Low Back Pain In Primary Care Research Articles

Primary care barriers and facilitators to nonpharmacologic treatments for low back pain: A qualitative pilot study.

Clinical practice guidelines encourage primary care providers (PCPs) to recommend nonpharmacologic treatment as first-line therapy for low back pain (LBP). However, the determinants of nonpharmacologic treatment use for LBP in primary care remain unclear, particularly in low-income settings. To pilot a framework-informed interview guide and codebook to explore determinants of nonpharmacologic treatment use in primary care. In this qualitative interview study, we enrolled PCPs and community health workers (CHWs) from four primary care clinics at a safety net hospital. A semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR) guided inquiry on barriers/facilitators to nonpharmacologic treatments for LBP (eg, acupuncture, chiropractic care, physical therapy). We included questions on whether current CHW roles may address barriers to nonpharmacologic treatment use. Interviews were audio-recorded, transcribed verbatim, and independently coded by four investigators. An a priori codebook composed of CFIR determinants and known CHW roles guided deductive content analysis to identify major themes. Eight individuals (six PCPs, two CHWs; age range: 32-51 years, five female) participated in hour-long interviews. Half had worked at the hospital for ≥15 years and all reported seeing patients with LBP (range: 2-20 patients per week). All participants identified the following CFIR factors as barriers/facilitators: nonpharmacologic treatment characteristics (perceived cost, relative advantage compared to other treatments); outer setting (patient needs/resources, limited connections with community-based nonpharmacologic treatment) and PCP characteristics (attitudes/beliefs about nonpharmacologic treatments). Although participants indicated several CHW roles could be adapted to address barriers (eg, care coordination, resource linking, case management), other roles seemed less feasible (eg, targeted health education) in our health care system. Preliminary insight on key determinants of nonpharmacologic treatments for LBP should be further examined in large multisite studies. Future studies may also determine whether a CHW-led strategy can improve nonpharmacologic treatment access and clinical outcomes in primary care.

Prognostic Models for Chronic Low Back Pain Outcomes in Primary Care Are at High Risk of Bias and Lack Validation-High-Quality Studies Are Needed: A Systematic Review.

OBJECTIVE: To provide an updated overview of available prognostic models for people with chronic low back pain (LBP) in primary care. DESIGN: Prognosis systematic review LITERATURE SEARCH: We searched for relevant studies on MEDLINE, Embase, Web of Science, and CINAHL databases (up to July 13, 2022), and performed citation tracking in Web of Science. STUDY SELECTION CRITERIA: We included observational (cohort or nested case-control) studies and randomized controlled trials that developed or validated prognostic models for adults with chronic LBP in primary care. The outcomes of interest were physical functioning, pain intensity, and health-related quality of life at any follow-up time-point. DATA SYNTHESIS: Data were extracted using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS), and the Prediction model Risk of Bias Assessment Tool (PROBAST) tool was used to evaluate the risk of bias of the models. Due to the number of studies retrieved and the heterogeneity, we reported the results descriptively. RESULTS: Ten studies (out of 5593 hits screened) with 34 models met our inclusion criteria, of which six are development studies and four are external validation studies. Five studies reported the area under the curve of the models (ranging from 0.48 to 0.84), whereas no study reported calibration indices. The most promising model is the Örebro Musculoskeletal Pain Screening Questionnaire Short-Form. CONCLUSIONS: Given the high risk of bias and lack of external validation, we cannot recommend that clinicians use prognostic models for patients with chronic LBP in primary care settings. J Orthop Sports Phys Ther 2024;54(5):1-13. Epub 15 February 2024. doi:10.2519/jospt.2024.12081.

An interprofessional approach to collaborative management of low-back pain in primary care: A scholarly analysis of a successful educational module for prelicensure learners.

In 2008, an interprofessional education (IPE) working group was formed to develop a module on interdisciplinary low-back pain management to fill a curricular gap at our institution. This article describes the program evaluation outcomes and highlights factors contributing to its successful implementation over 8 years through reference to Brigg's Presage-Process-Product (3-P) Model of Teaching and Learning. Program evaluation occurred through administration of a pre- and postmodule Health Professional Collaborative Competency Perception Scale, with scores compared using paired t tests. Descriptive statistics were analyzed from 5-point Likert scales for module session components. A total of 853 students from 9 health care occupations (medicine, chiropractic, physiotherapy, pharmacy, nursing, nurse practitioner, occupational therapy, physiotherapy assistants, and occupational therapist assistants) participated in 51 iterations of the module from 2011 to 2019, averaging 16 participants each session. All Health Professional Collaborative Competency Perception Scale items significantly improved from pre- to postintervention (p < .001) for learners from 6 health professions. Module components were rated highly, with the majority of learners rating these as 4 (helpful) or 5 (very helpful) for their learning. Participants also improved their scores in perceived history and physical exam comfort, knowledge of pharmacotherapy, management options, and attitudes regarding an interprofessional approach to back pain (p < .001). This article describes the presage, process factors, and products of this model IPE program that provides learners from various health care professions with an opportunity to gain a deeper understanding of the interdisciplinary management of low-back pain, as demonstrated through improvement in collaborative competencies.

Best Practices for the Evaluation and Management of Low Back Pain in Primary Care: A Multidisciplinary Expert Consensus

Abstract Purpose: International guidelines for the management of patients with low back pain (LBP) are available, but there are no India-specific guidelines for the diagnosis and management of LBP in primary care. This article aims to provide clinical insights for the diagnosis and treatment of LBP for primary care practitioners in India. Methods: A 3-step modified Delphi method was used to get insights and opinions from a panel of 9 multidisciplinary specialist (neurology, orthopedics, and pain management). In rounds 1 and 2, 203 and 60 statements, respectively, were circulated to the expert panel and they were asked to respond with an “agree” or “disagree” to each statement and provide comments. At least 80% of the experts had to agree for a statement to reach a concordance. More than 80% concordance was reached for 175 and 32 statements in rounds 1 and 2, respectively. Round 3 was a direct interaction with the experts. Results: There was good agreement among the expert panelist in round 3 for the consensus-derived statements from the earlier two rounds of the survey. The panel agreed that diagnostic triage is important to exclude specific spinal pathology, routine imaging is not recommended unless suspecting serious pathology, specialist referral is needed for serious pathologies/no improvement in pain with treatment, and management is to be individualized depending on etiology and patient factors. Conclusions: Primary care physicians are the first point of contact for patients with back pain. These consensus recommendations will assist primary care physicians in India to choose an appropriate course of action for managing patients with LBP.

Potential blood markers as screening tools for subjects with low back pain: an age- and gender-matched cross-sectional analysis

Background Mechanical and inflammatory factors were suggested as the causes of spine degeneration and low back pain (LBP). Previous studies partly reported the association of LBP with inflammation. However, none of them compared patients with LBP and asymptomatic subjects in terms of complete blood count and inflammatory markers in detail. We aimed to analyze the association of serum white blood cell (WBC) count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) with chronic LBP by comparing the patients with chronic LBP and age- and gender-matched asymptomatic subjects. Methods Lumbar intervertebral disc degeneration and vertebral end-plates were evaluated using Pfirrmann grading and Modic classification on lumbar spine magnetic resonance images, respectively. Serum WBC counts, CRP levels, and ESRs were recorded from chart reviews. Results We included 147 patients with chronic LBP and 101 asymptomatic subjects. Patients with chronic LBP had significantly higher serum neutrophil, monocyte, and basophil counts, higher neutrophil-to-lymphocyte ratio, higher ESR, and lower serum CRP levels compared to the asymptomatic subjects. Serum monocyte and basophil cell counts and ESR were the most remarkable predictive factors for chronic LBP, severe IVDD, and Modic changes. Higher serum monocyte and basophil cell counts and higher serum ESR above cut-off values of 0.42 × 103/μL, 0.025 × 103/μL, and 3.5 mm/hour could be used as screening tools for subjects with persistent LBP in primary care. Discussion Higher serum monocyte and basophil counts and serum ESR above new cut-off values should highlight the need to obtain early spinal imaging to prevent chronicity in patients with LBP.

Imaging incidence and type in primary care patients with low back pain: a cross-sectional study on new referrals to an Australian specialist spinal surgical centre.

Introduction Low back pain (LBP) is common and a significant cause of morbidity. Many patients receive inappropriate imaging for LBP in primary care. Aim To explore the incidence and type of spinal imaging conducted for LBP patients referred from general practice for specialist surgical opinion, and evaluate whether imaging conformed to clinical guidelines. Methods Audit of a sequential cohort (n = 100) of new LBP patients referred from primary care for specialist opinion at a suburban Australian capital city independent Spinal Centre. Results In the 6 months before referral, 90% (95% CI 83-95%) of patients underwent spinal imaging. Imaging was performed in 95% of those who did and 79% of those who did not meet guidelines for radiological investigation. 35% of patients were inappropriately imaged and 3% inappropriately not imaged. Spinal computed tomography (CT) imaging was used in 52% of patients, magnetic resonance imaging (MRI) in 42% and image-guided lumbar spinal interventional procedures in 28%. Discussion Most patients with LBP referred for surgical opinion have diagnostic radiological investigations whether or not it is indicated by clinical guidelines. The more frequent use of spinal CT compared to MRI may be due to idiosyncrasies of the Australian Medicare Benefits Schedule (MBS) rebate system. The findings of this pilot study provide support for the changes recommended by the 2016 MBS Review Taskforce on LBP that permit GP access to subsidised lumbar MRI, while constraining access to lumbar CT, and provide novel data about spinal imaging and practice in this cohort of patients.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

BackgroundLow back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL).MethodsThis was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging.ResultsNine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation.ConclusionsFamily physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Comparable Quality Performance of Acute Low-Back Pain Care in Telemedicine and Office-Based Cohorts.

Introduction: Back pain is among the most common presentations in primary care offices. National organizations have standardized the appropriate use of imaging for acute low-back pain (LBP). The objective of this study was to evaluate the use of imaging in LBP between telemedicine and in-person clinical encounters. Methods: This retrospective cohort compared secondary data from 20,624 telemedicine and office encounters in a large nonprofit health system from July 1, 2019, to June 30, 2021. The proportion of patients aged 18-50 years who did not receive imaging for acute LBP (X-ray, computed tomography, or magnetic resonance imaging) within 28 days of the provider encounter was measured according to Healthcare Effectiveness Data and Information Set specifications. Performance was compared across race, ethnicity, age, body mass index, overall risk score, and insurance type. Chi-squared tests determined significant differences between cohorts (p < 0.05). Results: Patients seen via telemedicine had significantly lower rates of imaging within 28 days of their physician encounter (office: 16.32%, telemedicine: 11.20%; difference: 5.12%; p < 0.01). This was consistent across racial, ethnic, and risk score subgroups. Discussion: For practices and health systems, telemedicine might be a higher value approach for initial evaluation of acute LBP in primary care. For policy makers, telemedicine can save on health care costs without negatively impacting quality performance measures. Conclusions: Telemedicine is unlikely to compromise quality of acute LBP care, supporting this virtual space as an alternative care venue. The most beneficial use of telemedicine might be triaging initial encounters of acute LBP in primary care. Stronger evidence could support its long-term potential for driving value through cost savings.

Improving appropriate imaging for non-specific low back pain

Non-specific low back pain (LBP) is a common condition in the USA, with approximately 80% of adults who will have LBP at some point during their life and roughly 30%...

Patients’ experiences of the BetterBack model of care for low back pain in primary care – a qualitative interview study

ABSTRACT Purpose: The aim of this study was to describe patient experiences of received primary care for low back pain (LBP) according to the BetterBack Model of Care (MoC) with a focus on illness beliefs and self-management enablement. Methods: Individual interviews were conducted with 15 adults 4–14 months after receiving treatment according to the BetterBack MoC for LBP in primary care in Sweden. Data were analysed using content analysis. Results: When analysing the data, the following theme emerged; “Participant understanding of their treatment for low back pain and self-management strategies—a matter of support systems”, comprising the following categories: “Knowledge translation”, “Interaction and dialogue”, “The health care professional support” and “Form organization”. Participants experienced that they had better knowledge about their LBP and received tools to better manage their health condition. The participants expressed good communication with the treating physiotherapist and provided suggestions to further improve the treatment of LBP. Conclusions: Participants experienced that they had gained new knowledge about their health problems and after the treatment they had the tools to handle their back problems. This suggests that the BetterBack MoC may be used as a basis for a support system to provide valuable tools for self-management for patients with low back pain.

Developing theory-informed knowledge translation strategies to facilitate the use of patient-reported outcome measures in interdisciplinary low back pain clinical practices in Quebec: mixed methods study

BackgroundThere is a growing interest among healthcare providers (HCPs) to use Patient Reported Outcome Measures (PROMs) in clinical care. PROMs can help improve patient-care provider communication and may be used to inform the need for interdisciplinary care for Low Back Pain (LBP). However, PROM implementation to support clinical decision-making is complex and requires knowledge translation (KT) interventions that will overcome barriers to using PROMs in interdisciplinary clinical settings.Objectivesto 1) identify potential barriers and enablers to using PROMs in primary care LBP clinical practice from the perspective of healthcare team members, and 2) develop a theory-based tailored KT intervention to facilitate the use of PROMs in interdisciplinary clinical practice.MethodsWe invited 25 HCPs working in an interdisciplinary team to complete a self-administered survey designed based on the Theoretical Domain Framework (TDF) to identify the barriers and enablers to using PROM scores in LBP clinical practice. The questionnaire consisted of 30 questions rated on a 5-point Likert scale (quantitative) and included open-ended questions (qualitative). Quantitative and qualitative data were analysed to estimate the frequency of barriers and enablers. Findings were then reviewed by a panel of four KT experts who mapped behaviour change techniques to barriers identified that informed the design of a KT intervention.ResultsEighteen HCPs responded to the survey. Factors identified as likely to restrict the use of PROM scores included knowledge, skills, social/professional role and identity, goals, decision processes, beliefs about consequences, environmental context and resources, behavioural regulation, and social influence. A multi-component evidence-based KT intervention was proposed by the panel of experts to address these barriers: a training workshop; educational materials; and use of PROM score reports to HCPs that were all delivered by an opinion leader.ConclusionThe routine use of PROMs in clinical practice may optimize the quality of LBP care and improve patients’ outcomes. The proposed multi-component KT intervention is expected to be an effective strategy to increase HCPs’ ability to integrate PROMs into clinical decision-making and to engage patients in their care.

Supporting self-management of low back pain with an internet intervention in primary care: a protocol for a randomised controlled trial of clinical and cost-effectiveness (SupportBack 2)

IntroductionSelf-management and remaining physically active are first-line recommendations for the care of patients with low back pain (LBP). With a lifetime prevalence of up to 85%, novel approaches to support...

Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial.

BackgroundMusculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations.ObjectiveThis study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care.MethodsThis is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain–related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons.ResultsTrial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020.ConclusionsThis trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020.Trial RegistrationISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334.International Registered Report Identifier (IRRID)DERR1-10.2196/17939

A classification-based approach to low back pain in primary care \u2013 protocol for a benchmarking controlled trial

BackgroundGuidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care.MethodsWe will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up.DiscussionThe implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway.Trial registrationISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.

Management of non-specific low back pain in primary care – A systematic overview of recommendations from international evidence-based guidelines

Systematic identification, characterization and analysis of recommendations concerning the diagnosis and treatment of non-specific low back pain (LBP) in primary care provided in international evidence-based guidelines from high-income countries. LBP is one of the most common reasons for consulting a primary care physician and its prevalence is higher in high-income than in middle- or low-income countries. The majority of LBP is non-specific and treatment recommendations are not often based on high-quality and patient-oriented evidence. We systematically searched PubMed and major guideline databases from 2013 to 2020. Two independent reviewers performed literature selection and the quality assessment of included guidelines using the AGREE II tool. We extracted all relevant recommendations including the corresponding Grade of Recommendation. We grouped all included recommendations by topic and compared them to each other. This overview includes 10 current guidelines and overall 549 relevant recommendations. Recommendations covered aspects of assessment and diagnosis (15%), non-pharmacological interventions (46%), pharmacological interventions (26%), invasive treatments (8%) and multimodal pain management (5%). In total, 30% of all recommendations were strong and 57% weak or very weak. The proportion of recommendations for and against an intervention was 45% and 38%, respectively. The recommendations from the different guidelines were largely in good agreement. We identify only a small number of contradictory recommendations, mostly dealing with very specific interventions. In conclusion, current evidence-based guidelines published in high-income countries provide recommendations for all major aspects of the management of people with LBP in primary care. Recommendations from different guidelines were largely consistent. More than 50% of these recommendations were weak or very weak and a high proportion of recommendation advised against an intervention.

The experiences and needs of people seeking primary care for low-back pain in Australia.

There is a knowledge gap about the current experiences and needs of people with low back pain (LBP) seeking primary care in Australia. The aim of this study was to understand the experiences and needs of Australians who have received treatment for LBP in primary care. This was a prospective, cross-sectional internet survey conducted between July 2017 and September 2017. Participants were adults who had experienced an episode of LBP in the past year, had sought primary care in Australia, and were proficient in English. Outcomes were patient-reported experiences about primary care treatment, including reasons for seeking care, health care practitioners consulted, components of care received, and patients' evaluations of the importance and helpfulness of treatment. A total of 426 Australians completed the survey. The response rate of survey completion was 50%. Participants reported seeking primary care for LBP not only for pain relief, but for difficulties with activities and participation with usual social roles as well as quality of life and mood. Participants consulted multiple health care practitioners and used numerous treatment modalities. Only half reported they received education and a very low proportion were aware of receiving guideline-based advice. The level of satisfaction with care was below moderate for 42% of respondents. Participants reported that they want LBP care to be more person-centred and better tailored to their needs; they also reported wanting more education, particularly about prevention of future episodes and self-management. The needs of people currently seeking primary care for LBP in Australia do not seem to be adequately met. Improving patients' experiences and outcomes may require better integration of health care across providers and delivery of more person-centred care.

Lumbar disc degeneration is longitudinally associated with low back pain presence in older adults

Purpose: Low back pain (LBP) is the most prevalent musculoskeletal complaint throughout the world and causes activity limitation and work absenteeism. The large majority of people with LBP are given the label ‘non-specific’, meaning that a specific patho-anatomical cause for the pain cannot be established. As a phenotype of spinal osteoarthritis, lumbar disc degeneration (LDD) was found to be associated with LBP and can be one of the pain contributing factors. Nevertheless, the predictive value of LDD for long-term LBP outcomes has not been investigated. This study assessed the longitudinal association between LDD and long-term outcomes in older adults presenting with LBP in primary care. Methods: The BACE cohort study was used, including 675 patients aged >55 years visiting a general practitioner with a new episode of non-specific LBP. Osteophytes and disc space narrowing were considered LDD features, and they were investigated as categorical and dichotomous determinants. The 4-grade Lane Atlas classification was used (i.e. grade 0= none, grade 1= mild, grade 2= moderate, grade 3= severe); osteophytes of grade 2 or higher at two or more levels for L1-2 to L5-S1 were defined as LDD presence, likewise disc space narrowing grade 1 or higher at two or more levels from L1-2 to L5-S1. Outcomes at 1-year follow-up were: LBP presence (yes/no), and LBP severity [measured on an 11-point numeric rating scale (NRS)] defined as a NRS score ≥ 4/10. The association between LDD at baseline and 1-year follow-up outcomes was assessed with logistic regression models. Models were adjusted for age, gender and BMI. Results: Five-hundred and forty-three patients (85% of the cohort) with baseline and 1-year follow-up data were included in this study. Mean age was 67 years (SD 8), 59% was female and 62% reported severe LBP at baseline. One-hundred eighty-six patients (34%) met the LDD definition for osteophytes and 389 (72%) the LDD definition of disc space narrowing. The LDD definition of osteophytes was significantly associated with LBP presence, but not the 4-grade classification of osteophytes (Table 1). The LDD definition of disc space narrowing was not associated, but patients with grade 1 to 3 narrowing displayed higher odds (compared to grade 0) of having LBP at follow-up (Table 1). LDD definitions for osteophytes (OR=1.4, 95% CI 0.9-2.1) and narrowing (OR=1.5, 95% CI 0.9-2.4) were not associated with LBP severity. Patients with grade 3 disc space narrowing exhibited higher odds (compared to grade 0 patients) of having severe LBP (OR=2.9, 95% CI 1.0-8.3); patients with other LDD grade classification did not show an association with pain severity. Conclusions: This study found an association between some of the features of LDD at baseline and the presence of LBP at 1-year follow-up (Table 1). On the other hand, LDD features were not associated with LBP severity, with the sole exception of grade 3 disc space narrowing (as compared to grade 0). This study warrants further investigation of LDD features as potential prognostic factors in future longitudinal studies.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study \u2013 the Back ON study

BackgroundAt any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings.MethodsThe project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients.DiscussionThis will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Diagnosis and management of low-back pain in primary care.

KEY POINTS Low-back pain is the leading cause of disability worldwide.[1][1] It is the second most common symptom-related reason for seeking care from a primary care physician.[2][2] In Australia, low-back pain is the number one cause of early retirement and income poverty.[3][3] Although most

Testing a Model of Consultation-based Reassurance and Back Pain Outcomes With Psychological Risk as Moderator: A Prospective Cohort Study.

Reassurance is an essential part of treatment for low back pain (LBP), but evidence on effective methods to deliver reassurance remains scarce. The interaction between consultation-based reassurance and patients' psychological risk is unknown. Our objective was to investigate the relationship between consultation-based reassurance and clinical outcomes at follow-up, in people with and without psychological risk. We tested the associations between specific reassurance components (data gathering, relationship building, generic reassurance, and cognitive reassurance), patients' psychological risk (the presence of depression, anxiety, catastrophizing, or fear-avoidance), and postconsultation outcomes including, satisfaction and enablement, disability, pain, and mood at 3-month follow-up. Adjusted linear regression models using data from patients who had recently consulted for LBP in primary care (n=142 in 43 practices) indicated that all reassurance components were strongly associated with increased satisfaction, whereas generic reassurance was significantly associated with postconsultation enablement. Generic reassurance was also associated with lower pain at 3 months, whereas cognitive reassurance was associated with increased pain. A significant interaction was observed between generic reassurance and psychological risk for depression at 3 months: high rates of generic reassurance were associated with lower depression in low-risk patients, but with higher rates of depression for high-risk groups. The findings support the hypothesis that different components of reassurance are associated with specific outcomes, and that psychological risk moderates this relationship for depression. Clinicians reassuring behaviors might therefore have the potential to improve outcomes in people with LBP, especially for patients with higher psychological risk profiles.