Background

Social context may be important in chronic pain. One focus is reactions to pain between persons with LBP and their partners. Researchers have investigated partner reactions and found influences on pain levels and psychological outcomes, but little is known about factors underpinning these reactions.

Background: Sciatica is an important cause of pain and disability but relatively few studies have looked at predictors of outcome in sciatica populations. Prognostic studies in non-specific low back pain are more common, but it has been suggested that the prognostic indicators for sciatica may be different. Our aim was to systematically review and describe the literature investigating the predictors of outcome in sciatica populations.

Methods: A systematic literature search of the databases (Medline, EMBASE, and CINAHL) and reference list of identified articles was conducted. Studies were included if they described subjects with sciatica, had a follow-up period of at least three months and measured outcomes including pain, disability, recovery, psychological outcomes or return to work. Methodological quality was assessed using a 15 item checklist.

Results: 596 papers were identified but only 12 met the criteria for inclusion. A combination of individual (e.g. gender, BMI), biomedical (e.g. size of disc prolapse, neurological deficit), social (e.g. job satisfaction, social status, manual labour) and psychological (distress, mental health) predictors of outcome were reported.

Conclusions: There are few high quality studies that have investigated prognostic factors associated with persistence of sciatic symptoms. Those identified explored a range of different factors, in a variety of settings and in subjects with variable duration of symptoms. Although the studies are difficult to interpret due to heterogeneity of the techniques used in analysis and presentation, they seem to suggest that clinical, occupational and individual factors might be more strongly associated with outcome than psychological factors in sciatica populations.

Conflicts of Interest: None

Funding: None

A key factor delaying rehabilitation after a tendo Achillis (TA) rupture is gait abnormality. We quantified changes in planter pressures after a rupture of the TA in four groups of patients:

15 controls subjects, mean 40 years, with no history of lower limb abnormality

Mean and maximum peak planter pressures within the forefoot and heel were measured using in-shoe pressure pads two weeks after removal of the cast/orthosis; five gait cycles were recorded. The terminal stance and pre-swing phases were also measured as a proportion of the total stance phase of the gait cycle. One-way ANOVA was used to compare the difference in means between the groups.

The normal control group had less than 2% difference between the limbs on all of the measured parameters. The patients in the plaster cast and ‘rigid’ orthotic groups had significant deficits (p = 0.04 and < 0.001 compared to control) in mean peak forefoot pressures, implying weakness in the triceps surae. However, the patients in the flexible orthosis group had only an 11% deficit (p = 0.25 compared to control). All of the patients treated for a TA rupture had increased heel pressures but only the ‘rigid’ orthotic group had cadence abnormalities (p = < 0.001). This may be the result of abnormal motor patterns secondary to mobilising in the rigid orthosis.

This study highlights the gait abnormalities associated with triceps surae weakness following rupture of the TA. Accelerated rehabilitation using weight-bearing orthotics may alleviate some of these problems, but new designs for flexible orthotics may be required for maximum benefit.

Background: LBP Epidemiological studies have identified important causal and prognostic factors, but these frequently only identify a proportion of the variance, and new factors add little to these models. Recently, interest has increased in studying diseases over the lifecourse, a move accompanied by crucial conceptual and methodological developments. This has resulted in improvements in the understanding of conditions such as cardiovascular and respiratory disease.

Aim: To examine how conceptual frameworks from lifecourse epidemiology could enhance LBP research.

Method and Results: Concept 1: patterns over time, risk chains and accumulation. Simple ‘chains of risk’ have been studied, e.g. depression leading to LBP, but studies involving more risk factors in the chain are infrequent. Also, we have not examined how risk accumulation influences outcome, e.g. whether multiple episodes or duration of depression, throughout the lifecourse, better predicts LBP. One-year LBP trajectories have been described, but descriptions of longer-term patterns with associated transitions and turning points are lacking. Concept 2: influences and determinants of pathways. LBP studies commonly adjust for confounders, but factors modifying risk, or related to resilience or susceptibility to LBP, are rarely studied. Concept 3: timing of risk. Studies of critical or sensitive periods – crucial times of life which influence later health in life – are scarce in LBP research.

Conclusion: LBP researchers should develop hypotheses and models of how risks from different stages of life might interact and influence the onset, persistence and prognosis of LBP throughout the lifecourse. Adoption of concepts and methods from lifecourse epidemiology could facilitate this.

Background: Many studies have investigated predictors of outcome in low back pain (LBP) patients, including the role of coping. However, the relative importance of different coping strategies is unclear.

Objective: To systematically review prospective cohort studies to determine the role of specific coping strategies in the prediction of LBP outcome in primary care settings.

Methods: Medline, PsychINFO, and Embase electronic databases were searched from inception to April 2008. Prospective cohort studies focusing on aspects of coping with LBP in settings relevant to primary care were included. Studies were excluded if they focused on specific populations (e.g. nursing staff) or patients aged under 18 years, or if they were not published in English. Prior to data extraction, studies were quality assessed and coping strategies were conceptualised as either cognitive or behavioural.

Results: 782 potentially relevant articles were identified, of which 34 were included with an average follow-up of 10 months. There was considerable variability in the prognostic risk factors measured. Fear avoidance beliefs were most frequently associated with outcome. Negative affect, anxiety and depression, use of active or passive coping strategies, and catastrophizing were also commonly associated with outcome. Behavioural coping strategies were measured by only 5 of the 34 studies.

Conclusion: Despite considerable heterogeneity, most studies were of acceptable quality, enabling the identification of several key coping strategies predictive of LBP outcome. However, the majority of studies focused on cognitive coping factors only. Therefore further research is needed, particularly to investigate the influence of behavioural coping strategies on LBP outcome.

Introduction: Detecting relevant clinical subgroups of patients with non-specific LBP is a priority for research as it has potential for improving treatment effectiveness. The STarT Back Tool (SBT) was recently developed and validated to subgroup LBP patients into targeted treatment pathways in primary care. This study tested the SBT’s criterion validity against a popular existing LBP subgrouping tool – the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ).

Methods: 244 consecutive ‘non-specific’ LBP consulters at 8 GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the OMPSQ & SBT; disability (RMDQ); pain intensity (11-item NRS); duration of symptoms; and demographics. Instruments were compared using Spearman’s rank correlation, discriminant analysis of subgroups, tests for allocation agreement and predictive validity using published data.

Results: Completed SBT (9-items) and OMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and OMPSQ scores was ‘excellent (rs = 0.80, p=< 0.001). Subgroup characteristics from both tools were similar particularly among the ‘low’ risk groups, however, the proportion of patients allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with more distressed patients in the SBT’s high risk group. The SBT better predicted pain and disability at 6 months and both equally predicted time off work.

Conclusion: The SBT psychometric properties perform as well or better than the OMPSQ, but the SBT is shorter and easier to score. It is therefore an appropriate alternative for screening LBP patients in primary care.

Background: Last year we presented the STarT Back Tool, which is validated for use in Primary Care. It subgroups patients into 3 categories (high, medium and low risk) on the basis of modifiable risk factors for chronicity. We are now piloting the feasibility of using the tool as part of a new approach to sub-grouping and targeting back pain in primary care.

Methods: The physiotherapy interventions for the 3 subgroups were developed after reviewing the literature, current guidelines, the content of existing targeted treatment programmes, and convening workshops with internationally recognised experts. Both the intervention training modules, and the targeted treatments were piloted. Consecutive back pain consulters were identified using GP electronic Read Codes (weekly downloads) and invited to attend the study’s back pain clinic. Consenting patients completed a baseline questionnaire and were classified by the tool into one of 3 sub-groups.

Results: 60 patients were recruited. 50 patients were allocated to receive treatment according to their subgroup allocation and 10 patients (control group) received a triage physiotherapy assessment (usual care) to decide if they needed further physiotherapy treatment. Primary outcomes include the Roland Morris Disability Questionnaire and the Pain Catastrophising Scale. Three-month follow-up postal questionnaires are currently being administered and outcomes will be presented at the conference. Clinicians involved (GPs, and physiotherapists) will be interviewed to identify the feasibility of this approach.

Conclusions: Once feasibility is established we will take this developmental work forwards into the clinical trial arena to investigate whether this novel “sub-grouping for targeted treatment” approach provides a cost effective way of reducing long-term risk of chronic disability in patients consulting their GP with back pain.

Background: Most reports of sickness absence come either from company records, which are limited to specific workforces, or rely on self-report. Electronic recording of sickness certification in primary care medical records provides an alternative source of information.

Purpose: To investigate the validity of electronic sickness certification records in primary care.

Methods: Analysis included 292 primary care LBP consulters, who returned a questionnaire including self-reported work absence, and consented to medical record review. Sickness certification records for 2001–2 were downloaded. Self-reported sickness absence for the previous 2-weeks was matched with electronic records for the same time period. Records were considered to match if there was no reported absence and no certificate, if there was reported absence > =7 days and a certificate, or if reported absence was < 7 days and no certificate was issued.

Results: Overall, 84% of records matched; 87% of employed consulters and 90% of unemployed consulters. Among the employed, 100% of reports of no absence did not have a certificate, 49% of reported absences > =7 days were matched by a certificate for the same time period and lastly, 80% of reported absences of < 7 days did not have a certificate.

Conclusion: We have demonstrated that people with none or short self-reported work absences do not have sickness certificates in their records, but only a small proportion of people with longer self-reported absences appear to have certificates. Further work will investigate possible reasons for non-matching, these may include non-requirement of a certificate, recall errors or incomplete recording of sickness certificates.

Background: Patients with LBP, ‘at risk’ of persistent symptoms, require targeted treatment in primary care. We have therefore developed and validated a new screening tool to classify these patients into appropriate management groups.

Methods: A list of LBP prognostic indicators was compiled by reviewing published studies and analysing existing datasets. Indicators were selected for the tool according to face and construct validity, consistency and strength of association. For each indicator outcome measure (e.g. Pain Catastrophising Scale) an individual question (e.g. ‘I feel that my back pain is terrible and that it is never going to get an better’) was selected for inclusion (ROC analysis). The tool was modelled to classify patients into 3 categories of risk. The screening tool and corresponding complete scales were mailed to 244 consecutive primary care LBP consulters. Individual items were validated against complete scales. Reliability was examined on 53 responders.

Results: This new screening tool classifies patients using 9-items to cover 8 key prognostic indicators. The questionnaires returned by 131 consulters demonstrated excellent construct validity for all individual items. 33% of patients were classified as ‘high risk’ (psychosocial and physical factors), 44% ‘intermediate risk’ (physical factors alone) and 23% ‘low risk’. Discrimination between groups across relevant constructs such as pain, disability, days off work and psychological distress was highly significant. Test-retest reliability was moderate (kappa = 0.54).

Conclusions: A novel LBP screening tool has been validated in primary care and effectively classifies patients ‘at risk’ of persistent symptoms. This will facilitate appropriate targeting of treatment.