Piet Portegijs

A longitudinal study on the predictive validity of the fear-avoidance model in low back pain

&NA; Recently, fear–avoidance models have been quite influential in understanding the transition from acute to chronic low back pain (LBP). Not only has pain‐related fear been found to be associated with disability and increased pain severity, but also treatment focused at reducing pain‐related fear has shown to successfully reduce disability levels. In spite of these developments, there is still a lack in well‐designed prospective studies examining the role of pain‐related fear in acute back pain. The aim of the current study was to prospectively test the assumption that pain‐related fear in acute stages successfully predicts future disability. Subjects were primary care acute LBP patients consulting because of a new episode of LBP (≤3 weeks). They completed questionnaires on background variables, fear–avoidance model variables and LBP outcome (Graded Chronic Pain Scale, GCPS) at baseline, 3, 6, and 12 months follow‐up and at the end of the study. Two‐hundred and twenty‐two acute LBP patients were included, of whom 174 provided full follow‐up information (78.4%). A backward ordinal regression analysis showed previous LBP history and pain intensity to be the most important predictors of end of study GCPS. Of the fear–avoidance model variables, only negative affect added to this model. Our results do not really support the longitudinal validity of the fear–avoidance model, but they do feed the discussion on the role of pain‐related fear in early stages of LBP.

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain‐related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain‐related fear and sequential relationships between the occurrence of pain‐related fear, pain and pain catastrophizing. Forty‐four general practice patients who consulted their physician with a new episode of non‐specific low back pain were recruited. They completed diaries on pain‐related fear, pain and pain catastrophizing for 14 days following the consultation. Follow‐up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain‐related fear over the 2‐week period. These groups differed on baseline characteristics and outcome at follow‐up. A time‐shift between the occurrence of pain‐events and pain‐related fear or pain catastrophizing could not be demonstrated.

Somatization in frequent attenders of general practice.

The DSM-III-(R) definition of somatization disorder is too restrictive for use in general practice. A more comprehensive definition, the “somatic symptom index” (SSI) has shown good validity in open populations. However, a definition has to differentiate validlywithin a population of frequent attenders to be a useful diagnostic instrument in general practice. We studied a threshold of five complaints (nearly identical to the SSI) in 80 Dutch general practice patients. Patients were selected on age (20–44 years), history of back, neck or abdominal complaints, and on frequency of consultation—at least 12 consultations in the previous 3 years, corrected for consultations with compelling somatic reason for encounter. Prevalence of somatization in this group was 45%. Women had a 2 times higher risk of somatization. A relation with age was not found. Somatization was related to depressive complaints (relative risk 2.5) and probably also to anxiety. Somatizing patients consulted their general practitioner more often and had more health problems (especially psychic problems) than non-somatizers. These results support the validity of this definition. The distinction between our definition of somatization and somatization defined as a symptom of psychiatric (e.g. depressive or anxiety) disorder is emphasized.

Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care.

Abstract Objective: To test whether a disclosure intervention improves subjective health and reduces medical consumption and sick leave in somatising patients in general practice. Design: Non-blind randomised controlled trial. Setting: 10 general practices in the Netherlands. Participants: 161 patients who frequently attended general practice with somatising symptoms. Intervention: Patients in the intervention group were visited two to three times and invited to disclose emotionally important events in their life. Control patients received normal care from their general practitioners. Main outcome measures: Use of medical services (drugs and healthcare visits), subjective health, and sick leave assessed by self completion questionnaires after 6, 12, and 24 months. Results: Of the 161 patients, 137 completed the trial (85%). Both groups were comparable at baseline. The intervention had no effect on the main outcome measures at any point. Intervention patients made one more visit to health care (95% confidence interval −4 to 6); the use of medicines did not change in both groups (−1 to 1); subjective health improved 3.6 points more in the control group (−11.2 to 4.3); and disclosure patients were on sick leave one more week (−1 to 3). Patients often had a depression or anxiety disorder for which they were not receiving adequate care. Conclusion: Although the intervention was well received by patients and doctors, disclosure had no effect on the health of somatising patients in general practice. What is already known on this topic Up to 5% of patients in general practice attend frequently with somatising symptoms Emotional expression techniques have been shown to have favourable effects on subjective health, visits to the doctor, and symptoms in healthy people What this study adds A disclosure intervention does not improve somatisation in primary care About 45% of patients had an anxiety or depressive disorder, which was often unrecognised

Use of diagnostic self-tests on body materials among Internet users in the Netherlands: prevalence and correlates of use

BackgroundA range of self-tests on body materials has become available to the general public, but the extent of their use has hardly been studied. This study examined how many people use diagnostic self-tests on body materials such as blood or urine, as well as the type of tests that are used, and factors associated with their use.MethodsCross-sectional survey. Participants were recruited from an existing Dutch Internet panel of 12,529 persons, and information was collected by means of a structured Internet-based questionnaire. Multiple logistic regression analyses were used to assess correlates of self-test use.ResultsResponse to the survey was 63%. Sixteen percent of the respondents said they had ever used at least one self-test, with a mean of 2.1 tests per self-tester. The most frequently reported self-tests were those for diabetes and cholesterol. Self-testers generally reported lower health status and had a higher BMI than non-testers. On the other hand, they were more likely to engage in health-related behaviour such as the use of dietary supplements and homeopathic medicine.ConclusionSelf-testing proved to be relatively prevalent among Dutch Internet users. We therefore think that it is essential to develop appropriate information for consumers, health care providers and policymakers, about the pros and cons of self-testing and specific self-tests. More test-specific research is needed.

Pain-related fear at the start of a new low back pain episode.

Previous research supports the fear‐avoidance model in explaining chronic low back pain (LBP) disability. The aims of the present study were to determine: (1) whether fear‐avoidance model variables are associated already during acute stages of LBP and (2) whether (increases in) pain‐related fear are associated with other patient characteristics routinely assessed by the General Practitioner (GP).

Somatisation in primary care: clinical judgement and standardised measurement compared.

Abstractu2002n Background:u2002In daily practice general practitioners (GPs) generally rely on their clinical judgement in assessing whether patients somatise distress. Nevertheless, conclusions derived from research on somatisation in primary care are largely based on standardised measurements of somatisation. We investigated the relation between GPs clinical judgement of somatisation and a somatisation research instrument (DSM-III-R), and examined how both operationalisations of somatisation related to other important variables. Methods:u2002In nine general practices, 407 frequently attending patients answered a questionnaire on somatisation symptoms, while the GPs gave their judgement on somatisation and communication for each patient. Other variables were extracted from the registered health status of the patients. Results:u2002We found a weak association (correlation: 0.27) between the GPs judgement and the research instrument; however, relations with other variables showed that both operationalisations were very similar constructs. The research instrument incorporated more psychological problems (depression and anxiety), while the GPs judgement of somatisation was more influenced by attendance rate and by aspects of communication with the patient. Conclusion:u2002For research addressing somatisation in primary care as a practical clinical problem, the operationalisation of somatisation should include the clinical judgement of the practitioner as well, thereby widening the focus from co-morbid mental disturbances to communication aspects.

A new episode of low back pain: Who relies on bed rest?

Bed rest has been shown to be an ineffective treatment for non‐specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non‐specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration.

General practitioners' treatment orientations towards low back pain: influence on treatment behaviour and patient outcome.

Background: In low back pain (LBP) treatment and research attention has shifted from a biomedical towards a biopsychosocial approach. Patients’ LBP beliefs and attitudes were found to predict long‐term outcome, and recently it has been suggested that the health care providers’ ideas about LBP are also important predictors of treatment behaviour and outcome.

Family history tools for primary care are not ready yet to be implemented. A systematic review.

Abstract Background: Taking the family history helps the doctor in estimating the probability of disease in individual patients. However, significant barriers to obtaining adequate family history information remain. Tools overcoming these barriers might support family physicians in this task. Objective: To review systematically the characteristics of existing family history tools and discuss their potential use in primary care. Methods: Studies were identified through searches of PubMed, Embase and Cinahl from 1 January 2002 until May 2012. All authors independently screened studies and included original research papers on family history tools of which assessment had been performed or was planned. We reviewed diseases for which family history information was collected, study setting, tool design, type of family history collection, presence of risk-assessment and recommendations for management, and assessment (categorized as either validity or benefit). Results: Eighteen family history tools were identified: six generic, two on cardiovascular disease and ten on cancer. The six generic tools were partly tested in primary care (3x), are mainly computerized (4x), rarely include management recommendations for the physician (1x) and were partly validated against a reference standard (genetic counsellor) (3x, plus one planned). Of the five specific tools studied in primary care, none was validated. No family history tool allows electronic transfer of family history information to electronic medical record systems. Use of a family history tool improved identification of patients at risk for disease. Conclusion: Several promising family history tools for primary care have been developed but large-scale implementation cannot be advised yet, based on available validation studies.