Johan P Bogefeldt

Sick leave reductions from a comprehensive manual therapy programme for low back pain: the Gotland Low Back Pain Study

Objective: To evaluate if a comprehensive manual therapy programme reduces sick leave due low back pain and facilitates return to work more than the conventional optimized activating care. Design: A randomized controlled trial over a 10-week period with a two-year follow-up. Setting: Primary health care and Visby Hospital, Municipality of Gotland, Sweden. Subjects: One hundred and sixty patients (70 women, 90 men, ages 20—55 years) with acute or subacute low back pain with or without pain radiation into the legs. Interventions: Standardized optimized activating care (n = 71) versus a comprehensive pragmatic manual therapy programme including specific corticosteroid injections (n = 89). Main measures: Sick leave measured as net sick leave volume, point prevalence and return to work. Results: After 10 weeks, significantly more manual therapy patients than reference patients had returned to work (hazards ratio 1.62, 95% confidence interval (CI) 1.006—2.60, P<0.05), and among those on sick leave at baseline, significantly fewer were still on sick leave (8/58 versus 13/40, ratio 0.35, 95% CI 0.13—0.97, P<0.05). For all other measures there were inconclusive differences in favour of the manual therapy group. No significant differences remained after two years. Conclusions: The manual therapy programme used in this study decreased sick leave and increased return to work more than the standardized optimized activating care only up to 10 weeks but not up to two years.

A randomized controlled trial of the effects of muscle stretching, manual therapy and steroid injections in addition to ‘stay active’ care on health-related quality of life in acute or subacute low back pain

Objective: To evaluate the health-related quality of life effects of muscle stretching, manual therapy and steroid injections in addition to ‘stay active’ care in acute or subacute low back pain patients. Study design: A randomized, controlled trial during 10 weeks with four treatment groups. Setting: Nine primary health care and one outpatient orthopaedic hospital department. Subjects: One hundred and sixty patients with acute or subacute low back pain. Interventions: Ten weeks of ‘stay active’ care only (group 1), or ‘stay active’ and muscle stretching (group 2), or ‘stay active’, muscle stretching and manual therapy (group 3), or ‘stay active’, muscle stretching, manual therapy and steroid injections (group 4). Main measures: The Gothenburg Quality of Life instrument subscales Well-being score and Complaint score. Results: In a multivariate analysis adjusted for possible outcome affecting variables other than the treatment given Well-being score was 68.4 (12.5), 72.1 (12.4), 72,3 (12.4) and 72.7 (12.5) in groups 1–4, respectively (P for trend <0.05). There were significant trends for the well-being components patience (P < 0.005), energy (P < 0.05), mood (P < 0.05) and family situation (P < 0.05). The remaining two components and Complaint score showed a non-significant trend towards improvement. Conclusion: The effects on health-related quality of life were greater the larger the number of treatment modalities available. The ‘stay active’ treatment group, with the most restricted number of modalities, had the most modest health-related quality of life improvement, while group 4 with the most generous choice of treatment modalities, had the greatest improvement.

Diagnostic Differences Between General Practitioners and Orthopaedic Surgeons in Low Back Pain Patients

Background. There is a growing consensus on low back pain treatment. However, whether this extends to diagnostic labelling is still largely unknown. The aim of this report was to compare the diagnostic assessment of low back pain patients between general practitioners trained in manual therapy and orthopaedic surgeons. Methods. Population-based randomized controlled trial in which 160 patients with acute or sub-acute low back pain were assessed and treated by general practitioners or orthopaedic surgeons. Information on diagnoses and use of diagnostic imaging was obtained from medical records and physician questionnaires covering the ten-week treatment period. The Quebec Task Force classification and free text analysis were used to group diagnostic labels. Results: At baseline there were no significant differences in medical history, findings at physical examination and distribution of the Quebec Task Force diagnostic classification between the patient groups, indicating that they were similar. However, there were significant differences in physicians’ use of diagnostic labels for local pain and their characterisation of radiating pain. General practitioners used more terms from manual medicine and reported more pseudoradicular pain than orthopaedic surgeons, who used non-specific pain labels, reported more true radicular pain and used more x-ray examinations. Differences were found at all times from first visit to ten week follow-up. Conclusions: There were significant differences in diagnostic assessment and use of diagnostic radiology between general practitioners and orthopaedic surgeons.

A population-based study of nearly 15 000 observations among Swedish women and men during 1973-2003

Objectives Global self-rated health (SRH) has become extensively used as an outcome measure in population health surveillance. The aim of this study was to analyse the effects of age and secular trend (year of investigation) on SRH. Design Prospective cohort study, using population-based data from eight ongoing cohort studies, with sampling performed between 1973 and 2003. Setting Sweden. Participants 11 880 women and men, aged 25–99 years, providing 14 470 observations. Primary outcome measure Global SRH. Results In multiple ordinal logistic regression analyses, adjusted for the effects of covariates, there were independent effects of age (p<0.0001) and of year of investigation (p<0.0001) on SRH. In women the association was linear, showing lower levels of SRH with increased age, and more recent year of investigation. In men the association was curvilinear, and thus more complex. The final model explained 76.2% of the SRH variance in women and 74.5% of the variance in men. Conclusions SRH was strongly and inversely associated with age in both sexes, after adjustment for other outcome-affecting variables. There was a strongly significant effect of year of investigation indicating a change in SRH, in women towards lower levels over calendar time, in men with fluctuations across time.