Martin Underwood

Non-specific low back pain

Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Management guidelines endorse triage to identify the rare cases of low back pain that are caused by medically serious pathology, and so require diagnostic work-up or specialist referral, or both. Because non-specific low back pain does not have a known pathoanatomical cause, treatment focuses on reducing pain and its consequences. Management consists of education and reassurance, analgesic medicines, non-pharmacological therapies, and timely review. The clinical course of low back pain is often favourable, thus many patients require little if any formal medical care. Two treatment strategies are currently used, a stepped approach beginning with more simple care that is progressed if the patient does not respond, and the use of simple risk prediction methods to individualise the amount and type of care provided. The overuse of imaging, opioids, and surgery remains a widespread problem.

A Consensus Approach Toward the Standardization of Back Pain Definitions for Use in Prevalence Studies

Study Design. A modified Delphi study conducted with 28 experts in back pain research from 12 countries. Objective. To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. Summary of Background Data. Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. Methods. Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. Results. Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. Conclusion. These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis.

BACKGROUND Low-back pain is a common and costly problem. We estimated the effectiveness of a group cognitive behavioural intervention in addition to best practice advice in people with low-back pain in primary care. METHODS In this pragmatic, multicentre, randomised controlled trial with parallel cost-effectiveness analysis undertaken in England, 701 adults with troublesome subacute or chronic low-back pain were recruited from 56 general practices and received an active management advisory consultation. Participants were randomly assigned by computer-generated block randomisation to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). Primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff scores at 12 months. Assessment of outcomes was blinded and followed the intention-to-treat principle, including all randomised participants who provided follow-up data. This study is registered, number ISRCTN54717854. FINDINGS 399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included in the primary analysis at 12 months. The most frequent reason for participant withdrawal was unwillingness to complete questionnaires. At 12 months, mean change from baseline in the Roland Morris questionnaire score was 1.1 points (95% CI 0.39-1.72) in the control group and 2.4 points (1.89-2.84) in the cognitive behavioural intervention group (difference between groups 1.3 points, 0.56-2.06; p=0.0008). The modified Von Korff disability score changed by 5.4% (1.99-8.90) and 13.8% (11.39-16.28), respectively (difference between groups 8.4%, 4.47-12.32; p<0.0001). The modified Von Korff pain score changed by 6.4% (3.14-9.66) and 13.4% (10.77-15.96), respectively (difference between groups 7.0%, 3.12-10.81; p<0.0001). The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was 1786 pound sterling, and the probability of cost-effectiveness was greater than 90% at a threshold of 3000 pound sterling per QALY. There were no serious adverse events attributable to either treatment. INTERPRETATION Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider. FUNDING National Institute for Health Research Health Technology Assessment Programme.

Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation

BackgroundThe ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.MethodsThe OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.ResultsHomes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.ConclusionsThe intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.

Early management of persistent non-specific low back pain: summary of NICE guidance

Most episodes of acute low back pain resolve spontaneously.1 However, among those in whom low back pain and disability have persisted for over a year, few return to normal activities. Thus the focus for preventing the onset of long term disability caused by non-specific low back pain is on the early management of persistent low back pain (pain present for more than six weeks and less than one year). No consensus exists on how to help health professionals and their patients choose the best treatments for this condition. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the early management of non-specific low back pain.1 The diagnosis of specific causes of low back pain (malignancy, infection, fracture, ankylosing spondylitis, and other inflammatory disorders) is not part of this guideline. NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. The box lists treatments that should not be offered for non-specific low back pain. #### Treatments not recommended for non-specific low back pain ##### Do not offer

Evaluation of two time-specific back pain outcome measures.

STUDY DESIGN Postal questionnaire to individuals with back pain. OBJECTIVE To assess the acceptability, validity, and reliability of two existing back pain outcome measures, the Roland-Morris Questionnaire and the Von Korff scales, modified to measure the preceding 4 weeks. SUMMARY OF BACKGROUND DATA The ideal outcome measure for studies of low back pain and disability remains elusive. Most existing measures assess current pain and disability. Measuring these factors over a preceding 4-week period may be more appropriate. METHODS Individuals with back pain identified in a community survey were asked to complete the modified questionnaires. Validity was assessed by comparison with the Medical Outcome Study Short Form 36 and two general comparator questions on self-reported pain and disability. Repeatability was assessed using retest questionnaires. RESULTS Completed questionnaires were returned by 95 individuals with chronic back pain. The modified Roland-Morris Questionnaire and Von Korff pain and Von Korff disability scales were completed satisfactorily by 83 (87%), 89 (94%), and 87 (92%) participants, respectively. Mean scores of the modified measures changed significantly and in a predictable manner with increasing ratings of pain and disability. They also correlated with aspects of the Medical Outcome Study Short Form 36 questionnaire. Retest data suggest that these measures are repeatable. The modified Roland-Morris Questionnaire provided adequate analyzable data only if missing values were imputed, and it explained less of the variance in the comparator questions than the modified Von Korff scales. CONCLUSIONS The modified Von Korff scales were completed easily and appear to be valid and repeatable in this format.

A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement.

Introduction The Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement is a consensus statement aimed at improving the quality of prospective investigations into the transition from early stages of low back pain (LBP) to persistent problems. The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection. The MMICS Statement is primarily aimed at researchers who want to investigate prognosis in LBP, and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems. One approach to preventing acute new episodes of LBP (up to 3 weeks from onset) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability. Targeting interventions at those at highest risk could reduce the population burden of chronic LBP. A wide range of baseline parameters have been associated with poor outcome in inception cohort studies (1–6). Few existing studies have been of sufficient size and methodologic rigor to produce conclusive findings. Even in methodologically robust studies, baseline factors only account for a small proportion of the variance in outcome (7), typically around 30%. Systematic reviews of the literature could not pool data because studies used different measurements (1–3). Despite some information on physical, psychosocial, and work-related risk factors, it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP. How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003. A steering group for the collaboration was appointed, and 8 national team leaders volunteered to recruit teams of national experts. Three additional team leaders were recruited by the steering group (Australia, France, and Germany). Independent experts were invited to advise on the quality of the MMICS process. The MMICS steering group, located in the UK, met regularly and included expert researchers in clinical and outcome factors in back pain (AB), work-related issues in back pain (AKB), psychosocial aspects of back pain (TP and RS), and general practice aspects of back pain (MU). The MMICS Statement set out to include 1) a minimal but comprehensive number of predictor factors based on current evidence and theory; 2) appropriate measurement instruments for agreed predictor factors based on their clinometric properties, availability, and practical characteristics; and 3) a minimum set of followup measures, including recommendations about measurement and timing.

A systematic review and meta-synthesis of the impact of low back pain on people's lives

BackgroundLow back pain (LBP) is a common and costly problem that many interpret within a biopsychosocial model. There is renewed concern that core-sets of outcome measures do not capture what is important. To inform debate about the coverage of back pain outcome measure core-sets, and to suggest areas worthy of exploration within healthcare consultations, we have synthesised the qualitative literature on the impact of low back pain on people’s lives.MethodsTwo reviewers searched CINAHL, Embase, PsycINFO, PEDro, and Medline, identifying qualitative studies of people’s experiences of non-specific LBP. Abstracted data were thematic coded and synthesised using a meta-ethnographic, and a meta-narrative approach.ResultsWe included 49 papers describing 42 studies. Patients are concerned with engagement in meaningful activities; but they also want to be believed and have their experiences and identity, as someone ‘doing battle’ with pain, validated. Patients seek diagnosis, treatment, and cure, but also reassurance of the absence of pathology. Some struggle to meet social expectations and obligations. When these are achieved, the credibility of their pain/disability claims can be jeopardised. Others withdraw, fearful of disapproval, or unable or unwilling to accommodate social demands. Patients generally seek to regain their pre-pain levels of health, and physical and emotional stability. After time, this can be perceived to become unrealistic and some adjust their expectations accordingly.ConclusionsThe social component of the biopsychosocial model is important to patients but not well represented in current core-sets of outcome measures. Clinicians should appreciate that the broader impact of low back pain includes social factors; this may be crucial to improving patients’ experiences of health care. Researchers should consider social factors to help develop a portfolio of more relevant outcome measures.

Diagnosis and management of gout

Gout is a common cause of acute arthritis. An ageing population, increasing obesity, and lifestyle changes will render it more common.1 Here I outline the epidemiology of gout, appraise the evidence base for its management, and suggest ways of managing idiopathic gout. Management of hyperuricaemia due to inborn errors of metabolism (for example, Lesch-Nyhan syndrome) and its prevention during cancer chemotherapy are not discussed here. The material for this review draws heavily on my chapter on gout in Clinical Evidence and from my work on a recent systematic review of studies on the prevention and treatment of recurrent gout. To ensure that no relevant randomised controlled trials published since the systematic review had been overlooked, I ran a previous search strategy in PubMed and the Cochrane database of systematic reviews. I identified other relevant studies from my personal database of papers on gout, did forward and backward citation tracking from other key papers, and carried out new targeted searches of multiple electronic databases. The clinical syndrome of gout arises from deposition of urate crystals in joints, where they cause an inflammatory response, and in soft tissues, where they do not. The classic symptom of gout affecting the big toe, podagra, literally a “foot catch,” has been recognised since antiquity. Crystal deposition occurs when serum becomes saturated with urate, the final breakdown product of purine metabolism. Most patients with idiopathic gout have a genetically reduced renal excretion of urate. This alone does not usually lead to hyperuricaemia. Many other factors affect serum urate concentration (box 1). Typically, gout produces an acute monoarthritis of rapid onset, often waking patients from sleep. The most commonly affected joints are the great toe, foot, ankle, knee, wrist, finger, and elbow, possibly because urate is more likely to crystallise in cooler parts of the body. …

Adverse events and manual therapy: A systematic review

OBJECTIVE To explore the incidence and risk of adverse events with manual therapies. METHOD The main health electronic databases, plus those specific to allied medicine and manual therapy, were searched. Our inclusion criteria were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models. RESULTS Eight prospective cohort studies and 31 manual therapy RCTs were accepted. The incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar, but for drug therapies greater (RR 0.05, CI 95% 0.01-0.20) and less with usual care (RR 1.91, CI 95% 1.39-2.64). CONCLUSIONS The risk of major adverse events with manual therapy is low, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care.