Pain Referral Research Articles

Current Perspectives on the Adjunctive Use of Botulinum Toxin A in Endodontic Practice for Nonodontogenic Pain Management: A Web-Based Survey.

Despite the increasing use of botulinum toxin A (BoNT-A) in dentistry, there is limited research on its use in endodontics, a specialty that often receives referrals for dental pain that can coexist with nonodontogenic pain. The purpose of this study was to assess whether endodontists believe BoNT-A can be useful in an endodontic practice as an adjunctive treatment for nonodontogenic conditions overlapping with dental pain. A 23-question survey was emailed to 3,979 members of the American Association of Endodontists (AAE). Descriptive statistics, bivariate analysis, and logistic regression were performed with significance at α = 0.05. Among the 211 respondents confirmed to be endodontists in the United States, one in eleven (9.14%) currently administer BoNT-A treatment. The top nonodontogenic conditions indicated for BoNT-A were myofascial orofacial pain (49.22%) and temporomandibular joint disorders (41.97%). Half of the endodontists (50.26%) believe that BoNT-A could be useful for nonodontogenic conditions overlapping with dental pain. Regression analysis identified variables significantly associated with this belief: BoNT-A can improve patient satisfaction (p < 0.05), BoNT-A training should be offered in residency (p < 0.05), BoNT-A would increase profitability (p < 0.05), and BoNT-A will be incorporated more in the future (p < 0.05). Endodontists have split opinions on administering BoNT-A for nonodontogenic conditions overlapping with dental pain. Including BoNT-A training in residency may be key to encouraging multidisciplinary pain management in endodontics.

C0-C1 joint injection: Anatomical, clinical and technical review

BackgroundCervicogenic headaches (CGH) are proven clinical entities. The prevalence of CGH arising from the atlanto-occipital (AO) joint is unknown. The best evidence for treatment of CGH is for third occipital nerve radiofrequency neurotomy. Treatment of CGH includes intra-articular injections into upper cervical spine joints. ObjectiveTo perform a review of the anatomy and clinical presentation of AO joint (AOJ) pain referral as well as a technical description to safely access the AOJ. MethodsA literature review was performed to explore the intricacies of the cranio-cervical junction (CCJ) with a focus on the relation between the AOJ and vascular anatomy. Our technical approach is described with complementary images. ResultsThe AOJ lies anterior to a venous sinus and slightly superior to the horizontally oriented vertebral artery crossing the joint line. ConclusionThe authors propose a modified superior needle trajectory that seeks to avoid these vascular structures and to access the AOJ safely.

Assessing MRI referrals’ appropriateness for low back pain post a radiology-initiated intervention

IntroductionThis study evaluated a pilot intervention to reduce low-value Magnetic Resonance Imaging (MRI) referrals for Low Back Pain (LBP). MethodsThis before-after intervention study analysed MRI referrals for LBP at two private imaging centres in Norway. MRI referrals for LBP obtained before and after an intervention of information campaigns and sending a return letter to clinicians for declined referrals were evaluated on information, quality, and justification rates. Four radiologists and two radiographers assessed the referrals. A point system was used to calculate referral quality. Each referral was given a score ‘good’ when rated above 5.5 and ‘poor’ below 2.5. Justification was based on assessors categorised rating as justified, unjustified or need more information. Stata Statistical Software (Release 18) was used for analysis. A mixed model analysed variations of the referrals pre- and post-intervention. A p-value of <.05 in variations was considered statistically significant. ResultsA total n = 300 patients’ referrals (150 referrals pre- and post-intervention) were collected and assessed. Post-intervention, 68% of referrals were justified, up from 63% pre-intervention. The assessment showed a 4% decrease in referrals with poor scores and a 2% increase in those rated as good or intermediate quality post-intervention. These changes were not statistically significant. ConclusionIt is important to state that it was not possible in our study to identify the subgroup of referrals that are known to be from clinicians who had received a return letter, although the information campaign targeted all referrers. Despite the limitations our findings suggest that providing reasons for declined referrals can serve as an educational tool for clinicians and contribute to the reduction of low value MRI for LBP. Implications for practiceRadiology department initiatives that raise awareness and offer referral criteria guidance to clinicians can serve as valuable educational tools, and further emphasize the importance of providing comprehensive information in MRI referrals for LBP.

Effects of the Muscle Energy Technique and Myofascial Release Technique in Cervicogenic Headache: A Brief Review

Headache is a substantial global public health problem. A type of headache known as cervicogenic headache (CGH) is caused by a referral of pain from the cervical spine. This type of headache is usually persistent, manifests as unilateral cephalgia, and is thought to be brought on by neck musculoskeletal dysfunction. Numerous methods have been put forth to treat headaches, but the most effective approach has been suggested by recent research to involve manipulation and therapeutic exercise. Muscle energy technique is a beneficial and successful therapeutic exercise because the patient actively participates in its execution. Numerous studies have examined the benefits of myofascial release technique, including increased range of motion, improved joint biomechanics, increased soft tissue extensibilities, and a marked reduction in pain. Keywords: Cervicogenic headache, Muscle energy technique, Myofascial release technique.

Epidemiology of Disorders of the Gut-Brain Interaction: An Appraisal of the Rome IV Criteria and Beyond.

Disorders of the gut-brain interaction (DGBIs) are presently classified into mutually exclusive anatomical area-related symptom-based categories according to the Rome IV criteria. The pathophysiology of visceral nociception, which contributes to the wide range of symptoms of DGBIs, involves complex psychobiological processes arising from the bidirectional interactions of multiple systems at the gut and brain levels, which affect symptom expression and illness behaviors. The attitude toward an illness and expression of pain and bowel habit vary across cultures with variable interpretation based on sociocultural beliefs, which may not tally with the medical definitions. Thus, psychological factors impact DGBI definitions, their severity and health care utilization. Due to the poor localization and multisegment referral of visceral pain, the anatomical site of pain may not correspond to the affected segment, and there may be a variable degree of overlap among symptoms. The somewhat restrictively defined Rome IV criteria assume one-to-one correlation of symptoms with underlying pathophysiology and ignore overlapping DGBIs, nonstandardized symptom categories, and change or shift in category over time. The microorganic nature of DGBIs resulting from systemic, metabolic or motility disorders, gut dysbiosis and inflammation are not addressed in the Rome IV criteria. Although there is a multidimensional clinical profile that does address these factors, it is not followed rigorously in practice. Threshold changes for diagnostic criteria or addition/deletion of symptoms leads to wide variation among different DGBI criteria resulting in uncertain comparability of results. Although the Rome IV criteria are excellent for research studies and therapeutic trials in homogenous populations, further improvement is needed for their wider applicability in clinical practice.

E042 Referrals for back pain to rheumatology outpatients: time to rethink service delivery?

Abstract Background/Aims Diagnostic delay in inflammatory and mechanical back pain (IBP and MBP) is a challenge, leading to time-off-work, mental health deterioration and chronicity of pain. Here we describe referral and follow-up characteristics in patients referred to a rheumatology service with back pain. By identifying these patients earlier and having a more proactive approach we may be able to reduce diagnostic delay and prevent some of this burden. Methods All new patients attending rheumatology outpatients at Guys and St Thomas’ Trust in London, UK are routinely sent a digital pre-appointment questionnaire to complete prior to initial visit. Between 21/06/2021 and 20/10/2022, 137 patients referred with back pain completed this questionnaire, which included the Assessment of SpondyloArthritis International Society (ASAS) IBP criteria. Clinical records were reviewed until June 2023. Results Our cohort had a mean (SD) age of 40.5(13.5) years, 50% were female and 66% were referred from primary care. Average symptom duration was 5.2(6.1) years. A primary diagnosis of axial spondyloarthritis was made in 41%, 53% were diagnosed with MBP and 6% had MBP on a background of other inflammatory disease. Incomplete data was an issue, with only 54% of the referrals having a CRP result, 50% having an ESR result and 22% with HLAB27 done and result available at referral. Rheumatology requested an MRI spine in 61% of back pain referrals. Of the 38% with a prior MRI, 15% did not have the result available at first rheumatology visit, 21% did not have the correct MRI protocol done and 17% had a further MRI spine done through rheumatology clinic. Overall, 92% of patients had at least one MRI spine done. The referral to new appointment wait time in this cohort was 19.4 (41.4) weeks and new visit to first follow-up visit duration of 18.2(13.0) weeks. Only 18% of patients were referred for back pain physiotherapy prior to being seen in rheumatology, with 20% referred at first rheumatology visit and 38% referred after this time. Of those with MBP, 96% were discharged with 82% being discharged after one follow-up i.e. after reviewing new investigation results. Conclusion Delay in time to diagnosis and management of back pain is considerable, with long referral to review and follow-up times and less than 1/5 patients referred for physiotherapy prior to being seen in secondary care. With 92% of patients having at least one MRI spine done, there is a call for front-loading new back pain referrals with appropriate MRI spine imaging at point of vetting along with appropriate blood tests, which we feel would help reduce diagnostic delay and be in line with the UK Getting It Right First Time (GIRFT) programme which advocates that quality care is given first time, every time. Disclosure N. Arumalla: None. E. Okoye: None. R. Jones: None. F. Humby: None. S. Subesinghe: None. T. Golding: None. T. Garrood: Shareholder/stock ownership; Serac Healthcare. Honoraria; UCB, Abbvie. Grants/research support; Versus Arthritis, Pfizer, Gilead, Guy’s and St Thomas’ Charity, NHSX. Other; Fresnius-Kabi. R. Byng-Maddick: None.

P057 Scoping the role of the physiotherapist in the axial spondyloarthritis new patient clinic

Abstract Background/Aims Early diagnosis of Axial Spondyloarthritis (Axial SpA) is crucial to reduce negative impacts and support better patient outcomes through early intervention. There are a number of challenges contributing to delayed diagnosis, the focus of this report relates to the capacity pressures limiting timely assessment and diagnosis. There are a number of well-established, and more recently initiated, physiotherapist-led Axial SpA new patient clinics across UK Rheumatology. These clinics have been locally reported to reduce delays in diagnosis. There is growing interest from other rheumatology services to establish these clinics. A working group of physiotherapists providing physiotherapist-led Axial SpA clinics were supported by a BRITSpA Travelling Fellowship Grant to meet to share service experiences and to develop a consensus-driven best-practice set of recommendations to guide planning and implementing physiotherapist-led Axial SpA new patient assessment clinics in rheumatology departments across the UK. The aim of this report is to provide an overview of the two day Travelling Fellowship project process and the key initial outcomes from the workshop. Methods A two-day workshop attended by ten physiotherapists meeting in person and four joining virtually, all with expertise in providing physiotherapist-led new and review Axial SpA clinics. The workshop programme included presentations from national and international experts, encompassing GIRFT input, exemplar consensus development examples and an opportunity for all fellows to share their experience in setting up and delivering physiotherapist-led Axial SpA new patient clinics. Discussion time was prioritised to allow shared learning, discussion of similarities and local variations to support information gathering and the development of expert consensus-driven guidelines and implementation advice. Patient and public involvement was embedded into the workshop supporting planning discussions and providing lived experience perspectives, preferences and values concerning the implementation and service delivery discussions. Results The major themes and findings identified included the variation in role description and specific responsibilities between centres, including variation in support and mentoring available as well as administration time. However, similar outcomes were found regarding levels of confidence and independence in undertaking thorough triage and assessments of inflammatory back pain referrals leading to confirming or excluding Axial SpA diagnoses, and the skillset to manage these outcomes. Conclusion Following GIRFT recommendations, and in light of the workforce crisis in rheumatology, with support from the rheumatology physiotherapy capabilities framework we have seen the expansion of the physiotherapist role. We have good levels of confidence, following our sharing of clinic data and patient experience comments, that there is a valuable contribution to the rheumatology landscape to be made by physiotherapist-led Axial SpA new patient clinics. Disclosure W.J. Gregory: Honoraria; W.G. has received honoraria for speaking and advisory board from Abbvie, Novartis, Pfizer, Sobi and UCB. R. Adshead: None. Z. Cox: None. E.E. Deeney: None. P.A. Dowie: None. S.J. Fish: None. R. Galway: None. H. Harrison: None. R.J. Hayward: Honoraria; R.H. has received honoraria for speaking from Abbive and Novartis. C. Longton: Honoraria; C.L. has received honoraria for speaking from UCB. M. Motion: None. C. Tonks: None. C. McCrum: Honoraria; C.McC. has received honoraria for professional education workshops- Novartis, Janssen.

Feasibility of Physiotherapist-Led Rheumatology Triage: A Randomized Study.

Given global shortages in the rheumatology workforce, the demand for rheumatology assessment often exceeds the capacity to provide timely access to care. Accurate triage of patient referrals is important to ensure appropriate utilization of finite resources. We assessed the feasibility of physiotherapist (PT)-led triage using a standardized protocol in identifying cases of inflammatory arthritis (IA), as compared to usual rheumatologist triage of referrals for joint pain, in a tertiary care rheumatology clinic. We performed a single-center, prospective, nonblinded, randomized, parallel-group feasibility study with referrals randomized in a 1:1 ratio to either PT-led vs usual rheumatologist triage. Standardized information was collected at referral receipt, triage, and clinic visit. Rheumatologist diagnosis was considered the gold standard for diagnosis of IA. One hundred two referrals were randomized to the PT-led triage arm and 101 to the rheumatologist arm. In the PT-led arm, 65% of referrals triaged as urgent were confirmed to have IA vs 60% in the rheumatologist arm (P = 0.57), suggesting similar accuracy in identifying IA. More referrals were declined in the PT-led triage arm (24 vs 8, P = 0.002), resulting in fewer referrals triaged as semiurgent (6 vs 23, P = 0.003). One case of IA (rheumatologist arm) was incorrectly triaged, resulting in significant delay in time to first assessment. PT-led triage was feasible, appeared as reliable as rheumatologist triage of referrals for joint pain, and led to significantly fewer patients requiring in-clinic visits. This has implications for waitlist management and optimal rheumatology resource utilization.

Improving access to chronic pain care with central referral and triage: The 6-year findings from a single-entry model

ABSTRACT Background Despite the established efficacy of multidisciplinary chronic pain care, barriers such as inflated referral wait times and uncoordinated care further hinder patient health care access. Aims Here we describe the evolution of a single-entry model (SEM) for coordinating access to chronic pain care across seven hospitals in Toronto and explore the impact on patient care 6 years after implementation. Methods In 2017, an innovative SEM was implemented for chronic pain referrals in Toronto and surrounding areas. Referrals are received centrally, triaged by a clinical team, and assigned an appointment according to the level of urgency and the most appropriate care setting/provider. To evaluate the impact of the SEM, a retrospective analysis was undertaken to determine referral patterns, patient characteristics, and referral wait times over the past 6 years. Results Implementation of an SEM streamlined the number of steps in the referral process and led to a standardized referral form with common inclusion and exclusion criteria across sites. Over the 6-year period, referrals increased by 93% and the number of unique providers increased by 91%. Chronic pain service wait times were reduced from 299 (±158) days to 176 (±103) days. However, certain pain diagnoses such as chronic pelvic pain and fibromyalgia far exceed the average. Conclusions The results indicate that the SEM helped reduce wait times for pain conditions and standardized the referral pathway. Continued data capture efforts can help identify gaps in care to enable further health care refinement and improvement.

Chronic Sufferers and Environmental Conditions

Environmental conditions are associated with the onset of pain or the recurrence of symptoms of chronic sufferers either with musculoskeletal pathologies or neurological diseases. Recent research has indicated that physiotherapy also appears to be helpful in dealing with the symptoms of climate change. The purpose of this study was to investigate how temperature and precipitation are associated with referrals for physical therapy. All the data were collected retrospectively for three years, 2020–2022. A total of 2164 referrals were studied, 78% of which were female cases. Our results highlighted that (a) referrals with musculoskeletal problems are associated with the weather indicators of temperature and precipitation, (b) this relation was found to be stronger for females, and (c) there were slightly differentiated trends between them and those with neurological problems. These results suggest that low temperatures and high precipitation are strongly associated with increased referrals for chronic musculoskeletal pain and that females are more vulnerable to precipitation. Moreover, the increased number of referrals with chronic neurological problems was found to be associated with extreme temperatures. Considering these findings, rehabilitation centers and healthcare systems have the opportunity to immediately provide reliable and qualitative services, guided always by the safety and maximum relief of chronic sufferers.

Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial.

Myofascial pain syndrome (MPS) is a muscle pain disorder characterized by the presence of Myofascial Trigger Point (MTrP) within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena. The upper trapezius is the muscle most often affected by MTrPs. Manual myofascial release (MFR) and Instrument-Assisted Soft Tissue Mobilization (IASTM) are techniques of soft tissue release that are used to resolve MPS. Fifty six percent of physiotherapists complain of pain in multiple areas due to the massage and manual therapy that they have to perform. The objective of this study is to find whether IASTM is better than manual MFR in treating patients with MPS in upper trapezius. This study was a single-blinded randomized controlled trial that included 31 participants, both males and females between the age groups of 18-50 years. Participants were randomly divided into two groups. Three sessions were given over a period of one week for both groups. Group A received IASTM along with conventional treatment and Group B received Manual MFR along with the conventional treatment. The outcome measures evaluated were pain, cervical range of motion, pain pressure threshold (PPT) of trigger points, and the neck disability index. Pre- and post-measurements were taken and the analysis was done. Both the treatment methods significantly reduced pain, improved PPT, range of motion, and function. The effects between the groups showed that IASTM was significantly better than manual MFR to reduce pain. The improvement in PPT, range of motion and function were equal in both the groups. IASTM and manual MFR both are effective individually as treatment procedures for pain, PPT, range of motion, and function. Neither of the treatment options can be considered better that the other. The clinician can decide based on the availability of the instrument, training, patient's preference, and his/her comfort whether which of the two treatment methods should be used.

Clinicopathological profile of mastalgia in females: incidence, types, and pathological correlations. a cross-Sectional study.

Mastalgia was the most common symptom in patients attending a breast clinic. The two most common types of mastalgia were (cyclical and non-cyclical). The common cause of cyclical was Physiological changes due to premenstrual tension syndrome fibrocystic changes or fibroadenosis and (Aberrations in the Normal Development and Involution of the breast ). Non-cyclical diseases are mainly benign rather than malignant. Solid masses (fibroadenomas), cysts, infections, abscesses, trauma, and nipple discharge (hormones) are rare diseases associated with breast cancer. The aim of this study is to study the incidence of mastalgia, types (cyclical and non-cyclical) and pathological types of mastalgia (benign and malignant pathologies). A cross-sectional descriptive study of mastalgia was carried out at the Breast Center Department of Maternity Teaching Hospital located in Erbil, from January 2014 to September 2015. A total of 150 breast pain cases (available clinical data) were studied in detail. There are two types of mastalgia based on triple assessments, these are as follows, cyclical 90 cases (60%) and non-cyclical 60 cases (40%). Fibrocystic breast changes or fibroadenosis 35 cases (23.3%) and thirdly nipple discharges as part of fibrocystic (fibroadenosis) five cases (3.3%). Non-cyclical mastalgia was subdivided into benign breast pathologies, fibroadenoma 30 cases (20%), breast cyst 10 cases (6.7%), nipple discharge (hormonal) five cases (3.3%), mastitis three cases (2%) abscess two cases (1.3%), fat necrosis one case (0.7%), and malignant breast pathologies, cancer three cases (2%). Clinicopathological correlations in the current study were highly significant (P<0.005). Not all discomfort or pain can be diagnosed as mastalgia; occasionally, chest wall, referral pain, and systemic causes can mimic mastalgia. These results highlight the importance of differentiating between cyclical and non-cyclical mastalgia using clinical assessment, sonography, mammography, and blood investigations. Most mastalgia cases are benign, with cyclical mastalgia primarily related to hormonal changes during the menstrual cycle.

Prevalence and perceptions of pain in people with haemophilia: A UK study.

Joint bleeds in haemophilia cause destruction of articular structures, impaired function and pain. Up to 70% of people with haemophilia (PWH) report chronic pain. Little is known about the pain experiences in PWH in the UK. To identify prevalence and perceptions of pain among PWH living in the UK. A cross-sectional, non-interventional survey study conducted among PWH (all severities). The survey incorporated elements from validated tools (EQ-5D; EQ-VAS) and was distributed via participating treatment centres. Five hundred and ninety-nine PWH responded, 91% aged>18. 81% used factor prophylactically or on demand. More pain was reported by those treated on demand versus prophylaxis particularly in those who reported daily pain. 65% reported 'problem joints' based on individual impact rather than medically defined 'target joints', 2/3 reported multiple joint issues. The ankle was most commonly affected. 59% reported frequent pain, with 56% aware of pain constantly or most of the time and were more likely to report less favourable EQ-5D or EQ-VAS scores (p<.001). Pain frequency/awareness was consistent across all severities. Most discussed pain with care teams, 31% only when asked; 25% did not discuss it. Pain discussions resulted in physiotherapy referral (63%) analgesia prescription (48%), and a minority specialist pain referral (9%). Most felt well supported with regard to their pain, but 70% reported learning to live with it. Pain affects PWH of all ages and severities even in a well-resourced country significantly impacting quality of life. Clinicians must be more aware of chronic pain in PWH. Biopsychosocial approaches to pain assessment and management are recommended.

375 Introduction of a Physician Associate (PA) Led Surgical Ambulatory Emergency Clinic (SAEC) in the Highlands of Scotland

Abstract Aim The delivery of surgical care in the Highlands has changed. SAEC was developed to alleviate bed pressures, improve patient satisfaction, and avoid unnecessary workload. We aim to identify whether SAEC is alleviating pressures in the surgical inpatient department - is it used appropriately and cost effectively. Method Attendance was collected prospectively (1/9/22 to 31/10/22) using a dedicated data audit book and booking diary. Patient’s individual review outcomes were gathered. Results Of the 165 patients referred to SAEC, 90% were reviewed by the PA, 10% only by the consultant. On average, 3.7 patients were seen per day. The referral reasons were wide ranging: 64 referrals for abdominal pain in addition to abscesses, constipation, weight loss, vomiting, stoma reviews and more. The age of patients ranged from 20-91. 61% were female. 46% had a scan. 85% received a diagnosis. 93% received definitive management. No patients made an unplanned re-presentation within the week following their review. The average time spent in SAEC per patient was 2 hours 48 minutes. 17% of patients were admitted, preventing 116 admissions. This saved approximately £45,820 through admission prevention. In addition, approximately a further £47492 was saved as this was PA led rather than consultant. Conclusions Prior to the employment of a PA, SAEC did not provide a consistent service, brought all patients to its surgical ward, and required employment of a second consultant. SAEC has improved patient flow and increased bed capacity whilst providing safe and high-quality care that is cost-effective.

ThTP8.12 Introduction of a Physician Associate (PA) led surgical ambulatory emergency clinic (SAEC) in the Highlands of Scotland

Abstract Aim The delivery of surgical care in the Highlands has changed. SAEC was developed to alleviate bed pressures, improve patient satisfaction and avoid unnecessary workload. We aim to identify whether SAEC is alleviating pressures in the surgical inpatient department - is it used appropriately and cost effectively. Methods Attendance was collected prospectively (1/9/22 to 31/10/22) using a dedicated data audit book and booking diary. Patient’s individual review outcomes were gathered. Results Of the 165 patients referred to SAEC, 90% were reviewed by the PA, 10% only by the consultant. On average, 3.7 patients were seen per day. The referral reasons were wide ranging: 64 referrals for abdominal pain in addition to abscesses, constipation, weight loss, vomiting, stoma reviews and more. The age of patients ranged from 20-91. 61% were female. 46% had a scan. 85% received a diagnosis. 93% received definitive management. No patients made an unplanned re-presentation within the week following their review. The average time spent in SAEC per patient was 2 hours 48 minutes. 17% of patients were admitted, preventing 116 admissions. This saved approximately £45,820 through admission prevention. In addition, approximately a further £47492 was saved as this was PA led rather than consultant. Conclusion Prior to the employment of a PA, SAEC did not provide a consistent service, brought all patients to its surgical ward and required employment of a second consultant. SAEC has improved patient flow and increased bed capacity whilst providing safe and high-quality care that is cost-effective.

Exploring usual care for patients with low back pain in primary care: a cross-sectional study of general practitioners, physiotherapists and chiropractors

ObjectivesTo explore the elements and composition of care provided by general practitioners (GPs), physiotherapists (PTs) and chiropractors (DCs) to patients with low back pain (LBP).DesignObservational study.SettingPrimary care setting, Denmark.ParticipantsPrimary care...

Inefficient Admissions for Abdominal Pain Under an Acute General Surgical Unit

BackgroundThe acute general surgical unit (AGSU) model has become a standard of efficient acute surgical care. Whilst the AGSU has been compared to the traditional surgical model, there is a lack of research auditing referrals and admissions. This study evaluates abdominal pain referrals to AGSU and the necessity of admission.MethodsA retrospective cohort study of adult abdominal pain admissions was conducted over a two-year period at a single centre in metropolitan Victoria, Australia. The data were extracted from electronic medical records and key endpoints of data included the diagnosis, length of stay, investigations and subjective pain outcomes.ResultsA total of 1587 patients met the study criteria of which 1116 (70.3%) had a non-surgical diagnosis with the majority having non-specific abdominal pain. The non-surgical patients had a lower median length of stay (25.3 h) compared to surgical patients (44.2 h, p < 0.001). They were less likely to have an abnormal haemoglobin (p = 0.004), elevated white cell count (p = 0.02) or elevated C-reactive protein > 50 mg/L (p < 0.001). On multivariable analysis, surgical patients had higher odds of having a CRP > 50 mg/L (p = 0.024) and a positive imaging result (p < 0.001). The patient’s pain control also correlated with length of stay.ConclusionA large population of patients with non-specific abdominal pain are admitted to AGSU. These patients do not require surgery and have a short length of stay. Incorporating a negative CRP result and negative imaging result may be utilised in conjunction with optimised analgesia to help avoid these unnecessary admissions, thereby improving AGSU efficiency and workload.

Program Evaluation: exploring health disparities that impact chronic pain referrals within a VA Health Care System.

The present Program Evaluation study examines sociodemographic characteristics of Veterans in the Phoenix VA Health Care System who have back pain, and specifically the likelihood of those characteristics being associated with a referral to the Chronic Pain Wellness Center (CPWC) in the year 2021. We examined the following characteristics: Race/ethnicity, gender, age, mental health diagnosis, substance use disorder diagnosis, and service-connected diagnosis. Our study used cross sectional data from the Corporate Data Warehouse for 2021. 13624 records had complete data for the variables of interest. Univariate and multivariate logistic regression was used to determine the likelihood of patients' being referred to the Chronic Pain Wellness Center. The multivariate model found under-referral to be significant for younger adults and for patients who identified as Hispanic/Latinx, Black/African American, or Native American/Alaskan. Those with depressive disorders and opioid use disorders, on the other hand, were found to be more likely to be referred to the pain clinic. Other sociodemographic characteristics were not found to be significant. Study limitations include the use of cross-sectional data, which cannot determine causality, and the inclusion of patients only if the ICD-10 codes of interest were recorded for an encounter in 2021 (i.e., a prior history of a particular diagnosis was not captured). In future efforts, we plan to examine, implement, and track the impact of interventions designed to mitigate these identified disparities in access to chronic pain specialty care.

E009 A review of MRI indications and outcomes to identify a clinical predictor for joint inflammation

Abstract Background/Aims Due to the nature of symptoms there is often a delay in diagnosing axial spondyloarthritis (AxSpA), the median delay from initial symptoms is over 8 years. A Rheumatology IBP (inflammatory back pain) service can reduce this to 3 years. MRI is highly sensitive for recognising early spine and sacroiliac joint (SIJ) changes. The objective of this project was to evaluate the value of spinal and SIJ MRI requests in a rheumatology department to try and identify a clinical predictor of MRI inflammation. Methods A retrospective review of 107 patients who underwent a spinal and SIJ MRI. An assessment of the clinical indications, MRI findings, and the management impact. Numerous parameters were assessed for each patient, including appointment type (face-to-face vs telephone), referrer grade, AxSpA ASAS criteria, CRP, HLA-B27 status, MRI result and management impact. Results 41.25% of patients who had ≥2 AxSpA features had inflammation on MRI. However, only 11.54% of patients with ≤1 AxSpA feature had inflammation on MRI. ≥2 AxSpA features was a significant predictor for MRI inflammation, with a p-value of 0.00545 and sensitivity 91.67%. Additionally, just 33% of patients had HLA-B27 status documented, providing scope for improvement when using AxSpA features as a predictor. An active BASDAI score was not found to be a predictor of MRI inflammation. Additionally, there was no statistical difference in the MRI findings following face-to-face or telephone consultations; 35.53% had inflammation on MRI compared to 32.26%, respectively. Conclusion ≥2 AxSpA features is a statistically significant predictor of active MRI inflammation. This could be used to support a new triage assessment pathway for inflammatory back pain referrals to rheumatology. Disclosure L. Barry: None. A. Roberts: None. B. Menon: None. S. Subesinghe: None.

Diagnostic approach to low back pain

Low back pain is an important cause of pain referrals in the primary care setting. Overall, 85% of initial admissions are considered to be nonspecific low back pain that resolves in a few weeks without the need for additional evaluation. Myofascial pain, lumbar disc herniation, spinal stenosis, facet joint and disc degeneration, and sacroiliac joint pathologies are common causes of mechanical low back pain. Non-mechanical low back pain includes infections of the vertebral corpus and disc, malignant tumors and metastases, and inflammatory diseases. Red flag symptoms suggestive of serious diseases should be evaluated in all patients with low back pain, and the diagnosis process should be accelerated in patients with these symptoms. The so-called "yellow flags" associated with chronic low back pain include psychosocial factors. In the diagnosis process, pain relief is observed in patients with non-specific low back pain without the need for imaging methods. Laboratory tests and imaging methods can be used to distinguish other causes of low back pain.