Anne Jackman

The Rising Prevalence of Chronic Low Back Pain

BACKGROUND National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care-seeking characteristics of individuals with the condition have changed over the last 14 years. METHODS A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (>3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking. RESULTS The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]). CONCLUSIONS The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.

The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

BACKGROUND Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.

Acute severe low back pain : a population-based study of prevalence and care-seeking

Study Design Telephone interviews were conducted with a random sample of adults in 4437 North Carolina households. The response rate was 79%. Objective The prevalence of low back pain and the correlates of care-seeking in a defined population were examined. Summary of Background Data Previous research on low back pain has used varying definitions of the illness of low back pain, and has admixed patients with acute and chronic low back pain. Acute low back pain was examined in this study as a distinct phenomenon separate from chronic low back pain. Methods Respondents completed a detailed interview regarding the occurrence of and care sought for back pain in 1991. Acute back pain was defined as functionally limiting pain lasting less than 3 months. Results From this sample, 485 individuals had at least one occurrence of acute severe low back pain in 1991, representing 7.6% of the adult population. Symptoms were reported less commonly in individuals older than age 60 years (5% vs. 8.5%) and in nonwhites compared with whites (5% vs. 8%). Thirty-nine percent of those with back pain sought medical care; 24% sought care initially from an allopathic physician, 13% from a chiropractor, and 2% from other providers. More prolonged pain, more severe pain, and sciatica were associated with care-seeking. Gender, income, age, rural residence, and health insurance status did not correlate with the decision to seek medical care. Younger age, male gender, and nonjob-related pain did correlate with the decision to seek care from a chiropractor. Conclusions Acute back pain is common. Care is often sought regardless of income and insurance status. Seeing a health care provider for acute back pain may not be discretionary from the perspective of the patient.

Beyond the good prognosis: Examination of an inception cohort of patients with chronic low back pain

Study Design. A 22-month prospective cohort study. Objectives. To describe the course of an inception cohort of patients with chronic low back pain. Summary of Background Data. Chronic low back pain is a debilitating condition with great medical and social cost. Methods. A cohort of 1246 patients with acute low back pain who sought treatment from 208 North Carolina providers was observed. Patients who developed chronic low back pain were identified. Entry criteria were back pain of less than 10 weeks’ duration, no previous care for this episode of low back pain, no previous spine surgery, not pregnant, no nonskin malignancy, and access to a telephone. The providers were of four types: primary care medical doctors, doctors of Chiropractic, orthopedic surgeons, and health maintenance organization-based primary care providers. Patients were contacted by telephone shortly after enrollment and at 2, 4, 8, 12, and 24 weeks, with a final interview at 22 months. Patient functional status, care-seeking, and satisfaction were evaluated. Results. Ninety-six patients had chronic, continuous symptoms for 3 months, forming the inception cohort of chronic low back pain. A valid, reliable measure of back-specific functional disability also was used. Predictors of the development of chronicity were poor baseline functional status and sciatica. A more powerful predictor of chronicity was poor functional status at 4 weeks. Two thirds of patients with chronic low back pain at 3 months had functionally disabling symptoms at 22 months, and a majority of these were employed. Satisfaction with care was low. Forty-six patients (2.6% of the entire cohort) underwent surgery, with no statistically significant difference in surgical rates among initial provider strata. Patients who underwent surgery after 3 months had a Roland disability score at 22 months of 10 (7.7, 12.3). Forty-one percent of patients with chronic low back pain see an orthopedic or neurologic surgeon. Chronic low back pain occurs in 7.7% of patients who seek care for acute low back pain, with unremitting pain for 22 months in 4.7%. Conclusion. Once established, chronic low back pain is persistent. Most patients with chronic low back pain seek little care, and a majority are employed. Future research should emphasize maintenance of employment and function.

Recurrence and care seeking after acute back pain: Results of a long-term follow-up study

OBJECTIVE To explore the relationship between type of initial care as well as the likelihood of recurrence and consequent care seeking behavior. RESEARCH DESIGN Prospective observational cohort recruited from 208 randomly selected North Carolina practices. Cohort study examined the recurrence of low back pain among patients free of back pain 3 months after their index visit to a practitioner for that problem. The following four practitioner strata were examined: primary care providers, chiropractors, orthopedic surgeons, and practitioners in a group model HMO. Patients were interviewed by telephone at 6 and 22 months after the initial visit. MAIN OUTCOME MEASURES Rates of disabling and non-disabling low back pain; functional status using the Roland back disability scale; and care seeking. RESULTS Rates of recurrence were substantial; functionally disabling recurrence rates varied between 8% and 14% between 3 to 6 months, and 20% to 35% between 6 to 22 months. Differences in rates among practitioner strata were statistically significant only between 6 to 22 months with higher recurrence rates for HMO patients. Functional status, number of bed days, and time off work were very similar among the practitioner strata. Care seeking, however, was greater among those patients who had initially seen a chiropractor for their back pain. Patients with recurrence saw the same practitioner type they had seen for the index episode 88% of the time. Satisfaction was slightly greater for patients who saw chiropractors when compared with patients seeing allopathic physicians. CONCLUSIONS The recurrence of low back pain is common. Severe disability is rare. Patients who had sought care from chiropractors are more likely to return for recurrences than patients who had initially sought care from MDs.

Improving Decision-Making for Feeding Options in Advanced Dementia: A Randomized, Controlled Trial

To test whether a decision aid improves quality of decision‐making about feeding options in advanced dementia.

Hidden barriers between knowledge and behavior: the North Carolina prostate cancer screening and treatment experience.

Prostate cancer (PC) mortality is much greater for African American than for Caucasian men. To identify patient factors that might account for some of this disparity, men within 6 months of diagnosis were surveyed about health attitudes and behavior.

A long way to go: Practice patterns and evidence in chronic low back pain care

Study Design. A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006. Objective. The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition. Summary of Background Data. Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer. Methods. Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews. Results. Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state. Conclusion. Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

Reporting of acute low back pain in a telephone interview: Identification of potential biases

Study Design This was a survey of 235 individuals with and 132 individuals without documented low back pain. Objectives To approximate the magnitude of potential reporting biases in estimates of prevalence of and medical care use in low back pain. Summary of Background Data The use of survey techniques presents several possible biases in the reporting of acute symptoms. These biases are especially pertinent in musculoskeletal symptoms, which often are recurrent and not life-threatening. Methods Two-hundred-thirty-five patients with acute low back pain were contacted by telephone 4–16 months after their physician visit and surveyed regarding the presence and date of back pain episodes. One -hundred-thirty-two patients who had no functionally disabling back pain on physician interview were interviewed. Results Of the patients who had sought care for back pain,21% indicated they had not had back pain when interviewed 4–16 months later. Episodes of pain that occurred more than 8 months before the interview tended to be recalled as occurring more recently than they actually occurred, confirming “forward telescoping” of the illness episode. Only 3% of the individuals without functionally impairing pain reported such pain on a separate interview. Conclusions Lack of recall occurs regarding acute low back pain, usually a self-limited illness. This potential under-estimate of back pain prevalence may be balanced by forward telescoping of the date of illness occurrence.

Training Primary Care Physicians to Give Limited Manual Therapy For Low Back Pain : Patient Outcomes

Study Design. Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. Objectives. To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. Summary of Background Data. Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. Methods. Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland–Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. Results. No differences were found in Roland–Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%;P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days;P = 0.02). Conclusion. Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.