Guideline adherence and socioeconomic factors in Danish patients referred to secondary care for low back pain: a cross sectional study.

BACKGROUND: The pre-referral history of patients with low back pain referred to secondary care is poorly documented, and it is unclear whether it complies with clinical guideline recommendations; specifically, whether they have received appropriate treatment in primary care. This study describes the patient population referred to a spine clinic at a Danish hospital and investigates whether they have received an adequate course of treatment in primary care before referral. Furthermore, a possible association between primary care treatment and socioeconomic factors is estimated. METHODS: We examined self-reported data from 1035 patients with low back pain of at least eight weeks duration referred to secondary care at a medical spine clinic using a cross-sectional design. As an approximation to national clinical guidelines, the definition of an adequate course of treatment in primary care was at least five visits to a physiotherapist or chiropractor prior to referral. RESULTS: Patients were on average 53 years old, and 56% were women. The average Oswestry Disability Index score was 36, indicating a moderate level of disability. Nearly half of the patients reported pain for over a year, and 75% reported pain below knee level. Prior to referral, 33% of the patients had not received an adequate course of treatment in primary care. Based on multiple logistic regression with the three socioeconomic variables, age and sex in the model, those who were unemployed had an odds ratio of 2.35 (1.15-4.79) for not receiving appropriate treatment compared to employed patients. Similarly, the odds ratio for patients without vs. with health insurance was 1.71 (1.17-2.50). No significant association was observed with length of education. CONCLUSIONS: Despite national clinical guidelines recommending management for low back pain in primary care, one third of the patients had not received an adequate course of treatment before referral to secondary care. Moreover, the high probability of not having received recommended treatment for patients who were unemployed or lacked health insurance indicates an economic obstacle to adequate care. Therefore, reconsidering the compensation structure for the treatment of back pain patients is imperative to mitigate health inequality within low back pain management.

An Integrated Multidisciplinary Rehabilitation Program Experienced by Patients with Chronic Low Back Pain.

Purpose: To examine how an integrated, multidisciplinary rehabilitation program was experienced by patients with chronic low back pain and to gain insight into how these patients integrated knowledge, skills, and behaviors obtained by the program into their everyday lives.Materials and Methods: A phenomenological hermeneutic design using Ricoeur's interpretation theory was used in the analysis. Data were generated through nine semi-structured interviews in patients with chronic low back pain. The study adhered to the Consolidated criteria for reporting qualitative research (COREQ) checklist.Results: Standardized rehabilitation efforts adapted to individual needs and provided by a highly professional healthcare team in a combination of inpatient stay and home-based activities was experienced as beneficial, because the patients were able to integrate the obtained knowledge, skills, and behaviors into their everyday lives.Conclusions: The findings revealed that the multidisciplinary holistic approach led to higher bodily awareness, greater mental health, and increased social interaction, which improved happiness and quality of life among the patients. This study emphasizes and highlights a rehabilitation approach that promotes home-based activities to provide a base for co-creation across professions regarding rehabilitation initiatives for patients with chronic low back pain.

The effect of an integrated multidisciplinary rehabilitation programme for patients with chronic low back pain: Long-term follow up of a randomised controlled trial.

OBJECTIVE: To compare the long-term effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme, in terms of back-specific disability, in patients with chronic low back pain. DESIGN: A single-centre, pragmatic, two-arm parallel, randomised controlled trial. SETTING: A rheumatology rehabilitation centre in Denmark. SUBJECTS: A total of 165 adults (aged ⩾ 18 years) with chronic low back pain. INTERVENTIONS: An integrated programme (a pre-admission day, two weeks at home, two weeks inpatient followed by home-based activities, plus two 2-day inpatient booster sessions, and six-month follow-up visit) was compared with an existing programme (four-week inpatient, and six-month follow-up visit). MAIN MEASURE: The primary outcome was disability measured using the Oswestry Disability Index after one year. Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). Analysis was by intention-to-treat, using linear mixed models. RESULTS: 303 patients were assessed for eligibility of whom 165 patients (mean age 50 years (SD 13) with a mean Oswestry Disability Index score of 42 (SD 11)) were randomly allocated (1:1 ratio) to the integrated programme (n = 82) or the existing programme (n = 83). The mean difference (integrated programme minus existing programme) in disability was -0.53 (95% CI -4.08 to 3.02); p = 0.770). No statistically significant differences were found in the secondary outcomes. CONCLUSION: The integrated programme was not more effective in reducing long-term disability in patients with chronic low back pain than the existing programme.

The effect of an integrated multidisciplinary rehabilitation programme alternating inpatient interventions with home-based activities for patients with chronic low back pain: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain. DESIGN: A single-centre, pragmatic, two-arm parallel, randomized controlled trial (1:1 ratio). SETTING: A rheumatology inpatient rehabilitation centre in Denmark. SUBJECTS: A total of 165 adults (aged ⩾ 18 years) with chronic low back pain. INTERVENTIONS: An integrated rehabilitation programme comprising an alternation of three weeks of inpatient stay and 12 weeks of home-based activities was compared with an existing rehabilitation programme of four weeks of inpatient stay. MAIN MEASURES: Patient-reported outcomes were collected at baseline and at the 26-week follow-up. The primary outcome was back-specific disability (Oswestry Disability Index). Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). A complete case analysis was performed. RESULTS: A total of 303 patients were assessed for eligibility of whom 165 (mean age: 50 years (SD 13) and mean Oswestry Disability Index score 42 (SD 11)) were randomized (83 to existing rehabilitation programme and 82 to integrated rehabilitation programme). Overall, 139 patients provided the 26-week follow-up data. Baseline demographic and clinical characteristics were comparable between programmes. The between-group difference in the Oswestry Disability Index score when adjusting for the corresponding baseline score was -0.28 (95% confidence interval (CI): -4.02, 3.45) which was neither statistically nor clinically significant. No significant differences were found in the secondary outcomes. CONCLUSION: An integrated rehabilitation programme was no more effective than an existing rehabilitation programme at the 26-week follow-up.