sent to primary care physicians who are members of the Hong Kong College of Family Physician (HKCFP). The Pain Attitudes and Beliefs Scale for Physiotherapist (PABS-PT) was used as the questionnaire to determine the biomedical and biopsychosocial orientation of the participants.

Results

The mean Biomedical (BM) score was 34.8+/-6.1; the mean biopsychosocial (BPS) score was 35.6 (+/- 4.8). Both scores were higher than those of European doctors. Family medicine specialists had a lower biomedical score than General practitioners. Physicians working in the public sector tended to have low BM and low BPS scores; whereas physicians working in private practice tended to have high BM and high BPS scores.

Conclusion

The lack of concordance in the pain explanatory models used by private and public sector may have a detrimental effect on patients who are under the care of both parties. The uncertain treatment orientation may have a negative influence on patients’ attitudes and beliefs, thus contributing to the tension and, perhaps, even ailing mental state of a person with chronic LBP.     

Peripheral analgesia: Hitting pain where it hurts

Pain is a complex biological phenomenon that encompasses intricate neurophysiological, behavioural, psychosocial and affective components. Protracted or chronic pain alerts an individual to a possible pathological abnormality and is the main reason why patients visit a primary care physician. Despite the pervasiveness of chronic pain in the population, the effectiveness of current pharmacological therapies remains woefully inadequate and prolonged treatment often leads to the development of undesirable side-effects. Since the vast majority of chronic pain originates in a specific tissue or group of tissues, it may be advantageous to target pain control in the periphery and thereby circumvent the known risks associated with non-specific systemic treatments. This review spotlights a number of promising targets for peripheral pain control including the transient receptor potential (TRP) family of neuronal ion channels, the family of proteinase activated receptors (PARs), cannabinoids, and opioids. A critical appraisal of these targets in preclinical models of disease is given and their suitability as future peripheral analgesics is discussed.     

Response: Freedom from Pain as a Rawlsian Primary Good

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels’ developments of John Rawls’ theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors’ argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods.     

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.     

Cellular versus acellular matrix devices in treatment of diabetic foot ulcers: study protocol for a comparative efficacy randomized controlled trial

Background

The referral letter plays a key role both in the communication between primary and secondary care, and in the quality of the health care process. Many studies have attempted to evaluate and improve the quality of these referral letters, but few have assessed the impact of their quality on the health care delivered to each patient.

Methods

A cluster randomized trial, with the general practitioner office as the unit of randomization, has been designed to evaluate the effect of a referral intervention on the quality of health care delivered. Referral templates have been developed covering four diagnostic groups: dyspepsia, suspected colonic malignancy, chest pain, and chronic obstructive pulmonary disease. Of the 14 general practitioner offices primarily served by University Hospital of North Norway Harstad, seven were randomized to the intervention group. The primary outcome is a collated quality indicator score developed for each diagnostic group. Secondary outcomes include: quality of the referral, health process outcome such as waiting times, and adequacy of prioritization. In addition, information on patient satisfaction will be collected using self-report questionnaires. Outcome data will be collected on the individual level and analyzed by random effects linear regression.

Discussion

Poor communication between primary and secondary care can lead to inappropriate investigations and erroneous prioritization. This study’s primary hypothesis is that the use of a referral template in this communication will lead to a measurable increase in the quality of health care delivered.

Trial registration

This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963     

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Background

Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care.

Methods

We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort).

Results

The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83–0.91) for the derivation cohort and 0.90 (95% CI 0.87–0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3–5 points; negative result ≤ 2 points), which had a sensitivity of 87.1% (95% CI 79.9%–94.2%) and a specificity of 80.8% (77.6%–83.9%).

Interpretation

The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.Chest pain is common. Studies have shown a lifetime prevalence of 20% to 40% in the general population.¹ Its prevalence in primary care ranges from 0.7% to 2.7% depending on inclusion criteria and country,^2–4 with coronary artery disease being the underlying cause in about 12% of primary care patients.^1,5 General practitioners are challenged to identify serious cardiac disease reliably and also protect patients from unnecessary investigations and hospital admissions. Because electrocardiography and the cardiac troponin test are of limited value in primary care,^6,7 history taking and physical examination remain the main diagnostic tools.Most published studies on the diagnostic accuracy of signs and symptoms for acute coronary events have been conducted in high-prevalence settings such as hospital emergency departments.^8–10 Predictive scores have also been developed for use in emergency departments, mainly for the diagnosis of acute coronary syndromes.^11–13 To what degree these apply in primary care is unknown.^14–16A clinical prediction score to rule out coronary artery disease in general practice has been developed.¹⁷ However, it did not perform well when validated externally. The aim of our study was to develop a simple, valid and usable prediction score based on signs and symptoms to help primary care physicians rule out coronary artery disease in patients presenting with chest pain.     

Factors associated with physician follow-up among patients with chest pain discharged from the emergency department

Background:

Many patients with chest pain do not receive follow-up from a physician after discharge from the emergency department despite significant survival benefit associated with follow-up care. Our objective was to evaluate factors associated with physician follow-up to understand this gap in practice.

Methods:

We conducted an observational study involving patients at high risk who were assessed for chest pain and discharged from an emergency department in Ontario between April 2004 and March 2010. We used multivariable logistic regression to determine the association of clinical and nonclinical characteristics with physician follow-up.

Results:

We identified 56 767 patients, of whom 25.1% did not receive any follow-up by a physician, 69.0% were seen by their primary care physician, and 17.3% were seen by a cardiologist within 30 days. Patients who had medical comorbidities and cardiac conditions such as myocardial infarction or heart failure were less likely to have follow-up. In contrast, a previous visit to a primary care physician was associated with the highest odds of having physician follow-up (odds ratio [OR] 6.44, 95% confidence interval [CI] 5.91–7.01). Similarly, a previous visit to a cardiologist was strongly associated with follow-up by a cardiologist (OR 3.01, 95% CI 2.85–3.17). Patients evaluated in emergency departments with the highest tertile of chest pain volume were more likely to receive follow-up from any physician (OR 1.52, 95% CI 1.31–1.77) and from a cardiologist (OR 2.04, 95% CI 1.61–2.57).

Interpretation:

Nonclinical factors are strongly associated with physician follow-up for patients with chest pain after discharge from the emergency department. However, patients with comorbidities and at higher risk for future adverse events are less likely to receive follow-up care.Chest pain is one of the most common presenting symptoms in emergency departments. In Canada, about 500 000 visits to the emergency department are related to chest pain assessment each year.¹ Most of these visits result in discharge after excluding a cardiac diagnosis with an immediate risk of adverse effect.² Current clinical guidelines strongly advocate for patients with chest pain who have been discharged from the emergency department to receive outpatient follow-up with a physician within 72 hours for further assessment or treatment, because many patients remain at risk for future events.³Among patients at high baseline cardiovascular risk who were discharged from the emergency department after assessment of chest pain, our group has previously shown significantly reduced hazard of death or myocardial infarction associated with follow-up with either a primary care physician or a cardiologist within 30 days.² At 1-year postassessment, the rate of death or myocardial infarction was 5.5% among patients who received cardiologist follow-up, 7.7% with primary care follow-up and 8.6% with no physician follow-up.² In addition, we found a considerable gap in practice, with 1 in 4 high-risk patients with chest pain failing to follow-up with a physician within 30 days of assessment in Ontario, Canada.² A better understanding of why physician follow-up does not occur in accordance with guidelines is essential to improve the transition of care from the emergency department to home. Thus, the main objective of our study was to evaluate clinical and nonclinical factors associated with physician follow-up among patients with chest pain after discharge from the emergency department.