Care for low back pain: can health systems deliver?

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Les lombalgies sont la principale cause d'années de vie vécues avec une incapacité dans le monde. En 2018, un groupe de travail international a invité l'Organisation mondiale de la Santé à attirer l'attention sur la charge que représentent les lombalgies et sur la nécessité d'éviter le recours excessif aux solutions médicales. En effet, selon les dernières recommandations cliniques internationales, de nombreux cas de lombalgie ne nécessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommandé de limiter la prise d'analgésiques, les injections de stéroïdes et la chirurgie rachidienne, et d'encourager plutôt les thérapeutiques physiques et psychologiques. Très souvent, les systèmes de santé ne sont pas conçus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systèmes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous détaillons les principales difficultés de la prise en charge des lombalgies dans le cadre des systèmes de santé. Il s'agit notamment des intérêts financiers des laboratoires pharmaceutiques, entre autres; des systèmes de paiement obsolètes qui privilégient la prise en charge médicale à l'autogestion par les patients; et de croyances et traditions médicales profondément ancrées parmi les médecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systèmes de santé confrontés de plus en plus souvent à une prise en charge inefficace des lombalgies. Nous suggérons des politiques qui, sans incidence sur les coûts, en transférant les ressources allouées aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considérable. De petits ajustements des politiques de santé ne suffiront cependant pas. Les systèmes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte sociétal global dans lequel s'inscrit la santé devront également changer.

El dolor lumbar es la causa principal de vivir con discapacidad durante años en todo el mundo. En 2018, un grupo de trabajo internacional pidió a la Organización Mundial de la Salud que prestara más atención a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente médicas. De hecho, las principales directrices clínicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningún tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgésicos, inyecciones de esteroides y cirugía de la columna vertebral y, en su lugar, promover las terapias físicas y psicológicas. Muchos sistemas de salud no están diseñados para apoyar este enfoque. En este documento, se expone por qué el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atención del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las compañías farmacéuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atención médica por encima del autocuidado de los pacientes, así como las tradiciones y las creencias médicas profundamente arraigadas sobre la atención del dolor de espalda entre los médicos y el público general. Se presentan ejemplos internacionales de soluciones prometedoras y de políticas y prácticas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atención ineficaz para el dolor lumbar. Se sugieren políticas que, al desplazar los recursos de la atención innecesaria a la atención acorde con las directrices para el dolor lumbar, podrían ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequeños ajustes en la política sanitaria no funcionarán de forma aislada. Los sistemas del lugar de trabajo, los marcos jurídicos, las creencias personales, la política y el contexto social general en el que vivimos la salud también tendrán que cambiar.

Non-disclosure of symptoms in primary care: an observational study.

Background: Symptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation. Objectives: To estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients' intended agendas for mentioning symptoms compared with what was discussed. Method: We videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patient's agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and 'symptoms with intention to discuss' were compared with the actual topics of discussion. Results: Totally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed. Conclusion: This study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.

Change in physical activity level and clinical outcomes in older adults with knee pain: a secondary analysis from a randomised controlled trial.

BACKGROUND: Exercise interventions improve clinical outcomes of pain and function in adults with knee pain due to osteoarthritis and higher levels of physical activity are associated with lower severity of pain and higher levels of physical functioning in older adults with knee osteoarthritis in cross-sectional studies. However, to date no studies have investigated if change in physical activity level during exercise interventions can explain clinical outcomes of pain and function. This study aimed to investigate if change in physical activity during exercise interventions is associated with future pain and physical function in older adults with knee pain. METHODS: Secondary longitudinal data analyses of a three armed exercise intervention randomised controlled trial. Participants were adults with knee pain attributed to osteoarthritis, over the age of 45 years old (n = 514) from Primary Care Services in the Midlands and Northwest regions of England. Crude and adjusted associations between absolute change in physical activity from baseline to 3 months (measured by the self-report Physical Activity Scale for the Elderly (PASE)) and i) pain ii) physical function (Western Ontario and McMaster Universities Osteoarthritis Index) and iii) treatment response (OMERACT-OARSI responder criteria) at 3 and 6 months follow-up were investigated using linear and logistic regression. RESULTS: Change in physical activity level was not associated with future pain, function or treatment response outcomes in crude or adjusted models at 3 or 6 months (P > 0.05). A 10 point increase in PASE was not associated with pain ß = - 0.01 (- 0.05, 0.02), physical function ß = - 0.09 (- 0.19, 0.02) or likelihood (odds ratio) of treatment response 1.02 (0.99, 1.04) at 3 months adjusting for sociodemographics, clinical covariates and the trial intervention arm. Findings were similar for 6 month outcome models. CONCLUSIONS: Change in physical activity did not explain future clinical outcomes of pain and function in this study. Other factors may be responsible for clinical improvements following exercise interventions. However, the PASE may not be sufficiently responsive to measure change in physical activity level. We also recommend further investigation into the responsiveness of commonly used physical activity measures. TRIAL REGISTRATION: ( ISRCTN93634563 ). Registered 29th September 2011.

Quality of care for OA: the effect of a point-of-care consultation recording template.

OBJECTIVE: The aims of this study were to determine the feasibility of introducing a computerized template for identifying quality of care during an OA consultation, describe quality of OA care in practices in which the template was introduced and assess the effect of the template on routinely recorded clinician behaviour in those practices. METHODS: A computerized template to assist the recording of care in consultations for patients with OA was installed in eight general practices. Eligible patients were those ≥45 years of age consulting for clinical OA during a 6 month period. The main outcomes were frequency of template triggering, achievement of quality indicators during the consultation (assessment of pain and function, assessment for first-line analgesics, provision of information, exercise advice, consideration of physiotherapy referral, weight loss advice) and change in routinely recorded clinician behaviour (diagnostic coding, prescribing, referral, use of radiography, weight records) compared with the 12 months prior to template installation. RESULTS: The template was triggered for 1730 patients. Achievement of indicators ranged from 36% (for consideration of physiotherapy referral) to 63% (for pain assessment), with substantial variability between clinicians. There was an increase in prescription of recommended first-line analgesics following the template installation: paracetamol [odds ratio (OR) 1.49 (95% CI 1.22, 1.82) compared with pre-template] and topical NSAIDs [OR 1.95 (95% CI 1.61, 2.35)]. CONCLUSION: This new template is a feasible tool for capturing data during OA consultations to aid assessment of quality of care. It was associated with significant improvements in recommended care processes. However, strategies are needed to ensure consistent approaches between clinicians. TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN06984617/mosaics.

The Identity Crisis of Osteoarthritis in General Practice: A Qualitative Study Using Video-Stimulated Recall.

PURPOSE: Patients and doctors report marked disenchantment with primary care consultation experiences relating to osteoarthritis. This study aimed to observe and analyze interactions between general practitioners (GPs) and patients presenting with osteoarthritis (OA) to identify how to improve care for OA. METHODS: We conducted an observational study in general practices in the United Kingdom using video-recorded real-life consultations of unselected patients and their GPs. Postconsultation interviews were conducted using video-stimulated recall. Both consultations and interviews were analyzed thematically. RESULTS: Three key themes were identified in an analysis of 19 OA consultations and the matched GP and patient interviews: complexity, dissonance, and prioritization. The topic of osteoarthritis arises in the consultation in complex contexts of multimorbidity and multiple, often not explicit, patient agendas. Dissonance between patient and doctor was frequently observed and reported; this occurred when GPs normalized symptoms of OA as part of life and reassured patients who were not seeking reassurance. GPs used wear and tear in preference to osteoarthritis or didn't name the condition at all. GPs subconsciously made assumptions that patients did not consider OA a priority and that symptoms raised late in the consultation were not troublesome. CONCLUSIONS: The lack of a clear illness profile results in confusion between patients and doctors about what OA is and its priority in the context of multimorbidity. This study highlights generic communication issues regarding the potential negative consequences of unsought reassurance and the importance of validation of symptoms and raises new arguments for tackling OA's identity crisis by developing a clearer medical language with which to explain OA.

The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies.

BACKGROUND: Evidence suggests that the course of low back pain (LBP) symptoms in randomised clinical trials (RCTs) follows a pattern of large improvement regardless of the type of treatment. A similar pattern was independently observed in observational studies. However, there is an assumption that the clinical course of symptoms is particularly influenced in RCTs by mere participation in the trials. To test this assumption, the aim of our study was to compare the course of LBP in RCTs and observational studies. METHODS: Source of studies CENTRAL database for RCTs and MEDLINE, CINAHL, EMBASE and hand search of systematic reviews for cohort studies. Studies include individuals aged 18 or over, and concern non-specific LBP. Trials had to concern primary care treatments. Data were extracted on pain intensity. Meta-regression analysis was used to compare the pooled within-group change in pain in RCTs with that in cohort studies calculated as the standardised mean change (SMC). RESULTS: 70 RCTs and 19 cohort studies were included, out of 1134 and 653 identified respectively. LBP symptoms followed a similar course in RCTs and cohort studies: a rapid improvement in the first 6 weeks followed by a smaller further improvement until 52 weeks. There was no statistically significant difference in pooled SMC between RCTs and cohort studies at any time point:- 6 weeks: RCTs: SMC 1.0 (95% CI 0.9 to 1.0) and cohorts 1.2 (0.7to 1.7); 13 weeks: RCTs 1.2 (1.1 to 1.3) and cohorts 1.0 (0.8 to 1.3); 27 weeks: RCTs 1.1 (1.0 to 1.2) and cohorts 1.2 (0.8 to 1.7); 52 weeks: RCTs 0.9 (0.8 to 1.0) and cohorts 1.1 (0.8 to 1.6). CONCLUSIONS: The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. In addition to a shared 'natural history', enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design.

Does life course socio-economic position influence chronic disabling pain in older adults? A general population study.

BACKGROUND: Chronic pain is the leading cause of disability in developed countries. Prevalence is linked with socio-economic position (SEP), but little is known about the influence of SEP on disabling pain over the life course. We have investigated the influence of different life course trajectories of SEP on disabling pain ('pain interference') in postal surveys of adults aged ≥50 years sampled from the general population of adults registered with three UK general practices. METHODS: Current pain interference was measured using the dichotomized 36-item Short-Form (SF-36) health survey. Three recalled SEP measures (age left school, longest job and current/most recent job) were dichotomized into low SEP (left school at or before minimum school leaving age; reported routine or manual occupations) and high SEP, from which eight life course SEP trajectories were constructed. Associations of (i) eight SEP trajectories and (ii) three individual SEP measures adjusted for each other, with pain interference, adjusted for potential confounders, were calculated using logistic regression. RESULTS: A total of 2533 individuals provided data on all three SEP measures. A consistently low life course SEP trajectory was significantly associated with current pain interference compared with a high trajectory [odds ratio (OR) = 2.76, 95% confidence interval (CI): 2.19-3.47], even after adjustment for age and gender. Further adjustment reduced the association but it remained significant (OR = 2.04; 95% CI: 1.55-2.68). In the model with individual measures, low age left school (OR = 1.45; 95% CI: 1.15-1.82) and manual longest job (OR = 1.47; 95% CI: 1.13-1.91) were independently associated with pain interference. CONCLUSIONS: Our results highlight the potential for reducing chronic disabling pain in later life by addressing inequalities in both childhood education and adult occupational opportunities.

Validity of two simple measures for estimating life-course socio-economic position in cross-sectional postal survey data in an older population: results from the North Staffordshire Osteoarthritis Project (NorStOP).

BACKGROUND: Since few cohorts encompass the whole life-course, many studies that measure socio-economic position (SEP) across the life-course rely on participant recall of SEP measures from cross-sectional postal or interview surveys. It is also particularly important that SEP measures should be appropriate for the age of the population studied, as the level of missing data has been shown to increase in older people. The aim of this study was to investigate the accuracy of recall of two SEP measures in older adults, age left school and longest job, by examining their validity in a general population postal survey in North Staffordshire, UK. METHODS: Sets of questions on education and longest job were included in a questionnaire at different stages of the study. All patients aged 50+ registered with three general practices were sent a baseline Health Questionnaire. 6 years later, 3410 responders were mailed a follow-up Health Questionnaire; a sub-sample of these participants took part in independent qualitative interviews. Validity was assessed by: percentage completion; internal percentage agreement within each set of questions; percentage agreement of qualitative and quantitative data for age left school and longest job; comparing recall of age left school with historical change in legal school leaving age; comparing frequency of pottery job titles with those in 1981 Census data for Stoke-on-Trent. RESULTS: The adjusted response to different stages of the study was 71-85%. Completion of questions was 83-98%. Internal agreement was 84-97% (education) and 95-100% (longest job). Comparison of survey and interview data showed 86% agreement (± 1 year) for age left school and 91% agreement for longest job. The change in age left school data concurred with the historical shift in legal school leaving age. 11% of job titles were pottery in NorStOP data and 15% in Stoke-on-Trent Census data. CONCLUSIONS: The results from this study provide evidence for the accuracy of recall of two simple measures of SEP (age left school and longest job) in a postal survey of older adults. Consistency with evidence from external datasets indicated the potential validity of these measures for studying life-course SEP in population surveys.

Musculoskeletal foot problems in primary care: what influences older people to consult?

OBJECTIVE: To estimate the incidence of, and factors associated with, consultation for musculoskeletal foot problems in primary care. METHODS: Survey data from 13 986 people aged ≥50 years who took part in the North Staffordshire Osteoarthritis Project were linked to a database of primary care consultations. Foot problems were defined as responding affirmatively to the questions: 'Have you had any problems with your feet over the last year?' or 'Have you had pain in the last year in and around the foot?'. The main outcome measure was a record of a musculoskeletal foot-related consultation within 18 months following the survey. RESULTS: Of the 3858 participants with foot problems who had not consulted before the survey, 350 (9.1%) consulted in the 18 months following the survey. Age, sex, education, general health and pain in other regions were not associated with future consultation. However, those who consulted were more likely to have reported foot pain [adjusted odds ratio (OR) 2.04; 95% CI 1.22, 3.42) and to consider treatments to be effective in controlling disease (OR 1.54; 95% CI 1.07, 2.21) in the baseline survey, and to have been a frequent consulter in the 18 months before the survey (OR 1.65; 95% CI 1.30, 2.09). CONCLUSIONS: Only a minority of older people with musculoskeletal foot problems consult their general practitioner about them. Foot pain, frequent consultation for other problems and positive perceptions of treatment efficacy appear to be the strongest factors influencing future consultation.

Characteristics of primary care consultations for musculoskeletal foot and ankle problems in the UK.

OBJECTIVE: Foot and ankle problems are highly prevalent in the general population; however, little is known about the characteristics of those seeking medical assessment for these problems. The objective of this study was to explore the extent and types of musculoskeletal foot and ankle problems in primary care. METHODS: Consultation data related to musculoskeletal foot and ankle problems in 2006 were extracted from the Consultations in Primary Care Archive (CiPCA), which covers consultations in 12 general practices in North Staffordshire. Data were cross-tabulated by age and gender, and annual consultation prevalence per 10,000 registered persons was calculated. RESULTS: Of the 55,033 musculoskeletal consultations documented in CiPCA in 2006, 4500 (8%) related to foot and ankle problems. The most commonly documented Read term was 'foot pain' (1281 consultations; 28%), followed by 'ankle pain' [451 (10%)]. Most consultations [3538 (79%)] involved non-traumatic conditions. Females accounted for slightly more consultations than males (55 vs 45%), and the highest proportion of consultations involved people aged 45-64 years (36%). The number of consultations per patient ranged from 1 to 11. Annual consultation prevalence was 290 per 10,000 registered persons and increased with age, reaching a peak in the 65- to 74-year age group (411 per 10,000 registered persons). CONCLUSION: Foot and ankle problems account for a substantial number of consultations in primary care, and most frequently involve non-traumatic conditions. Further research is required to evaluate the factors that influence consultation for foot problems and strategies that general practitioners use to manage these conditions.

The search for stable prognostic models in multiple imputed data sets.

BACKGROUND: In prognostic studies model instability and missing data can be troubling factors. Proposed methods for handling these situations are bootstrapping (B) and Multiple imputation (MI). The authors examined the influence of these methods on model composition. METHODS: Models were constructed using a cohort of 587 patients consulting between January 2001 and January 2003 with a shoulder problem in general practice in the Netherlands (the Dutch Shoulder Study). Outcome measures were persistent shoulder disability and persistent shoulder pain. Potential predictors included socio-demographic variables, characteristics of the pain problem, physical activity and psychosocial factors. Model composition and performance (calibration and discrimination) were assessed for models using a complete case analysis, MI, bootstrapping or both MI and bootstrapping. RESULTS: Results showed that model composition varied between models as a result of how missing data was handled and that bootstrapping provided additional information on the stability of the selected prognostic model. CONCLUSION: In prognostic modeling missing data needs to be handled by MI and bootstrap model selection is advised in order to provide information on model stability.

The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature.

BACKGROUND: Studies have suggested that the symptoms of knee osteoarthritis (OA) are rather weakly associated with radiographic findings and vice versa. Our objectives were to identify estimates of the prevalence of radiographic knee OA in adults with knee pain and of knee pain in adults with radiographic knee OA, and determine if the definitions of x ray osteoarthritis and symptoms, and variation in demographic factors influence these estimates. METHODS: A systematic literature search identifying population studies which combined x rays, diagnosis, clinical signs and symptoms in knee OA. Estimates of the prevalence of radiographic OA in people with knee pain were determined and vice versa. In addition the effects of influencing factors were scrutinised. RESULTS: The proportion of those with knee pain found to have radiographic osteoarthritis ranged from 15-76%, and in those with radiographic knee OA the proportion with pain ranged from 15% - 81%. Considerable variation occurred with x ray view, pain definition, OA grading and demographic factors CONCLUSION: Knee pain is an imprecise marker of radiographic knee osteoarthritis but this depends on the extent of radiographic views used. Radiographic knee osteoarthritis is likewise an imprecise guide to the likelihood that knee pain or disability will be present. Both associations are affected by the definition of pain used and the nature of the study group. The results of knee x rays should not be used in isolation when assessing individual patients with knee pain.

Justifications for using complementary and alternative medicine reported by persons with musculoskeletal conditions: A narrative literature synthesis.

BACKGROUND: Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people's reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions. METHODS: A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions. RESULTS: We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person's philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care (such as practitioner time or quality of the therapeutic relationship), orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM's capacity to give them control over their condition and its treatment. CONCLUSION: Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met.

Epidemiology of insomnia: a longitudinal study in a UK population.

STUDY OBJECTIVES: To investigate the incidence, persistence, and consequences of insomnia and their associations with psychological health and pain. DESIGN: A population based, longitudinal, cohort study using postal questionnaires at baseline and 12-month follow-up. Sleep problems in the past month were assessed using 4 questions: insomnia was defined as having at least 1 of the sleep problems "on most nights." Questions about psychological health, presence of pain at different sites, and demographic details were included in the questionnaire. SETTING: Five general practices in Staffordshire, UK. PARTICIPANTS: The questionnaire was mailed to a random sample of 4885 adults aged 18 years and over registered with these practices. There were 2662 questionnaires returned. RESULTS: Of the responders, 2363 completed all 4 sleep questions at baseline: 870 (37%) had insomnia and 1493 (63%) did not have insomnia. Of those without insomnia at baseline, the incidence of insomnia at 12 months was 15%, and this was significantly associated with baseline anxiety, depression, and pain. Of those who did have insomnia at baseline, 69% had insomnia at 12-month follow-up; persistence of insomnia was significantly associated with older age. Insomnia at baseline was significantly associated with incidence of anxiety, depression, and widespread pain at 12-month follow-up. CONCLUSIONS: Insomnia is common and often persistent. Older people appear more vulnerable to persistent symptoms. Our results provide evidence that the common problems of insomnia, pain, and psychological distress are intertwined and suggest that combined approaches to treatment may be needed to reduce the onset and persistence of these problems in the community.

Chest pain and subsequent consultation for coronary heart disease: a prospective cohort study.

BACKGROUND: Chest pain may not be reported to general practice but could be an important first sign of coronary heart disease (CHD). AIMS: To determine whether self-reported chest pain predicts future consultation for CHD in those with no history of consultation for CHD. DESIGN OF STUDY: Population-based study, with 7 year's follow up by GP record linkage. SETTING: General practice in North Staffordshire. METHOD: A survey, including the Rose angina questionnaire, was mailed to 4002 adults. Linked GP records used to identify responders with no record of CHD (G3 Read code or British National Formulary code for nitrate use) in the 32 months before the survey to form the sample for a 7-year prospective study. 'Survival' was compared in those with and without self-reported chest pain up to the earliest date of GP diagnosis of CHD, death, or end of the study period. RESULTS: The survey response was 65% and 2348 participants gave permission to access their GP records. Of these, 2229 had no prior consultation for CHD. From the questionnaire, 558 reported chest pain of which 186 reported exertional pain and 103 met the criteria for angina. When followed prospectively, incidence of CHD consultations was higher in those with any chest pain definition, compared with no pain, and continued to be so for 7 years subsequently. Although these associations were strongly age related, self-reported symptoms were found to be an independent risk factor for future consultation for CHD. CONCLUSION: This study highlighted that self-reported chest pain is a marker of future CHD. The usefulness of early identification of people with this symptom remains to be established.

Prognostic factors for musculoskeletal pain in primary care: a systematic review.

BACKGROUND: Estimating the future course of musculoskeletal pain is an important consideration in the primary care consultation for patients and healthcare professionals. Studies of prognostic indicators tend to have been viewed in relation to each site separately, however, an alternative view is that some prognostic indicators may be common across different sites of musculoskeletal pain. AIM: To identify generic prognostic indicators for patients with musculoskeletal pain in primary care. DESIGN OF STUDY: Systematic review. SETTING: Observational cohort studies in primary care. METHOD: MEDLINE, EMBASE, PsychINFO and CINAHL electronic databases were searched from inception to April 2006. Inclusion criteria were that the study was a primary care-based cohort, published in English and contained information on prognostic indicators for musculoskeletal conditions. RESULTS: Forty-five studies were included. Eleven factors, assessed at baseline, were found to be associated with poor outcome at follow up for at least two different regional pain complaints: higher pain severity at baseline, longer pain duration, multiple-site pain, previous pain episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction. CONCLUSION: Despite substantial heterogeneity in the design and analysis of original studies, this review has identified potential generic prognostic indicators that may be useful when assessing any regional musculoskeletal pain complaint. However, Its unclear whether these indicators, used alone, or in combination, can correctly estimate the likely course of individual patients' problems. Further research is needed, particularly in peripheral joint pain and using assessment methods feasible for routine practice.

A cross sectional study of requests for knee radiographs from primary care.

BACKGROUND: Knee pain is the commonest pain complaint amongst older adults in general practice. General Practitioners (GPs) may use x rays when managing knee pain, but little information exists regarding this process. Our objectives, therefore, were to describe the information GPs provide when ordering knee radiographs in older people, to assess the association between a clinical diagnosis of osteoarthritis (OA) and the presence of radiographic knee OA, and to investigate the clinical content of the corresponding radiologists' report. METHODS: A cross sectional study of GP requests for knee radiographs and their matched radiologists' reports from a local radiology department. Cases, aged over 40, were identified during an 11-week period. The clinical content of the GPs' requests and radiologists' reports was analysed. Associations of radiologists' reporting of i) osteoarthritis, ii) degenerative disease and iii) individual radiographic features of OA, with patient characteristics and clinical details on the GPs' requests, were assessed. RESULTS: The study identified 136 cases with x ray requests from 79 GPs and 11 reporting radiologists. OA was identified clinically in 19 (14%) of the requests, and queried in another 31 (23%). The main clinical descriptor was pain in 119 cases (88%). Radiologists' reported OA in 22% of cases, and the features of OA were mentioned in 63%. Variation in reporting existed between radiologists. The commonest description was joint space narrowing in 52 reports (38%). There was an apparent although non significant increase in the reporting of knee OA when the GP had diagnosed or queried it (OR 1.95; 95% CI 0.76, 5.00). CONCLUSION: The features of radiographic OA are commonly reported in those patients over 40 whom GPs send for x ray. If OA is clinically suspected, radiologists appear to be more likely to report its presence. Further research into alternative models of referral and reporting might identify a more appropriate imaging policy in knee disorders for primary care.

Relationship Between Attitudes and Beliefs and Physical Activity in Older Adults With Knee Pain: Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To investigate how attitudes and beliefs about exercise relate to physical activity behavior in older adults with knee pain attributable to osteoarthritis (OA). METHODS: We conducted secondary data analyses of a randomized controlled trial of exercise interventions (ISRCTN: 93634563). Participants were adults ≥45 years old with knee pain attributable to OA (n = 514). Crude and adjusted cross-sectional and longitudinal associations between baseline Self-Efficacy for Exercise (SEE), Positive Outcome Expectations for Exercise (POEE), Negative Outcome Expectations for Exercise scores, and physical activity level, at baseline, 3 months, and 6 months (measured by self-report using the Physical Activity Scale for the Elderly [PASE]), and important increases in physical activity level (from baseline to 6-month followup) were investigated using multiple linear and logistic regression. RESULTS: Cross-sectional associations were found between SEE and PASE scores (ß = 4.14 [95% confidence interval (95% CI) 0.26, 8.03]) and POEE and PASE scores (ß = 16.71 [95% CI 1.87, 31.55]), adjusted for sociodemographic and clinical covariates. Longitudinal associations were found between baseline SEE and PASE scores at 3 months (ß = 4.95 [95% CI 1.02, 8.87]) and 6 months ß = 3.71 (0.26, 7.16), and baseline POEE and PASE at 3 months (ß = 34.55 [95% CI 20.13, 48.97]) and 6 months (ß = 25.74 [95% CI 11.99, 39.49]), adjusted for baseline PASE score and intervention arm. However, no significant associations with important increases in physical activity level were found. CONCLUSION: Greater exercise self-efficacy and more positive exercise outcome expectations were associated with higher current and future physical activity levels. These may be targets for interventions aimed at increasing physical activity.

The importance of symptom duration in determining prognosis.

Symptom duration is integral to clinical and epidemiological research on pain. It is widely used for sample selection and commonly assessed in clinical practice. However, there has been little specific investigation of the link between duration and outcome. This work aimed to examine the association of episode duration with symptoms and clinical course in primary care consulters with low back pain (LBP). In a cohort of general practice LBP consulters, 619 patients returned two or more questionnaires during a 12-month period. LBP episode duration at baseline consultation was defined by time since their last pain-free month. Associations of duration with pain, disability and psychological status at baseline were examined. Survival analysis was used to assess the association between episode duration and time taken for disability to improve by 30%. At baseline, increasing episode duration was associated with worse pain, disability and psychological status (p < 0.001), but there were no differences between people with more or less than 3 months of pain. People with 3 years' or more duration at baseline took significantly longer to improve than those with shorter duration (adjusted hazard ratio 1.57, 95% confidence interval 1.27-1.95). In conclusion, memory of LBP episode duration is associated with pain, disability and psychological status, and is an independent predictor of time to improvement. There are important differences between people who recall more or less than 3 years' duration. Mechanisms for these associations are poorly understood, but this research suggests that duration itself is an important focus for research.