Psychological models can be used to understand and predict behaviour in a wide range of settings. However, they have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. The aim of this study was to explore the usefulness of a range of psychological theories to predict health professional behaviour relating to management of upper respiratory tract infections (URTIs) without antibiotics.
Psychological measures were collected by postal questionnaire survey from a random sample of general practitioners (GPs) in Scotland. The outcome measures were clinical behaviour (using antibiotic prescription rates as a proxy indicator), behavioural simulation (scenario-based decisions to managing URTI with or without antibiotics) and behavioural intention (general intention to managing URTI without antibiotics). Explanatory variables were the constructs within the following theories: Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model (SM), and knowledge (a non-theoretical construct). For each outcome measure, multiple regression analysis was used to examine the predictive value of each theoretical model individually. Following this 'theory level' analysis, a 'cross theory' analysis was conducted to investigate the combined predictive value of all significant individual constructs across theories.
All theories were tested, but only significant results are presented. When predicting behaviour, at the theory level, OLT explained 6% of the variance and, in a cross theory analysis, OLT 'evidence of habitual behaviour' also explained 6%. When predicting behavioural simulation, at the theory level, the proportion of variance explained was: TPB, 31%; SCT, 26%; II, 6%; OLT, 24%. GPs who reported having already decided to change their management to try to avoid the use of antibiotics made significantly fewer scenario-based decisions to prescribe. In the cross theory analysis, perceived behavioural control (TPB), evidence of habitual behaviour (OLT), CS-SRM cause (chance/bad luck), and intention entered the equation, together explaining 36% of the variance. When predicting intention, at the theory level, the proportion of variance explained was: TPB, 30%; SCT, 29%; CS-SRM 27%; OLT, 43%. GPs who reported that they had already decided to change their management to try to avoid the use of antibiotics had a significantly higher intention to manage URTIs without prescribing antibiotics. In the cross theory analysis, OLT evidence of habitual behaviour, TPB attitudes, risk perception, CS-SRM control by doctor, TPB perceived behavioural control and CS-SRM control by treatment entered the equation, together explaining 49% of the variance in intention.
The study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.
BACKGROUND: Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain. Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely. However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care. AIM: To compare short and long-term physical, social, and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice. DESIGN OF STUDY: A randomised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial. SETTING: Ninety-four general practices in south London and the South Thames region. METHOD: Patients consulting their general practitioner (GP) with low back pain at first presentation were recruited to a randomised controlled trial (RCT) or to an observational group. Patients in the trial were randomly allocated to immediate referral for x-ray or to no referral. All patients were asked to complete questionnaires initially, and then at six weeks and one year after recruitment. RESULTS: Six hundred and fifty-nine patients were recruited over 26 months: 153 to the randomised trial and 506 to the observational arm. In the RCT referral for x-ray had no effect on physical functioning, pain or disability, but was associated with a small improvement in psychological wellbeing at six weeks and one year. These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation; however, those referred for x-ray had lower depression scores. CONCLUSIONS: Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.
Psychological models are used to understand and predict behaviour in a wide range of settings, but have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. This study explored the usefulness of a range of models to predict an evidence-based behaviour -- the placing of fissure sealants.
Measures were collected by postal questionnaire from a random sample of general dental practitioners (GDPs) in Scotland. Outcomes were behavioural simulation (scenario decision-making), and behavioural intention. Predictor variables were from the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model, and knowledge (a non-theoretical construct). Multiple regression analysis was used to examine the predictive value of each theoretical model individually. Significant constructs from all theories were then entered into a 'cross theory' stepwise regression analysis to investigate their combined predictive value
Behavioural simulation - theory level variance explained was: TPB 31%; SCT 29%; II 7%; OLT 30%. Neither CS-SRM nor stage explained significant variance. In the cross theory analysis, habit (OLT), timeline acute (CS-SRM), and outcome expectancy (SCT) entered the equation, together explaining 38% of the variance. Behavioural intention - theory level variance explained was: TPB 30%; SCT 24%; OLT 58%, CS-SRM 27%. GDPs in the action stage had significantly higher intention to place fissure sealants. In the cross theory analysis, habit (OLT) and attitude (TPB) entered the equation, together explaining 68% of the variance in intention.
The study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that may predict clinical behaviour and so provide possible targets for knowledge translation interventions. Results suggest that more evidence-based behaviour may be achieved by influencing beliefs about the positive outcomes of placing fissure sealants and building a habit of placing them as part of patient management. However a number of conceptual and methodological challenges remain.
To reduce variability in primary care physicians' use of procedures for imaging the lumbar spine.
Controlled intervention using clinical practice guideline and practice pattern feedback.
Sixty-seven internists and 28 family practitioners in a large, group-model HMO.
MEASUREMENTS AND MAIN RESULTS
Intervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians' changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study.
Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed.
low back pain; treatment; clinical practice guidelines; practice pattern feedback
In the field of implementation research, there is an increased interest in use of theory when designing implementation research studies involving behavior change. In 2003, we initiated a series of five studies to establish a scientific rationale for interventions to translate research findings into clinical practice by exploring the performance of a number of different, commonly used, overlapping behavioral theories and models. We reflect on the strengths and weaknesses of the methods, the performance of the theories, and consider where these methods sit alongside the range of methods for studying healthcare professional behavior change.
These were five studies of the theory-based cognitions and clinical behaviors (taking dental radiographs, performing dental restorations, placing fissure sealants, managing upper respiratory tract infections without prescribing antibiotics, managing low back pain without ordering lumbar spine x-rays) of random samples of primary care dentists and physicians. Measures were derived for the explanatory theoretical constructs in the Theory of Planned Behavior (TPB), Social Cognitive Theory (SCT), and Illness Representations specified by the Common Sense Self Regulation Model (CSSRM). We constructed self-report measures of two constructs from Learning Theory (LT), a measure of Implementation Intentions (II), and the Precaution Adoption Process. We collected data on theory-based cognitions (explanatory measures) and two interim outcome measures (stated behavioral intention and simulated behavior) by postal questionnaire survey during the 12-month period to which objective measures of behavior (collected from routine administrative sources) were related. Planned analyses explored the predictive value of theories in explaining variance in intention, behavioral simulation and behavior.
Response rates across the five surveys ranged from 21% to 48%; we achieved the target sample size for three of the five surveys. For the predictor variables, the mean construct scores were above the mid-point on the scale with median values across the five behaviors generally being above four out of seven and the range being from 1.53 to 6.01. Across all of the theories, the highest proportion of the variance explained was always for intention and the lowest was for behavior. The Knowledge-Attitudes-Behavior Model performed poorly across all behaviors and dependent variables; CSSRM also performed poorly. For TPB, SCT, II, and LT across the five behaviors, we predicted median R2 of 25% to 42.6% for intention, 6.2% to 16% for behavioral simulation, and 2.4% to 6.3% for behavior.
We operationalized multiple theories measuring across five behaviors. Continuing challenges that emerge from our work are: better specification of behaviors, better operationalization of theories; how best to appropriately extend the range of theories; further assessment of the value of theories in different settings and groups; exploring the implications of these methods for the management of chronic diseases; and moving to experimental designs to allow an understanding of behavior change.
To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.
Randomised unblinded controlled trial.
73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.
421 patients with low back pain of a median duration of 10 weeks.
Radiography of the lumbar spine.
Main outcome measures
Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.
The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.
Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
Finite element analysis results will show significant differences if the model used is performed under various material properties, geometries, loading modes or other conditions. This study adopted an FE model, taking into account the possible asymmetry inherently existing in the spine with respect to the sagittal plane, with a more geometrically realistic outline to analyze and compare the biomechanical behaviour of the lumbar spine with regard to the facet force and intradiscal pressure, which are associated with low back pain symptoms and other spinal disorders. Dealing carefully with the contact surfaces of the facet joints at various levels of the lumbar spine can potentially help us further ascertain physiological behaviour concerning the frictional effects of facet joints under separate loadings or the responses to the compressive loads in the discs.
A lumbar spine model was constructed from processes including smoothing the bony outline of each scan image, stacking the boundary lines into a smooth surface model, and subsequent further processing in order to conform with the purpose of effective finite element analysis performance. For simplicity, most spinal components were modelled as isotropic and linear materials with the exception of spinal ligaments (bilinear). The contact behaviour of the facet joints and changes of the intradiscal pressure with different postures were analyzed.
The results revealed that asymmetric responses of the facet joint forces exist in various postures and that such effect is amplified with larger loadings. In axial rotation, the facet joint forces were relatively larger in the contralateral facet joints than in the ipsilateral ones at the same level. Although the effect of the preloads on facet joint forces was not apparent, intradiscal pressure did increase with preload, and its magnitude increased more markedly in flexion than in extension and axial rotation.
Disc pressures showed a significant increase with preload and changed more noticeably in flexion than in extension or in axial rotation. Compared with the applied preloads, the postures played a more important role, especially in axial rotation; the facet joint forces were increased in the contralateral facet joints as compared to the ipsilateral ones at the same level of the lumbar spine.
The purpose of this case report is to describe a case of metastatic non-Hodgkin lymphoma in the lumbar spine presenting as lumbar radiculopathy.
A 46-year-old man sought care from his doctor of chiropractic for low back pain and right leg radiculopathy. The patient was referred for a magnetic resonance imaging (MRI) scan to evaluate for a suspected disk herniation. The MRI scan revealed 2 lumbar pathologic compression fractures with cauda equina compression, and MRI short tau inversion recovery (STIR) sagittal image of the lumbar spine showed high signal in T12 and S2.
Intervention and Outcome
The patient was referred for an immediate consultation with his medical physician with the preliminary diagnosis of metastatic bone lesions or primary bone lesions of unknown etiology. The patient underwent bone biopsy, computed tomography, and positron emission tomography scanning and was diagnosed with small cell non-Hodgkin lymphoma with osseous metastasis. The patient underwent chemo- and radiation therapy, and the lymphoma is now in remission 18 months later.
This case describes the presentation of metastatic non-Hodgkin lymphoma as a possible contributing cause in a patient presenting with lumbar radiculopathy, a common musculoskeletal condition. As well, this case highlights the importance of STIR sequences as part of a routine lumbar spine MRI examination. Without the STIR sequences, the additional deposits in T12 and S1 would not have been readily appreciated. Although metastatic non-Hodgkin lymphoma of the spine is rare, it should be remembered in the differential diagnoses.
Non-Hodgkin lymphoma; Spine; Radiculopathy; Magnetic resonance imaging; Metastasis; Chiropractic
This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice.
General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation.
47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan.
The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour.
Australian New Zealand Clinical Trials Registry ACTRN012606000098538
Long term management of patients with Type 2 diabetes is well established within Primary Care. However, despite extensive efforts to implement high quality care both service provision and patient health outcomes remain sub-optimal. Several recent studies suggest that psychological theories about individuals' behaviour can provide a valuable framework for understanding generalisable factors underlying health professionals' clinical behaviour. In the context of the team management of chronic disease such as diabetes, however, the application of such models is less well established. The aim of this study was to identify motivational factors underlying health professional teams' clinical management of diabetes using a psychological model of human behaviour.
A predictive questionnaire based on the Theory of Planned Behaviour (TPB) investigated health professionals' (HPs') cognitions (e.g., beliefs, attitudes and intentions) about the provision of two aspects of care for patients with diabetes: prescribing statins and inspecting feet.
General practitioners and practice nurses in England and the Netherlands completed parallel questionnaires, cross-validated for equivalence in English and Dutch. Behavioural data were practice-level patient-reported rates of foot examination and use of statin medication. Relationships between the cognitive antecedents of behaviour proposed by the TPB and healthcare teams' clinical behaviour were explored using multiple regression.
In both countries, attitude and subjective norm were important predictors of health professionals' intention to inspect feet (Attitude: beta = .40; Subjective Norm: beta = .28; Adjusted R2 = .34, p < 0.01), and their intention to prescribe statins (Attitude: beta = .44; Adjusted R2 = .40, p < 0.01). Individuals' self-reported intention did not predict practice-level performance of either clinical behaviour.
Using the TPB, we identified modifiable factors underlying health professionals' intentions to perform two clinical behaviours, providing a rationale for the development of targeted interventions. However, we did not observe a relationship between health professionals' intentions and our proxy measure of team behaviour. Significant methodological issues were highlighted concerning the use of models of individual behaviour to explain behaviours performed by teams. In order to investigate clinical behaviours performed by teams it may be necessary to develop measures that reflect the collective cognitions of the members of the team to facilitate the application of these theoretical models to team behaviours.
Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.
Facet joint; Zygapophyseal joint; Low back pain; Pain; Radiculopathy; Sciatica; Catheter ablation; Steroids; Lumbar vertebrae; Humans; Male; Female; Nerve block; Diagnostic errors
A cross-sectional study was conducted to evaluate the possible use of a low-cost radiation-free technique in the prediction of degenerative changes in the lumbar spine. Although an inverse correlation between osteoporosis and degenerative changes in the lumbar spine has been reported, no previous studies have asked whether there is a correlation between calcaneal quantitative ultrasound results and degenerative findings in the lumbar spine. In 117 patients with low back pain or pain in the lower limb, ultrasonographic parameters (speed of sound, broadband ultrasound attenuation, stiffness) of the calcaneus were correlated with evidence of degenerative changes and stenosis on magnetic resonance scans of the lumbar spine. Linear and logistic regression, as well as receiver operator characteristic curve analyses, were used to evaluate the correlation. Lumbar spine stenosis was associated with elevated calcaneal ultrasonographic parameters, particularly speed of sound. For the identification of a narrowing of the lumbar spinal canal below 100 mm2 of dural sac cross-sectional area, speed of sound showed 89% sensitivity and 75% specificity in males older than 60 years. In male patients, we also found a significant positive correlation between ultrasonographic parameters and scores on a degenerative scale that primarily reflects intervertebral disc degeneration (P=0.019 for speed of sound; P=0.039 for stiffness). In conclusion, calcaneal quantitative ultrasound is frequently used in elderly patients with low back pain as a diagnostic test for osteoporosis. The incidental finding of high values on ultrasonographic parameters in these subjects, particularly in males, is highly correlated with lumbar spine degeneration and stenosis, and can help to identify those symptomatic patients needing more extensive diagnostic testing.
Quantitative ultrasound; Calcaneus; Magnetic resonance imaging; Lumbar spinal stenosis; Lumbar degeneration
The effect of low back pain, with or without nerve root signs, on the joint coordination and kinematics of the lumbar spine and hips during everyday activities, such as picking up an object from the floor, are largely unknown. An experimental study was designed to compare lumbar spine and hip joint kinematics and coordination in subjects with and without sub-acute low back pain, while picking up an object in a sitting position. A three-dimensional real-time electromagnetic tracking device was used to measure movements of the lumbar spine and hips. Sixty participants with subacute low back pain, with or without straight leg raise signs, and twenty healthy asymptomatic participants were recruited. The ranges of motions of lumbar spine and hips were determined. Movement coordination between the two regions was examined by cross-correlation. Results showed that mobility was significantly reduced in subjects with back pain, who compensated for limited motion through various strategies. The contribution of the lumbar spine relative to that of the hip was, however, found to be similar in all groups. The lumbar spine–hip joint coordination was substantially altered in subjects with back pain, in particular, those with a positive straight leg raise sign. We conclude that changes in the lumbar and hip kinematics were related to back pain and limitation in straight leg raise. Lumbar–hip coordination was mainly affected by the presence of positive straight leg raise sign when picking up an object in a sitting position.
Kinematics; Spine; Low back pain; Hip; Activities of daily living; Joint coordination
The development and description of interventions to change professional practice are often limited by the lack of an explicit theoretical and empirical basis. We set out to develop an intervention to promote appropriate disclosure of a diagnosis of dementia based on theoretical and empirical work.
We identified three key disclosure behaviours: finding out what the patient already knows or suspects about their diagnosis; using the actual words 'dementia' or 'Alzheimer's disease' when talking to the patient; and exploring what the diagnosis means to the patient. We conducted a questionnaire survey of older peoples' mental health teams (MHTs) based upon theoretical constructs from the Theory of Planned Behaviour (TPB) and Social Cognitive Theory (SCT) and used the findings to identify factors that predicted mental health professionals' intentions to perform each behaviour. We selected behaviour change techniques likely to alter these factors.
The change techniques selected were: persuasive communication to target subjective norm; behavioural modelling and graded tasks to target self-efficacy; persuasive communication to target attitude towards the use of explicit terminology when talking to the patient; and behavioural modelling by MHTs to target perceived behavioural control for finding out what the patient already knows or suspects and exploring what the diagnosis means to the patient. We operationalised these behaviour change techniques using an interactive 'pen and paper' intervention designed to increase intentions to perform the three target behaviours.
It is feasible to develop an intervention to change professional behaviour based upon theoretical models, empirical data and evidence based behaviour change techniques. The next step is to evaluate the effect of such an intervention on behavioural intention. We argue that this approach to development and reporting of interventions will contribute to the science of implementation by providing replicable interventions that illuminate the principles and processes underlying change.
Despite the availability of clinical guidelines for the management of low back pain (LBP), there continues to be wide variation in general practitioners' (GPs') referral rates for lumbar spine x-ray (LSX). This study aims to explain variation in GPs' referral rates for LSX from their accounts of the management of patients with low back pain.
Qualitative, semi-structured interviews with 29 GPs with high and low referral rates for LSX in North East England. Thematic analysis used constant comparative techniques.
Common and divergent themes were identified among high- and low-users of LSX. Themes that were similar in both groups included an awareness of current guidelines for the use of LSX for patients with LBP and the pressure from patients and institutional factors to order a LSX. Differentiating themes for the high-user group included: a belief that LSX provides reassurance to patients that can outweigh risks, pessimism about the management options for LBP, and a belief that denying LSX would adversely affect doctor-patient relationships. Two specific differentiating themes are considered in more depth: GPs' awareness of their use of lumbar spine radiology relative to others, and the perceived risks associated with LSX radiation.
Several key factors differentiate the accounts of GPs who have high and low rates of referral for LSX, even though they are aware of clinical guideline recommendations. Intervention studies that aim to increase adherence to guideline recommendations on the use of LSX by changing the ordering behaviour of practitioners in primary care should focus on these factors.
Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain.
Design Multicentre randomised controlled trial.
Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom.
Participants 349 participants aged 18-55 with chronic low back pain of at least one year's duration who were considered candidates for spinal fusion.
Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy.
Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure.
Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures.
Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.
This case-control pilot study examined whether vertebral bone mineral measures were associated with the presence of chronic low back pain (CLBP) and Modic changes (MCs), and to compare psychological wellbeing and inflammation among individuals with CLBP and MCs, compared to individuals with no history of low back pain and without MCs.
Eleven individuals with MRI-defined MCs in the lumbar spine and CLBP (cases) and 10 individuals with no history of CLBP or MCs (controls) responded to standard questionnaires regarding pain characteristics and psychological health. Bone mineral density (BMD) was measured with postero-anterior and lateral-projection dual energy X-ray absorptiometry (DXA) to estimate areal BMD (aBMD) and apparent volumetric BMD (ap.vBMD). High sensitivity serum C-reactive protein (hsCRP) was measured as an index of inflammation.
While there was no difference between the groups in measures of depression, anxiety and stress, cases reported significantly greater pain catastrophizing attitudes (P < 0.01). hsCRP concentrations did not differ between groups (P = 0.54). Among the 7 cases where MCs were identified between L3–4, significantly higher mean aBMD was observed at the affected vertebral level, compared to the adjacent, unaffected, cephalad level (P = 0.01–0.04), but not when ap.vBMD was calculated (P = 0.36).
Vertebral BMD is not reduced among individuals with CLBP and MCs compared to a control group, although pain catastrophizing attitudes are increased among individuals with CLBP and MCs.
Modic change; bone mineral density; hsCRP; psychological health
The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.
Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.
Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).
Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.
Theoretical domains framework; Focus groups; Content analysis; Social/professional role and identity; Social influence; Chiropractors; Radiography; X-ray guidelines; Back pain
Psychologic factors may have a major influence on the outcome of treatment for back pain. Psychologic disturbance is manifest as emotional distress and may be associated with inappropriate symptoms and signs. Few outcome studies describe the patient population in terms of their psychologic profile. Anecdotal evidence suggested that the routine use of psychologic screening tests in British spine practice was rare. An audit of the prevalent use of psychologic testing amongst a selected group of British spinal surgeons was conducted. This was followed by a prospective, double blind comparison of subjective evaluations of patients with formal psychologic tests. The principal aim was to determine how accurately treating physicians could identify psychologically distressed patients. A postal questionnaire was sent to all consultant members of the British Orthopaedic Spine Society. Details of their current practice and frequency of use of psychologic tests was obtained. In a subsequent study, 125 consecutive new patients attending a back pain clinic were initially evaluated by questionnaires and classified as either psychologically distressed or non-distressed. These patients were then interviewed and examined by treating physicians, who then allocated them to one of four psychologic categories, using predefined criteria. The two results were compared and sensitivity, specificity and predictive values for the subjective evaluations were calculated. Sixty-three percent of respondents to the postal survey either never or only occasionally used any form of psychologic testing in assessing back pain patients. The follow-up prospective study demonstrated that experienced spinal surgeons achieved only a 26% sensitivity when trying to identify distressed patients. The specificity for identifying non-distressed patients was 96%. The predictive value of a “distressed” evaluation was 69%. The predictive value for non-distressed patients was 77%. Subjective psychologic assessment of back pain patients has a low sensitivity and predictive value for distressed patients. Formal psychologic screening should be routinely included in the clinical decision making process.
Key words Psychologic tests; Back pain; Patient assessment
Spinal posture is commonly a focus in the assessment and clinical management of low back pain (LBP) patients. However, the link between spinal posture and LBP is not fully understood. Recent evidence suggests that considering regional, rather than total lumbar spine posture is important. The purpose of this study was to determine; if there are regional differences in habitual lumbar spine posture and movement, and if these findings are influenced by LBP.
One hundred and seventy female undergraduate nursing students, with and without LBP, participated in this cross-sectional study. Lower lumbar (LLx), Upper lumbar (ULx) and total lumbar (TLx) spine angles were measured using an electromagnetic tracking system in static postures and across a range of functional tasks.
Regional differences in lumbar posture and movement were found. Mean LLx posture did not correlate with ULx posture in sitting (r = 0.036, p = 0.638), but showed a moderate inverse correlation with ULx posture in usual standing (r = -0.505, p < 0.001). Regional differences in range of motion from reference postures in sitting and standing were evident. BMI accounted for regional differences found in all sitting and some standing measures. LBP was not associated with differences in regional lumbar spine angles or range of motion, with the exception of maximal backward bending range of motion (F = 5.18, p = 0.007).
This study supports the concept of regional differences within the lumbar spine during common postures and movements. Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. BMI influenced regional lumbar posture and movement, possibly representing adaptation due to load.
Objectives: To determine whether a correlation between motion palpation findings and abnormal coupling patterns, as viewed in lumbar functional X-rays, can be demonstrated in low back pain (LBP) patients.
Design: A prospective observational study of patients who present to a chiropractic clinic for assessment of low back pain.
Subjects: The sample population consisted of 27 consecutive patients presenting with LBP between the ages of 20-50 year old and who were capable of pain free lateral lumbar flexion.
Intervention: All subjects underwent motion palpation to determine whether a "fixation" at the L4/5 existed. All had lumbar spine X-rays in an anterior-posterior (AP) and bilateral AP lateral flexion position. X-rays were then analyzed to determine whether the coupling pattern at L4/5 was considered abnormal.
Results: In those patients with a perceived L4/5 motion restriction no coupling patterns where found in 6 cases (22.4%) and normal coupling patterns in 13 cases (48%). In those patients who presented with LBP and no motion findings at L4/5 no coupling was observed in 4 cases (14.8%) and normal coupling in another 4 cases (14.8%). The chi-squared test demonstrated no statistical differences (p>0.05) between the motion fixation at L4/5 and coupling patterns from lateral flexion X-rays.
Conclusion: It is of particular interest to note that the presence of the L4/5 fixation was not associated with abnormal coupling but conversely was frequently observed to be associated with normal coupling patterns. A simple correlation between a single motion palpation finding of a restriction at a L4/5 facet and an alteration in coupling patterns could not be supported.
Chiropractic; lumbar X-rays; motion palpation; biomechanic
BACKGROUND: Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny. Guidelines aiming to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed. Trial evidence suggests that guidelines can reduce radiography referrals. It is not clear whether this reduction has been achieved in routine practice. AIM: This study, using routine data, was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999. DESIGN OF STUDY: Analysis of primary care requests for lumbar spine radiography from computerised records. SETTING: Addenbrooke's Hospital, Cambridge (1 July 1994 to 30 June 1999), and Ipswich General Hospital (1 July 1995 to 30 June 1999), United Kingdom. METHOD: All primary care requests for lumbar radiography were identified electronically from computerised information systems. A random sample of 2100 radiography reports were classified according to clinical importance. These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999. RESULTS: There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital. General practitioners did not progressively refer more high-risk patients for lumbar radiography. Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy. CONCLUSION: The implementation of diagnostic guidelines offers much to the NHS. However in these two hospitals, the reduction in radiograph utilisation evident in trials was not achieved. Guideline development is a resource intensive process; distribution must be supported by more effective implementation strategies.
Overlap exists between psychological measures within back pain research; the focus needs to move from single constructs to their combined influence on outcomes for patients with back pain.
The biopsychosocial model is increasingly accepted in low back pain (LBP) research and clinical practice. In order to assess the role of psychological factors in the development and persistence of pain, a wide array of measures has been developed. Yet there is likely to be considerable conceptual overlap between such measures, and consequently, a lack of clarity about the importance of psychological factors. The aims of this study were to investigate the extent of any such overlap. An observational cohort study of 1591 LBP patients consulting in primary care completed data on a range of psychological instruments. Exploratory and confirmatory factor analyses (EFA and CFA, respectively) were carried out at the subscale level (n = 20) to investigate factor structure. The influences of the derived factors on clinical outcomes (pain intensity and self-reported disability) were then tested using linear regression. EFA yielded 4 factors, termed “Pain-related distress,” “Cognitive coping,” “Causal beliefs,” and “Perceptions of the future,” which accounted for 65.5% of the variance. CFA confirmed the validity of these factors models. The pain-related distress factor was found to have the strongest association to LBP patients’ outcomes, accounting for 34.6% of the variance in pain intensity, and 51.1% of the variance in disability. Results confirmed that considerable overlap exists in psychological measures commonly used in LBP research. Most measures tap into patients’ emotional distress. These findings help us to understand how psychological constructs relate together; implications for future research and clinical practice are discussed.
Low back pain; Factor analysis; Primary care; Psychological
The purpose of this report is to describe the response of a geriatric patient with low back pain and a history of leukemia, multiple compression fractures, osteoporosis, and degenerative joint disease using Activator chiropractic technique.
An 83-year-old man who is the primary caretaker for his disabled wife had low back pain after lifting her into a truck. The patient had a history of leukemia, multiple compression fractures, osteoporosis, and degenerative joint disease. His Revised Oswestry Low Back Pain Disability Questionnaire was 26%, with a 10/10 pain rating at its worst on the Numeric Pain Scale. The patient presented with a left head tilt, right high shoulder, and right high ilium with anterior translation and flexion of the torso and spasm and tenderness from the lower thoracic spine to lumbar spine.
Intervention and Outcome
The patient was cared for using Activator Methods protocol. After 8 treatments, the patient was stable and remained stable for 4 months without spasm or tenderness in his spine. His Revised Oswestry score dropped to 6%, with a 4/10 Numeric Pain Scale pain rating when at its worst; and the patient reported being able to take care of his wife.
The findings of this case suggest that Activator-assisted spinal manipulative therapy had a positive effect on low back pain and function in an elderly patient with a complex clinical history.
Chiropractic; Low back pain; Leukemia; Spinal fractures; Osteoporosis
Back pain is one of the most frequent complaints in the nursing profession. Thus, the 12-month prevalence of pain in the lumbar spine in nursing staff is as high as 76%. Only a few representative studies have assessed the prevalence rates of back pain and its risk factors among nursing staff in nursing homes in comparison to staff in home-based care facilities. The present study accordingly investigates the prevalence in the lumbar and cervical spine and determines the physical workload to lifting and caring in geriatric care.
1390 health care workers in nursing homes and home care participated in this cross sectional survey. The nursing staff members were examined by occupational physicians according to the principals of the multistep diagnosis of musculoskeletal disorders. Occupational exposure to daily care activities with patient transfers was measured by a standardised questionnaire. The lumbar load was calculated with the Mainz-Dortmund dose model. Information on ergonomic conditions were recorded from the management of the nursing homes. Comparisons of all outcome variables were made between both care settings.
Complete documentation, including the findings from the occupational physicians and the questionnaire, was available for 41%. Staff in nursing homes had more often positive orthopaedic findings than staff in home care. At the same time the values calculated for lumbar load were found to be significant higher in staff in nursing homes than in home-based care: 45% vs. 6% were above the reference value. Nursing homes were well equipped with technical lifting aids, though their provision with assistive advices is unsatisfactory. Situation in home care seems worse, especially as the staff often has to get by without assistance.
Future interventions should focus on counteracting work-related lumbar load among staff in nursing homes. Equipment and training in handling of assistive devices should be improved especially for staff working in home care.