Mary Wyatt

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.

2001 Volvo Award winner in clinical studies : effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice

Study Design. Quasi-experimental, nonrandomized, nonequivalent, parallel group-controlled study involving before and after telephone surveys of the general population and postal surveys of general practitioners was conducted, with an adjacent state used as a control group. Objectives. To evaluate the effectiveness of a population-based intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and workers’ compensation–related costs. Summary of Background Data. A multimedia campaign begun during 1997 in Victoria, Australia, positively advised patients with back pain to stay active and exercise, not to rest for prolonged periods, and to remain at work. Methods. The campaign’s impact on population beliefs about back pain and fear-avoidance beliefs was measured in telephone surveys, and the effect of the campaign on the potential management of low back pain by general practitioners was assessed by eliciting their likely approach to two hypothetical scenarios in mailed surveys. Demographically identical population groups in Victoria and the control state, New South Wales, were surveyed at three times: before, during, and after intervention in Victoria. Results. The studies were completed by 4730 individuals in the general population and 2556 general practitioners. There were large statistically significant improvements in back pain beliefs over time in Victoria (mean scores on the Back Beliefs Questionnaire, 26.5, 28.4, and 29.7), but not in New South Wales (26.3, 26.2, and 26.3, respectively). Among those who reported back pain during the previous year, fear-avoidance beliefs about physical activity improved significantly in Victoria (mean scores on the Fear-Avoidance Beliefs Questionnaire for physical activity, 14, 12.5, and 11.6), but not in New South Wales (13.3, 13.6, and 12.7, respectively). General practitioners in Victoria reported significant improvements over time in beliefs about back pain management, as compared with their interstate colleagues. There were statistically significant interactions between state and time for 7 of 10 responses on management of acute low back pain, and for 6 of 10 responses on management of subacute low back pain. Conclusion. A population-based strategy of providing positive messages about back pain improves the beliefs of the general population and general practitioners about back pain and appears to influence medical management.

Disseminating and Implementing the Results of Back Pain Research in Primary Care

Study Design. Description of a workshop entitled “Implementation and Dissemination: Getting Research into Practice,” that was held at the Fourth International Forum on Low Back Pain Research in Primary Care, in Israel in March 2000. Summary of Background Data. A gap exists between research endeavors and the dissemination and implementation of new research findings. Objectives. To describe the outcomes of a workshop on implementation and dissemination of research findings. Methods. The Fourth International Forum on Low Back Pain Research in Primary Care aimed to encourage open discussion and consensus building among leading experts in the field, and to develop a research agenda. The workshop on implementation and dissemination focused on issues surrounding the gap between research results and actual practice. These issues were introduced by several presentations. The broad conclusions of the subsequent debate are summarized in this paper as a series of responses to key questions: 1) who should do the implementation?, 2) what should researchers do to help implementation?, 3) what are the key outcomes?, and 4) what are important ingredients for successful implementation? Results. There was consensus about the importance of implementation of research findings, about the ineffectiveness of merely publishing or disseminating research findings, and about the need for prospective randomized trials evaluating the cost-effectiveness of different implementation strategies. The majority view is that the health provider professions and the professional bodies are the central organizations to implement guidelines, rather than the researchers themselves. Success in getting guidelines or research results into practice is dependent on involving local health service groups, experts, and opinion leaders (both local and national). Patient-centered outcomes and cost-effectiveness of guideline implementation were considered important. It was acknowledged that there are many potentially effective ingredients for successful implementation, but a clear indication of the contents of an effective implementation strategy is still lacking. Conclusions. The plenary and workshops focused on closing the gap between research results and actual practice. As long as we do not fully understand how best to influence and change physician behavior, the choice of implementation strategies should be based on the present knowledge of potentially effective interventions and should include considerations of available resources for, and potential barriers to, implementation.

Back pain and health policy research: the what, why, how, who, and when.

Study Design. A background literature, supported by discussion and outcomes on the subject of Health Policy and Back Pain, from the Fifth International Forum on Low Back Pain Research in Primary Care, in Montreal in May 2002. Summary of Background Data. A multitude of randomized controlled trials and systematic reviews have been completed in the field of back pain research. There has been limited health policy research in the field of back pain but a greater amount of health policy research in other medical fields. Methods. The focus of the workshop was on the contribution health policy could make in the area of back pain, the methodologies that are appropriate to research in back pain, and the barriers to back pain health policy research. The workshop was supported by the workshop coordinators’ literature review. Results. There was consensus about the lack of improved outcomes from randomized controlled trials and individual treatments and general agreement on the importance supporting current research initiatives with health policy research. That policy-makers were developing policy in this area was agreed, and study methodology to support evidence based policy development was explored. Conclusions. Health policy research is a relatively underdeveloped area of research in back pain. Back pain as a public health problem may be supported by a broader research approach and a collaborative association with policy-makers in this area.

Predictors of Acute and Persisting Ischemic Brain Lesions in Patients Randomized to Carotid Stenting or Endarterectomy

Background and Purpose— We investigated predictors for acute and persisting periprocedural ischemic brain lesions among patients with symptomatic carotid stenosis randomized to stenting or endarterectomy in the International Carotid Stenting Study. Methods— We assessed acute lesions on diffusion-weighted imaging 1 to 3 days after treatment in 124 stenting and 107 endarterectomy patients and lesions persisting on fluid-attenuated inversion recovery after 1 month in 86 and 75 patients, respectively. Results— Stenting patients had more acute (relative risk, 8.8; 95% confidence interval, 4.4–17.5; P<0.001) and persisting lesions (relative risk, 4.2; 95% confidence interval, 1.6–11.1; P=0.005) than endarterectomy patients. Acute lesion count was associated with age (by trend), male sex, and stroke as the qualifying event in stenting; high systolic blood pressure in endarterectomy; and white matter disease in both groups. The rate of conversion from acute to persisting lesions was lower in the stenting group (relative risk, 0.4; 95% confidence interval, 0.2–0.8; P=0.007), and was only predicted by acute lesion volume. Conclusions— Stenting caused more acute and persisting ischemic brain lesions than endarterectomy. However, the rate of conversion from acute to persisting lesions was lower in the stenting group, most likely attributable to lower acute lesion volumes. Clinical Trial Registration —URL: www.isrctn.org. Unique identifier: ISRCTN25337470.