Background
Numerous systematic reviews have attempted to synthesize evidence on prognostic factors for predicting future outcomes such as pain, disability and return‐to‐work/work absence in neck and ...low back pain populations.
Databases and datatreatment
An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for each prognostic factor investigated. Searches were limited to the last 10 years (2008‐11th April 2018, updated 28th September 2020). A two‐stage approach was undertaken: in stage one, data on prognostic factors was extracted from systematic reviews identified from the systematic search that met the inclusion criteria. Where a prognostic factor was investigated in ≥1 systematic review and where 50% or more of those reviews found an association between the prognostic factor and one of the outcomes of interest, it was taken forward to stage two. In stage two, additional information extracted included the strength of association found, consistency of effects and risk of bias. The GRADE approach was used to grade confidence in the evidence.
Results
Stage one identified 41 reviews (90 prognostic factors), with 35 reviews (25 prognostic factors) taken forward to stage two. Seven prognostic factors (disability/activity limitation, mental health; pain intensity; pain severity; coping; expectation of outcome/recovery and fear‐avoidance) were judged as having moderate confidence for robust findings.
Conclusions
Although there was conflicting evidence for the strength of association with outcome, these factors may be used for identifying vulnerable subgroups or people able to self‐manage. Further research can investigate the impact of using such prognostic information on treatment/referral decisions and patient outcomes.
Background and objective
This systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use ...across Europe.
Databases and Data Treatment
Comprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up‐to‐date evidence‐based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines.
Results
Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain‐specific subgroups—work‐based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain.
Conclusions
This review of European CPGs identified a range of mainly non‐pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe.
Significance
Consensus regarding evidence‐based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non‐pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back‐UP research team will transfer these evidence‐based treatment options to an accessible clinician decision support tool for first contact clinicians.
Back pain is a common and costly health problem worldwide. There is yet a lack of consistent methodologies to estimate the economic burden of back pain to society.
To systematically evaluate the ...methodologies used in the published cost of illness (COI) literature for estimating the direct and indirect costs attributed to back pain, and to present a summary of the estimated cost burden.
Six electronic databases were searched to identify COI studies of back pain published in English up to February 2021. A total of 1,588 abstracts were screened, and 55 full-text studies were subsequently reviewed. After applying the inclusion criteria, 45 studies pertaining to the direct and indirect costs of back pain were analysed.
The studies reported data on 15 industrialised countries. The national cost estimates of back pain in 2015 USD ranged from $259 million ($29.1 per capita) in Sweden to $71.6 billion ($868.4 per capita) in Germany. There was high heterogeneity among the studies in terms of the methodologies used for analysis and the resulting costs reported. Most of the studies assessed costs from a societal perspective (n = 29). The magnitude and accuracy of the reported costs were influenced by the case definition of back pain, the source of data used, the cost components included and the analysis method. Among the studies that provided both direct and indirect cost estimates (n = 15), indirect costs resulting from lost or reduced work productivity far outweighed the direct costs.
Back pain imposes substantial economic burden on society. This review demonstrated that existing published COI studies of back pain used heterogeneous approaches reflecting a lack of consensus on methodology. A standardised methodological approach is required to increase credibility of the findings of COI studies and improve comparison of estimates across studies.
Abstract Background The cost of low back pain (LBP) to employers is high, with an estimated £9090 million lost in the United Kingdom in 1998. Economic analysis of LBP has focused on work absence ...among the employed. There is little research characterising individuals who report reduced duties or who are not in employment because of LBP. Aims To compare the health related characteristics of primary care LBP consulters reporting usual employment, reduced duties, sick leave and non-employment as a result of LBP. Methods Prospective cohort study recruiting LBP consulters aged 30–59 years of age from five general practices in North Staffordshire. Results Nine hundred and thirty-five participants completed the baseline phase, 65% were in employment and 35% were not in employment. Of the employed participants over 1 in 10 (11%) were undertaking reduced duties and almost one-fifth were reporting sick leave (22%). Furthermore, 37% of non-employed consulters reported that LBP was the reason for non-employment. Significant differences at baseline in socioeconomic status, self-rated health, anxiety, depression and disability were found between those undertaking their usual job, those on reduced duties and those on sickness absence due to LBP, with those participants further removed from the work force reporting worse health across all measures. Significant differences were also found in self-rated health between those not working due to LBP and those not working for other reasons, with participants not working due to LBP reporting worse self-rated health. At follow-up, work status was found to be relatively stable. Conclusion These findings indicate that the economic impact of LBP may be higher than previously estimated when data on reduced duties is combined with work absence. The additional impact of unemployment due to LBP should also be included in future assessments of the impact of LBP on the workforce.
Background:
There are currently many treatment options for patients with subacromial shoulder conditions (SSCs). Clinical decision-making regarding the best treatment option is often difficult. This ...study aims to evaluate the comparative effectiveness of treatment options for relieving pain and improving function in patients with SSCs.
Methods:
Eight databases including MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Database of Systematic Reviews and World Health Organization (WHO) International Clinical Trials Registry were searched from inception until April 2020. Randomised clinical/controlled trials of adult patients investigating the effects of nonsurgical (e.g. corticosteroid injections, therapeutic exercise, shockwave therapy) and surgical treatment for SSCs, compared with each other, placebo, usual care or no treatment, were retrieved. Pairs of reviewers screened studies independently, quality appraised eligible studies using the Cochrane risk of bias tool, extracted and checked data for accuracy. Primary outcomes were pain and disability in the short term (⩽3 months) and long term (⩾6 months). Direct and indirect evidence of treatment effectiveness was synthesised using random-effects network meta-analysis.
Results:
The review identified 177 eligible trials. Summary estimates (based on 99 trials providing suitable data, 6764 patients, 20 treatment options) showed small to moderate effects for several treatments, but no significant differences on pain or function between many active treatment comparisons. The primary analysis indicated that exercise and laser therapy may provide comparative benefit in terms of both pain and function at different follow-up time-points, with larger effects found for laser in the short term at 2–6 weeks, although direct evidence was provided by one trial only, and for exercise in the longer term standardised mean difference (SMD) 0.39, 95% confidence interval (CI) 0.18, 0.59 at 3–6 months compared with control. Sensitivity analyses excluding studies at increased risk of bias confirmed only the comparative effects of exercise as being robust for both pain and function up until 3-month follow-up.
Conclusion:
Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six treatments had a high probability of being most effective, in the short term, for pain and function acupuncture, manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS), but with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality pragmatic randomised trials or meta-analyses are needed to better understand whether specific subgroups of patients respond better to some treatments than others.
ObjectivesThis paper aims to investigate historical patterns of sickness certification for back pain from 2000 to 2010.DesignElectronic medical records from 14 practices that are part of the National ...Institute for Health Research (NIHR) Clinical Research Network: West Midlands were reviewed. All records for back pain consultations from 2000 to 2010 were downloaded and matched, by date, to corresponding sickness certification records.SettingPrimary Care.ResultsA total of 93 896 back pain consultations were recorded over the 11-year period, resulting in 30 913 sickness certificates. There was a statistically significant decrease in the rate of certification over the period, falling from 376.8 (95% CI 362.1 to 392) per 1000 back pain consultations in 2000 to 246.5 (95% CI 236.5 to 332.9) per 1000 back pain consultations in 2010. There was also a statistically significant difference in certification between males and females, with males issued more certificates than females. There was a statistically significant difference in certification by age, with those aged 60 years and over being less likely to be issued a certificate compared to all other age groups.ConclusionsRates of sickness certification for back pain demonstrated a downward trend between 2000 and 2010. While the reasons for this are not transparent, it may be related to changing beliefs around working with back pain.
Little research exists on the effectiveness of motivational interviewing (MI) on return to work (RTW) in workers on long term sick leave. The objectives of this study protocol is to describe a ...randomized controlled trial (RCT) with the objectives to compare the effectiveness and cost-effectiveness of usual case management alone with usual case management plus MI or usual case management plus stratified vocational advice intervention (SVAI), on RTW among people on sick leave due to musculoskeletal (MSK) disorders.
A multi-arm RCT with economic evaluation will be conducted in Norway with recruitment of 450 participants aged 18-67 years on 50-100% sick leave for > 7 weeks due to MSK disorders. Participants will be randomized to either usual case management by the Norwegian Labour and Welfare Administration (NAV) alone, usual case management by NAV plus MI, or usual case management by NAV plus SVAI. Trained caseworkers in NAV will give two MI sessions, and physiotherapists will give 1-4 SVAI sessions depending upon risk of long-term sick leave. The primary outcome is the number of sick leave days from randomization to 6 months follow-up. Secondary outcomes are number of sick leave days at 12 months follow-up, time until sustainable RTW (≥4 weeks of at least 50% of their usual working hours) at 12 months, proportions of participants receiving sick leave benefits during 12 months of follow-up, and MSK symptoms influencing health at 12 months. Cost-utility evaluated by the EuroQoL 5D-5L and cost-benefit analyses will be performed. Fidelity of the interventions will be assessed through audio-recordings of approximately 10% of the intervention sessions.
The results from this RCT will inform stakeholders involved in supporting RTW due to MSK disorders such as staff within NAV and primary health care.
ClinicalTrials.gov ID: NCT03871712 registered March 12th 2020.
IntroductionPeople presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in ...management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals’ level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain.Methods and analysisThe Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist).Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options.Ethics and disseminationThe PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites.Trial registration numberISRCTN46948079.
To determine, in a group of persons involved in a motor vehicle collision, the contributions of pre-collision health and psychological factors, the social environment, collision-specific factors, and ...post-collision symptoms, to the new onset of widespread pain (WP).
A prospective cohort study of persons, registered with an insurance company, who had recently experienced a motor vehicle collision. Participants were sent a questionnaire to assess pre-collision health, collision-specific factors, post-collision health, and WP. Those reporting WP prior to the collision were excluded from followup. At 12 months, participants were sent a followup questionnaire to ascertain one-month period prevalence of (new onset) WP.
In total 957 individuals took part in the baseline survey and were eligible for followup. Subsequently, 695 (73%) completed a questionnaire at 12 months, of whom 54 (7.8%) reported new WP. Few collision-specific factors predicted the onset of WP. In contrast, post-collision physical symptoms (rate ratio 2.5, 95% confidence interval 1.2-5.1), pre-collision health-seeking behavior (RR 3.6, 95% CI 1.6-7.9), pre-collision somatization (RR 1.7, 95% CI 0.99-2.8), and perceived initial injury severity (RR 1.7, 95% CI 0.9-3.3), in addition to older age (RR 3.3, 95% CI 1.5-7.1), were all independently predictive of new onset WP. In combination, these factors accounted for about a 20-fold difference in the risk of new onset WP.
We identified 5 factors that independently predict the onset of WP following a motor vehicle collision. Early identification of this "at-risk" group may allow the targeting of preventive management in those at highest risk of developing future symptoms.
Spinal pain is very common and has considerable consequences for the individual (e.g. loss of employment, disability) as well as increased health care costs. It is now widely accepted that ...biological, psychological and social factors impact on spinal pain outcomes. The majority of research on social factors has been employment related, with little attention to the influence of informal social support (e.g. families, friends, social groups). The aim of this review is to investigate whether informal social support is associated with the occurrence and prognosis of spinal pain. Prognosis was considered in a broad sense within the biopsychosocial model inclusive of factors such as pain, function, general and psychological health. A systematic search of eight databases was conducted to search for studies who report findings on informal social support in populations with nonspecific spinal pain (i.e. no defined cause). Seventeen articles were identified and a best evidence synthesis was carried out on the data extracted from the studies. Results show that for cross‐sectional designs there was inconclusive evidence of a relationship between social support and pain but moderate evidence of a relationship between social support and patient psychological outcome related to prognosis. Evidence of social support as a factor for risk of occurrence was inconclusive with three studies reporting no significant associations with the remaining two studies reporting weak associations. Evidence of an effect of social support and prognosis revealed inconsistent findings. The variation in findings may reflect ongoing difficulties surrounding the conceptualisation and measurement of informal social support.
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