The Keele STarT Back approach is effective for stratifying patients with low back pain in primary care, but a similar approach has not been tested with a broader range of patients with musculoskeletal (MSK) pain. We report a feasibility and pilot trial examining the feasibility of a future main trial of a primary care based, risk-stratification (STarT MSK) approach for patients with back, neck, knee, shoulder or multi-site pain. A pragmatic, two-parallel arm, cluster randomised controlled trial (RCT) in 8 GP practices (4 stratified care involving use of the Keele STarT MSK tool and matched treatment options: 4 usual care). Following screening, adults with one of the five most common MSK pain presentations were invited to take part in data collection over 6 months. Feasibility outcomes included exploration of selection bias, recruitment and follow-up rates, clinician engagement with using the Keele STarT MSK tool and matching patients to treatments.Background and aims
Methods
Healthcare for sciatica is usually ‘stepped’ with initial advice and analgesia, then physiotherapy, then more invasive interventions if symptoms continue. The SCOPiC trial tested a stratified care algorithm combining prognostic and clinical characteristics to allocate patients into one of three groups, with matched care pathways, and compared the effectiveness of stratified care (SC) with non-stratified, usual care (UC). Pragmatic two-parallel arm RCT with 476 adults recruited from 42 GP practices and randomised (1:1) to either SC or UC (238 per arm). In SC, participants in group 1 were offered up to 2 advice/treatment sessions with a physiotherapist, group 2 were offered up to 6 physiotherapy sessions, and group 3 was ‘fast-tracked’ to MRI and spinal specialist opinion. Primary outcome was time to first resolution of sciatica symptoms (6-point ordinal scale) collected via text messages. Secondary outcomes (4 and 12 months) included leg and back pain intensity, physical function, psychological status, time-off-work, satisfaction with care. Primary analysis was by intention to treat.Background and Purpose
Methods
Medication prescribing patterns for patients with neuropathic low back-related leg pain (LBLP) in primary care are unknown. To estimate the proportion of patients prescribed pain medications, describe baseline characteristics of patients prescribed neuropathic pain (NP) medication and estimate the proportion of LBLP patients with refractory NP.Background
Purpose
There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care. To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP).Background
Purpose
Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in one primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was carried out on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-years follow-up plus at least 3 (of 6) subsequent monthly questionnaires. Baseline factors were measured using validated tools. Pain intensity scores from the 5-year follow-up and monthly questionnaires were used to cluster participants into 4 previously derived pain trajectories (no or occasional mild, persistent mild, fluctuating, persistent severe), using latent class analysis. Posterior probabilities of belonging to each cluster were estimated for each participant. The posterior probabilities for the assigned clusters were very high (>0.90) for each cluster except for the smallest ‘fluctuating’ cluster (0.74). Lower social class (OR 2.9; 95% CI 1.2, 7.0), higher pain intensity (1.6 per unit; 1.2, 2.2), and pain duration greater than 3 years (2.7; 1.0, 7.3), were significantly associated with a more severe trajectory 5-years later, as were higher physical disability, emotional impact of pain, and perception pain will last a long time.Background and objectives
Methods and results
Patients with low back-related leg pain (LBLP) can present with neuropathic pain; it is not known but is often assumed that neuropathic pain persists over time. This research aimed to identify cases with neuropathic pain that persisted at short, intermediate and longer-term time points, in LBLP patients consulting in primary care. LBLP patients in a primary care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible neuropathic pain) at baseline, 4-months, 12-months and 3-years. S-LANSS scores and percentages of patients with score of ≥12 are described at each time-point. Multiple imputation was used to account for missing data.Background
Methods
Low back-related leg pain (LBLP) is clinically diagnosed as referred leg pain or sciatica. Within the spectrum of LBLP there may be unrecognised subgroups of patients. This study aimed to identify and describe clusters of LBLP patients using latent class analysis (LCA). The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were described and compared to the clinically defined groups of LBLP patients.Background
Methods
Neuropathic pain is a challenging pain syndrome to manage. Low back-related leg pain (LBLP) is clinically diagnosed as either sciatica or referred leg pain and sciatica is often assumed to be neuropathic. Our aim was to describe the prevalence and characteristics of neuropathic pain in LBLP patients. Analysis of cross-sectional data from a prospective, primary care cohort of 609 LBLP patients. Patients completed questionnaires, and received clinical assessment including MRI. Neuropathic characteristics (NC) were measured using the self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (SLANSS; score of ≥12 indicates pain with NC).Purpose of study and background
Methods
To identify treatment effect modifiers within the STarT Back Trial which demonstrated prognostic stratified care was effective in comparison to standard care for patients with low back pain. Secondary analysis of the STarT Back Trial using 688 patients with available 4-month follow-up data. Disability (baseline and 4 months) was assessed using the Roland Morris Disability Questionnaire (RMDQ) using continuous and dichotomized (>7) outcome scores. Potential treatment effect modifiers were evaluated with group x predictor interaction terms using linear and logistic regression models. Modifiers included: age, gender, education, socio-economic status (SES), employment status, work satisfaction, episode duration, general health (SF-12), number of pain medications, and treatment expectations.Purpose and Background:
Methods:
Identification of nerve root involvement (NRI) in patients with low back-related leg pain (LBLP) can be challenging. Diagnostic models have mainly been developed in secondary care with conflicting reference standards and predictor selection. This study aims to ascertain which cluster of items from clinical assessment best identify NRI in primary care consulters with LBLP Cross-sectional data on 395 LBLP consulters were analysed. Potential NRI indicators were seven clinical assessment items. Two definitions of NRI formed the reference standards: (i) high confidence (≥80%) NRI clinical diagnosis (ii) high confidence (≥80%) NRI clinical diagnosis with confirmatory magnetic resonance imaging (MRI) findings. Multivariable logistic regression models were constructed and compared for both reference standards. Model performances were summarised using the Hosmer-Lemeshow statistic and area under the curve (AUC). Bootstrapping assessed internal validity.Background:
Methods:
Leg pain frequently accompanies low back pain and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back- related leg pain (LBLP) is important for clinical management and research applications. The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP. The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were quality appraised independently by two reviewers using a standardised scoring tool.Background
Methods
60% of back pain patients report pain radiation in the leg(s), which is associated with worse symptoms and poorer recovery. The majority are treated in primary care, but detailed information about them is scarce. The objective of this study is to describe the characteristics of patients with back and leg pain-seeking treatment in primary care. Adult patients consulting their GP with back and leg pain were invited to the study. Participants completed questionnaires including sociodemographic, physical and psychosocial measures. They also underwent standardised clinical assessments by physiotherapists, and received an MRI scan.Background
Methods
Pain with radiation to the leg is a common presentation in back pain patients. Radiating leg pain is either referred pain or radicular, commonly described as sciatica. Clinically distinguishing between these types of leg pain is recognized as difficult but important for management purposes. The aim of this study was to investigate inter-therapist agreement when diagnosing referred or radicular pain. Thirty-six primary care consulters with low back-related leg pain were assessed and diagnosed as referred or radicular leg pain by one of six trained experienced musculoskeletal physiotherapists. Assessments were videoed, excluding any diagnosis discourse, and viewed by a second physiotherapist who made an independent diagnosis. Therapists rated their confidence with diagnosis and reasons for their decision. Data was summarized using percentage agreements and kappa (K) coefficients with two sided 95% confidence intervals (CI).Background
Methods
A wide array of measures has been developed to assess the role of psychological factors in the development and persistence of pain. Yet there is likely to be considerable conceptual overlap between such measures, and consequently a lack of clarity about the importance of psychological factors. To investigate whether conceptual overlap exists within psychological measures used in back pain research.Background
Purpose
People with back pain often experience long-term pain with recurrences and fluctuations. However, few studies have considered which factors predict long-term outcomes. To determine the prognostic factors, measured around the time of a primary care back pain consultation, that predict clinically significant pain in both the short (6 months) and long-term (5 years).Background
Purpose
One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes. 1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-related health care costs.Background
Methods
To identify the early functional outcomes, survivorship and complications associated with the Corin Uniglide Unicompartmental Knee Replacement (UKRs) from an independent centre. A prospective consecutive case series of sixty Uniglide UKRs was carried out in fifty-one patients between January 2006 and March 2009. The data collected included:
Primary outcome measures: Pre- and post-operative American Knee Society Score (AKSS), Oxford Knee Scores (OKS), WOMAC Survivorship Secondary outcome measures: X-ray error scores assessing component position Complications No cases were lost to follow-up. Mean follow-up time was 19 months (12 to 36months) and mean age was 66 years (39 to 78 years). Kaplan-Meier Survivorship showed 95% survival at 3 years (CI:6.4). All functional outcomes showed significant improvement p <0.05. There were two revisions within the first year, which were the main complications, secondary to aseptic tibial loosening and collapse of the posteromedial tibia. The x-ray error score identified the most common error as the femoral flexion/extension angle followed by the anterior/posterior fit.Purpose of Study
Methods and Results
To compare the contribution of physical, psychological and social indicators to predicting disability after one year between consulters with low back pain (LBP) of less than 3 months duration and more than 3 months duration. Data from two large prospective cohort studies of consecutive patients consulting with LBP in general practices were merged, with disability measured by the Roland Morris Disability Questionnaire (RMDQ). There were complete data for 258 cases with acute/subacute LBP and 668 cases with chronic LBP at 12 months follow-up. Univariate and adjusted multivariate regression analyses of various potential prognostic indicators for disability at 12 months were carried out.Purpose
Methods
Although low back pain (LBP) with leg pain, is considered by most a poor prognostic indicator, it is at the same time believed to have a favourable natural resolution, and is often treated along similar lines to non-specific LBP, in line with current guidelines. It is unclear whether patients with LBP and leg pain are a distinct subgroup that might benefit from early identification and targeted interventions. We set out to investigate the impact of LBP with leg pain on health outcomes and health resources compared with that of LBP alone, and to explore which factors contribute to the observed disability outcomes. A systematic literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1994 to 2009.Purpose and background
Methods
Trajectories of change over time can illustrate the course of pain. Back pain trajectories have previously been identified among adults. Understanding different patterns of back pain among adolescents could shed light on how persistent back pain develops. We aimed to identify and compare trajectories of back pain among adolescents in the general population. This prospective cohort study followed 1,336 adolescents (initially aged 11 years) every three months for three years, using self-completion questionnaires. Latent class growth analysis was used to cluster subjects into distinct trajectories of back pain. Six clusters were identified. Most subjects (78%) had very low likelihood of back pain throughout follow-up. The second largest cluster (10%) had relatively low and falling probability of back pain. Two clusters (4% each) showed increasing probability of back pain. One cluster had a peak likelihood of pain around age 13 (2%). The smallest cluster (1%) had very high probability of back pain throughout follow-up. The more painful trajectories had significantly fewer males, higher levels of depression and somatization, and lower life satisfaction at baseline, but differed little in physical activity or BMI.Background and purpose
Methods and results
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. To investigate the associations of relationship quality and perceived partner responses with LBP intensity and disability.Background
Aim
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 14 patients, mean 48 years, treated in a non-weight-bearing plaster cast 12 patients, mean age 45 years, treated with immediate weight-bearing in a ‘rigid’ orthosis. 14 patients, mean age 51 years, treated with immediate weight-bearing in a ‘flexible’ orthosis. 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.
