Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment.

BACKGROUND: Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms. AIM: This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting. METHOD: This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome. RESULTS: Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP. CONCLUSION: GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study.

BACKGROUND: Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery. METHODS: This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs. RESULTS: The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (ß = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (ß = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (ß = - 0.02 SE = 0.008, p = 0.011) and 365-days (ß = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: ß = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: ß = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: ß = - 0.06, SE = 0.41, p = 0.880 EQ-5D: ß = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect. CONCLUSIONS: Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Opioid deprescribing: Qualitative perspectives from those with chronic non-cancer pain.

AIM: Deprescribing is the systematic process of discontinuing medications when the harms outweigh the benefits. This study aimed to identify barriers and facilitators in people with chronic non-cancer pain when deprescribing opioid analgesics, and their views on resources that assist with deprescribing. METHODS: A purposive sampling strategy was used to recruit 19 adults with chronic non-cancer pain from the community who were, or had been, on long-term opioid therapy. Recruitment continued until thematic saturation was achieved. Semi-structured telephone interviews were conducted. A five-step framework and thematic analysis method identified themes for each study aim. RESULTS: Themes identifying barriers to opioid deprescribing raised challenges of a lack of available alternatives, managing opioid dependency and withdrawal symptoms or inability to function without opioids when in extreme pain. Facilitating themes described the value of support networks, including a trusting doctor-patient relationship and finding individual coping strategies to address deprescribing barriers. We explored a variety of resources from electronic forms such as websites and apps to paper-based or face to face. Participants expressed that whatever the form, resources need to be educational but also simple and engaging. CONCLUSIONS: Most people suffering from chronic non-cancer pain expressed dissatisfaction with being on opioids but most were still unwilling to deprescribe due to insufficient alternatives, a lack of support from their doctors and lack of information about the deprescribing process. Deprescribing can be facilitated by improving supportive networks and strategies and providing simple and positive educational resources.

Walking, Cycling, and Swimming for Nonspecific Low Back Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: To investigate the effectiveness of walking/running, cycling, or swimming for treating or preventing nonspecific low back pain (LBP). DESIGN: Intervention systematic review. LITERATURE SEARCH: Five databases were searched to April 2021. STUDY SELECTION CRITERIA: Randomized controlled trials evaluating walking/running, cycling, or swimming to treat or prevent LBP were included. DATA SYNTHESIS: We calculated standardized mean differences (SMDs) and 95% confidence intervals (CIs). Certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: No trials assessed LBP prevention or addressed acute LBP. Nineteen trials (2362 participants) assessed treatment of chronic/recurrent LBP. Low-certainty evidence suggests that walking/running was less effective than alternate interventions in reducing pain in the short term (8 trials; SMD, 0.81; 95% CI: 0.28, 1.34) and medium term (5 trials; SMD, 0.80; 95% CI: 0.10, 1.49). High-certainty evidence suggests that walking/running was less effective than alternate interventions at reducing disability in the short term (8 trials; SMD, 0.22; 95% CI: 0.06, 0.38) and medium term (4 trials; SMD, 0.28; 95% CI: 0.05, 0.51). There was high-certainty evidence of a small effect in favor of walking/running compared to minimal/no intervention for reducing pain in the short term (10 trials; SMD, -0.23; 95% CI: -0.35, -0.10) and medium term (6 trials; SMD, -0.26; 95% CI: -0.40, -0.13) and disability in the short term (7 trials; SMD, -0.19; 95% CI: -0.33, -0.06). Scarcity of trials meant few conclusions could be drawn regarding cycling and swimming. CONCLUSION: Although less effective than alternate interventions, walking/running was slightly more effective than minimal/no intervention for treating chronic/recurrent LBP. J Orthop Sports Phys Ther 2022;52(2):85-99. Epub 16 Nov 2021. doi:10.2519/jospt.2022.10612.

Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: a systematic review.

QUESTIONS: What is the effect of advice/education compared with placebo or no advice/education on pain and disability in people with non-specific spinal pain? To what extent do characteristics of the patients, trial or intervention modify the estimate of the treatment effects? DESIGN: A systematic review with meta-analyses of randomised controlled trials. PARTICIPANTS: Adults with non-specific back and/or neck pain with or without radiating leg/arm pain of any duration were included. Trials recruiting pregnant women or surgical patients in the immediate postoperative phase were ineligible. INTERVENTION: Advice or education. OUTCOME MEASURES: The primary outcomes were self-reported pain and disability, and the secondary outcome was adverse events. The following potential effect modifiers were examined: risk of bias, duration of pain, location of pain, intensity of intervention and mode of intervention. RESULTS: Twenty-seven trials involving 7,006 participants were included. Eighteen of the included trials were assessed as being at low risk of bias (≥ 6 on the PEDro scale). There was low-quality evidence that advice had a small effect on pain (MD -8.2, 95% CI -12.5 to -3.9, n = 2,241) and moderate-quality evidence that advice had a small effect on disability (MD -4.5, 95% CI -7.9 to -1.0, n = 2,579) compared with no advice or placebo advice in the short-term. None of the items that were assessed modified the treatment effects. CONCLUSION: Advice provides short-term improvements in pain and disability in non-specific spinal pain, but the effects are small and may be insufficient as the sole treatment for patients with spinal pain. REGISTRATION: PROSPERO CRD42020162008.

Physical Activity Interventions for Increasing Objectively Measured Physical Activity Levels in Patients With Chronic Musculoskeletal Pain: A Systematic Review.

OBJECTIVE: To investigate whether physical activity interventions increase objectively measured physical activity levels of patients with chronic musculoskeletal pain (e.g., osteoarthritis, low back pain) compared to no/minimal intervention. METHODS: We performed a systematic review with meta-analysis searching the Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, SportDiscus, and Physiotherapy Evidence Database (PEDro) databases, and the main clinical trials registries. Quasirandomized or randomized controlled trials investigating the effect of physical activity interventions on objectively measured physical activity levels (e.g., using accelerometers or pedometers) of patients with chronic musculoskeletal pain compared with no/minimal intervention were considered eligible. Analyses were conducted separately for short-term (≤3 months), intermediate (>3 months and <12 months), and long-term (≥12 months) followups. Pooled effects were calculated using the standardized mean difference (SMD), and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used in summary conclusions. RESULTS: Eight published trials and 6 registered trials were included. For the short-term followup, pooling of 6 trials showed no significant effect (SMD 0.34, 95% confidence interval -0.09, 0.77) between a physical activity intervention and no/minimal intervention. Similarly nonsignificant results were found for the intermediate and long-term followups. The overall evidence according to the GRADE approach was classified as low quality. CONCLUSION: Our findings suggest that physical activity-based interventions may lead to little or no difference in objectively measured physical activity levels of patients with chronic musculoskeletal pain compared with no/minimal interventions. Given the number of registered trials, the pooled effect found in this review is likely to change once the results of these trials become available.