Görel Kjellman

A CRITICAL ANALYSIS OF RANDOMISED CLINICAL TRIALS ON NECK PAIN AND TREATMENT EFFICACY. A REVIEW OF THE LITERATURE

The efficacy of physiotherapy or chiropractic treatment for patients with neck pain was analysed by reviewing 27 randomised clinical trials published 196-1995. Three different methods were employed: systematic analyses of; methodological quality; comparison of effect size; analysis of inclusion criteria, intervention and outcome according to The Disablement Process model. The quality of most of the studies was low; only one-third scored 50 or more of a possible 100 points. Positive outcomes were noted for 18 of the investigations, and the methodological quality was high in studies using electromagnetic therapy, manipulation, or active physiotherapy. High methodological quality was also noted in studies with traction and acupuncture, however, the interventions had either no effect or a negative effect on outcome. Pooling data and calculation of effect size showed that treatments used in the studies were effective for pain, range of motion, and activities of daily living. Inclusion criteria, intervention, and outcome were based on impairment in most of the analysed investigations. Broader outcome assessments probably would have revealed relationships between treatment effect and impairment, functional limitation and disability.

A RANDOMIZED CLINICAL TRIAL COMPARING GENERAL EXERCISE, MCKENZIE TREATMENT AND A CONTROL GROUP IN PATIENTS WITH NECK PAIN

Seventy-seven patients with neck pain in the primary health care were included in a prospective, randomized clinical trial and randomly assigned to general exercise, McKenzie treatment, or a control group. Seventy patients completed the treatment; response rate 93% at 12-month follow-up. All three groups showed significant improvement regarding the main outcomes, pain intensity and Neck Disability Index, even at 12-month follow-up, but there was no significant difference between the groups. In all, 79% reported that they were better or completely restored after treatment, although 51% reported constant/daily pain. In the McKenzie group compared with the control group, a tendency toward greater improvement was noted for pain intensity at 3 weeks and at 6-month follow-up, and for post-treatment Neck Disability Index. Significant improvement in Distress and Risk Assessment Method scores was shown in the McKenzie group only. The three groups had similar recurrence rates, although after 12 months the McKenzie group showed a tendency toward fewer visits for additional health care. The study did not provide a definite evidence of treatment efficacy in patients with neck pain, however, there was a tendency toward a better outcome with the two active alternatives compared with the control group.

Course of back pain in primary care : a prospective study of physical measures

OBJECTIVE To describe physical measures used in patients with back pain when no specific treatment is given, to examine associations between change over time in these measures and changes in pain and back-related disability, and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months. DESIGN A prospective consecutive study. SUBJECTS Forty-four patients presenting with low back pain in primary care. METHODS The patients underwent a physical examination at baseline and at 4 weeks. Follow-up was carried out using questionnaires until 12 months. Linear regression was used to identify predictors. RESULTS Most measures had improved significantly at the 4-week follow-up. Thoracolumbar rotation, isometric endurance back extensors, and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up. Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline. This group of patients improved more in physical measures between baseline and the 4-week follow-up. CONCLUSION Physical measures assessed at the 4-week follow-up, but not at baseline, could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months.

Prognostic factors for perceived pain and function at one-year follow-up in primary care patients with neck pain

Purpose: To identify prognostic factors for perceived pain and function with focus at one-year follow-up in primary care patients treated for non-specific neck pain. Methods: A prospective study was performed including 193 neck pain patients. Before and after treatment period, and 12 months after the start date for treatment, patients completed a questionnaire including background data and aspects of pain, function and general health. Linear multiple regression analysis was used to identify prognostic factors with the dependent variables Oswestry score and pain intensity at 12-month follow-up. Response rate 81%. Results: At 12-month follow-up, Oswestry score identified four prognostic factors: pain intensity; well-being; expectations of treatment; and duration of current episode. Adjusted R2 for the model was 0.32, and 20% of the patients had three of the four prognostic factors at entry, indicating risk of poor outcome. The dependent variable pain intensity revealed three prognostic factors: Oswestry score; duration of current episode; and similar problem during the previous five years. Adjusted R2 was 0.24, and 60% of the patients had two of the three prognostic factors at entry, indicating risk of poor outcome. Conclusions: Different prognostic factors (with the exception of duration of current episode) were identified by the two outcome variables. Thus the results suggest that it should be taken into account whether an impairment or disability outcome is used.

Back Pain in Primary Care: a Prospective Cohort Study of Clinical Outcome and Healthcare Consumption

The aim was to describe the clinical course without active treatment in patients with low back and neck pain visiting primary care. A prospective consecutive study was done with follow-ups weekly for 6 weeks and at 3, 6, 12 and 30 months. Main outcome measures were proportion of patients who were free of pain and back-related disability and proportion of patients found to have received additional healthcare at 3-, 6-, 12- and 30-month follow-ups. The physiotherapist predicted additional treatment. Eighty consecutive patients were included. 39 low back pain and 17 neck pain patients underwent 30 months of follow-up. The results on a group level were consistent from about 4 weeks. In the low back pain group, 41% reported no pain and no disability after 30 months, within 3 months 33% and within 30 months 64% had received additional healthcare. In the neck pain group, 12% reported no pain and no disability after 30 months, within 3 months 59% and within 30 months 71% had received additional healthcare. A higher proportion of the patients, predicted with a high probability to seek additional care also reported additional care. It can be expected that half the back pain patients being cared for in primary care will continue to suffer from problems 30 months later. The slope of recovery is most prominent during the first 4 weeks, and a worse outcome is in the neck pain patients. Further healthcare is not equal to self-reported back pain problems at baseline. The 4-week evaluation can be used to predict groups with future healthcare utilization up until 30 months. Further studies including larger cohorts are needed to confirm the results.