Iben Axén

What have we learned from ten years of trajectory research in low back pain

BackgroundNon-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals’ course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.DiscussionLBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients.ConclusionsInvestigations of trajectories underpin the notion that differentiation between acute and chronic LBP is overly simplistic, and we believe it is time to shift from this paradigm to one that focuses on trajectories over time. We suggest that trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients, and might have a potential for supporting clinical decision making, but their usefulness is still underexplored.

The Nordic Subpopulation Research Programme: prediction of treatment outcome in patients with low back pain treated by chiropractors - does the psychological profile matter?

BackgroundIt is clinically important to be able to select patients suitable for treatment and to be able to predict with some certainty the outcome for patients treated for low back pain (LBP). It is not known to what degree outcome among chiropractic patients is affected by psychological factors.ObjectivesTo investigate if some demographic, psychological, and clinical variables can predict outcome with chiropractic care in patients with LBP.MethodsA prospective multi-center practice-based study was carried out, in which demographic, clinical and psychological information was collected at base-line. Outcome was established at the 4th visit and after three months. The predictive value was studied for all base-line variables, individually and in a multivariable analysis.ResultsIn all, 55 of 99 invited chiropractors collected information on 731 patients. At the 4th visit data were available on 626 patients and on 464 patients after 3 months. Fee subsidization (OR 3.2; 95% CI 1.9-5.5), total duration of pain in the past year (OR 1.5; 95% CI 1.0-2.2), and general health (OR 1.2; 95% CI 1.1-1.4) remained in the final model as predictors of treatment outcome at the 4th visit. The sensitivity was low (12%), whereas the specificity was high (97%). At the three months follow-up, duration of pain in the past year (OR 2.1; 95% CI 1.4-3.1), and pain in other parts of the spine in the past year (OR1.6; 1.1-2.5) were independently associated with outcome. However, both the sensitivity and specificity were relatively low (60% and 50%). The addition of the psychological variables did not improve the models and none of the psychological variables remained significant in the final analyses. There was a positive gradient in relation to the number of positive predictor variables and outcome, both at the 4th visit and after 3 months.ConclusionPsychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.

Analyzing repeated data collected by mobile phones and frequent text messages. An example of Low back pain measured weekly for 18 weeks

BackgroundRepeated data collection is desirable when monitoring fluctuating conditions. Mobile phones can be used to gather such data from large groups of respondents by sending and receiving frequently repeated short questions and answers as text messages.The analysis of repeated data involves some challenges. Vital issues to consider are the within-subject correlation, the between measurement occasion correlation and the presence of missing values.The overall aim of this commentary is to describe different methods of analyzing repeated data. It is meant to give an overview for the clinical researcher in order for complex outcome measures to be interpreted in a clinically meaningful way.MethodsA model data set was formed using data from two clinical studies, where patients with low back pain were followed with weekly text messages for 18 weeks. Different research questions and analytic approaches were illustrated and discussed, as well as the handling of missing data. In the applications the weekly outcome “number of days with pain” was analyzed in relation to the patients’ “previous duration of pain” (categorized as more or less than 30 days in the previous year).Research questions with appropriate analytical methods1: How many days with pain do patients experience? This question was answered with data summaries.2: What is the proportion of participants “recovered” at a specific time point? This question was answered using logistic regression analysis.3: What is the time to recovery? This question was answered using survival analysis, illustrated in Kaplan-Meier curves, Proportional Hazard regression analyses and spline regression analyses.4: How is the repeatedly measured data associated with baseline (predictor) variables? This question was answered using generalized Estimating Equations, Poisson regression and Mixed linear models analyses.5: Are there subgroups of patients with similar courses of pain within the studied population? A visual approach and hierarchical cluster analyses revealed different subgroups using subsets of the model data.ConclusionsWe have illustrated several ways of analysing repeated measures with both traditional analytic approaches using standard statistical packages, as well as recently developed statistical methods that will utilize all the vital features inherent in the data.

The Nordic maintenance care program: the clinical use of identified indications for preventive care

BackgroundLow back pain (LBP) is a prevalent condition and has been found to be recurrent and persistent in a majority of cases. Chiropractors have a preventive strategy, maintenance care (MC), aimed towards minimizing recurrence and progression of such conditions. The indications for recommending MC have been identified in the Nordic countries from hypothetical cases. This study aims to investigate whether these indications are indeed used in the clinical encounter.MethodsData were collected in a multi-center observational study in which patients consulted a chiropractor for their non-specific LBP. Patient baseline information was a) previous duration of the LBP, b) the presence of previous episodes of LBP and c) early improvement with treatment. The chiropractors were asked if they deemed each individual patient an MC candidate. Logistic regression analyses (uni– and multi-level) were used to investigate the association of the patient variables with the chiropractor’s decision.ResultsThe results showed that “previous episodes” with LBP was the strongest predictor for recommending MC, and that the presence of all predictors strengthens the frequency of this recommendation. However, there was considerable heterogeneity among the participating chiropractors concerning the recommendation of MC.ConclusionsThe study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.

GPs opinions and perceptions of chiropractic in Sweden and Norway: a descriptive survey.

BackgroundIn Sweden, chiropractic is not included in mainstream health care. In Norway chiropractic is a recognized health care profession. The aim of this study was to explore the perceptions of chiropractic among Swedish and Norwegian General Practitioners (GPs).MethodsEight hundred surveys in each country were distributed randomly by post to Swedish and Norwegian GPs offices. The survey contained two main sections: Experiences and opinions about chiropractic and referral patterns. The data were then described and compared between the countries.ResultsIn Sweden the response rate was 44.8% and in Norway 45.3%. More than half of the Swedish GPs participating in this study stated that they had poor knowledge about chiropractic, while just a tenth of Norwegian GPs stated the same. Nearly all Norwegian GPs had some experience of chiropractic treatment whilst a fairly large number of the Swedish GPs said that they had no experience at all of chiropractic. It was twice as common for GPs in Norway to refer patients to a chiropractor as compared to Sweden. However, Swedish and Norwegian GPs agreed that chiropractors were competent to treat musculo-skeletal conditions with an adequate education to be part of mainstream medicine.ConclusionsSwedish and Norwegian GPs agree that chiropractors are competent to treat musculoskeletal conditions. However, there are many differences in GPs perceptions of chiropractic between the two countries and the overall picture indicates that chiropractic is more accepted and recognised as a health care profession in Norway.

Validity and test–retest reliability of an at-work production loss instrument

BACKGROUND Besides causing ill health, a poor work environment may contribute to production loss. Production loss assessment instruments emphasize health-related consequences but there is no instrument to measure reduced work performance related to the work environment. AIMS To examine convergent validity and test-retest reliability of health-related production loss (HRPL) and work environment-related production loss (WRPL) against a valid comparable instrument, the Health and Work Performance Questionnaire (HPQ). METHODS Cross-sectional study of employees, not on sick leave, who were asked to self-rate their work performance and production losses. Using the Pearson correlation and Bland and Altmans Test of Agreement, convergent validity was examined. Subgroup analyses were performed for employees recording problem-specific reduced work performance. Consistency of pairs of HRPL and WRPL for samples responding to both assessments was expressed using Intraclass Correlation Coefficient (ICC) and tests of repeatability. RESULTS A total of 88 employees participated and 44 responded to both assessments. Test of agreement between measurements estimates a mean difference of 0.34 for HRPL and -0.03 for WRPL compared with work performance. This indicates that the production loss questions are valid and moderately associated with work performance for the total sample and subgroups. ICC for paired HRPL assessments was 0.90 and 0.91 for WRPL, i.e. the test-retest reliability was good and suggests stability in the instrument. CONCLUSIONS HRPL and WRPL can be used to measure production loss due to health-related and work environment-related problems. These results may have implications for advancing methods of assessing production loss, which represents an important cost to employers.

Conducting practice-based projects among chiropractors: a manual

IntroductionPractice-based research is a challenge as clinicians are busy with their patients and any participation in research activities will be secondary to the needs of the patients and the clinic. As a result, it is difficult to obtain high compliance among clinicians. A method to enhance compliance in multicentre practice-based research has been developed and refined for use in the chiropractic setting and possibly also by other researchers in different settings.MethodThis manual provides a stringent step-by-step approach for conducting clinic-based research. It describes the competencies and requirements of an effective working group, how to recruit participating clinicians and how to empower, encourage and support these clinicians to obtain good compliance.DiscussionThe main advantage of the method is the high compliance of participating clinicians compared to many other clinical studies. Difficulties with the method are described and suggestions for solutions are presented.ConclusionsThis manual is a description of a method that may be of use for clinical researchers in the chiropractic setting.

Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? - a comparative qualitative case study in the Scandinavian context

BackgroundDespite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management.MethodsThis study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions.ResultsTwelve interviews were conducted. Thematically, chiropractors’ capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management.ConclusionAllied health providers, in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices.

Individual preferences for physical exercise as secondary prevention for non-specific low back pain : a discrete choice experiment

Background Exercise is effective in improving non-specific low back pain (LBP). Certain components of physical exercise, such as the type, intensity and frequency of exercise, are likely to influence participation among working adults with non-specific LBP, but the value and relative importance of these components remain unknown. The study’s aim was to examine such specific components and their influence on individual preferences for exercise for secondary prevention of non-specific LBP among working adults. Methods In a discrete choice experiment, working individuals with non-specific LBP answered a web-based questionnaire. Each respondent was given ten pairs of hypothetical exercise programs and asked to choose one option from each pair. The choices comprised six attributes of exercise (i.e., type of training, design, intensity, frequency, proximity and incentives), each with either three or four levels. A conditional logit regression that reflected the random utility model was used to analyze the responses. Results The final study population consisted of 112 participants. The participants’ preferred exercise option was aerobic (i.e., cardiovascular) rather than strength training, group exercise with trainer supervision, rather than individual or unsupervised exercise. They also preferred high intensity exercise performed at least once or twice per week. The most popular types of incentive were exercise during working hours and a wellness allowance rather than coupons for sports goods. The results show that the relative value of some attribute levels differed between young adults (age ≤ 44 years) and older adults (age ≥ 45 years) in terms of the level of trainer supervision required, exercise intensity, travel time to exercise location and financial incentives. For active study participants, exercise frequency (i.e., twice per week, 1.15; CI: 0.25; 2.06) influenced choice of exercise. For individuals with more than one child, travel time (i.e., 20 minutes, -0.55; CI: 0.65; 3.26) was also an influential attribute for choice of exercise, showing that people with children at home preferred to exercise close to home. Conclusions This study adds to our knowledge about what types of exercise working adults with back pain are most likely to participate in. The exercise should be a cardiovascular type of training carried out in a group with trainer supervision. It should also be of high intensity and preferably performed twice per week during working hours. Coupons for sports goods do not appear to motivate physical activity among workers with LBP. The findings of the study could have a substantial impact on the planning and development of exercise provision and promotion strategies to improve non-specific LBP. Providers and employers may be able to improve participation in exercise programs for adults with non-specific LBP by focusing on the exercise components which are the most attractive. This in turn would improve satisfaction and adherence to exercise interventions aimed at preventing recurrent non-specific LBP.

ECU convention 2017 research presentations

O-01 Care seeking patterns during one year after visiting a chiropractor Alice Kongsted, Lise Hestbaek Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark Correspondence: Alice Kongsted (a.kongsted@nikkb.dk) Chiropractic & Manual Therapies 2017, 25(Suppl 1):O-01