Strong Association of Depression and Anxiety With the Presence of Back Pain While Impact of Spinal Imaging Findings is Limited: Analysis of an MRI Cohort Study.

Development of back pain is multifactorial, and it is not well understood which factors are the main drivers of the disease. We therefore applied a machine-learning approach to an existing large cohort study data set and sought to identify and rank the most important contributors to the presence of back pain amongst the documented parameters of the cohort. Data from 399 participants in the KORA-MRI (Cooperative health research in the region Augsburg-magnetic resonance imaging) (Cooperative Health Research in the Region Augsburg) study was analyzed. The data set included MRI images of the whole body, including the spine, metabolic, sociodemographic, anthropometric, and cardiovascular data. The presence of back pain was one of the documented items in this data set. Applying a machine-learning approach to this preexisting data set, we sought to identify the variables that were most strongly associated with back pain. Mediation analysis was performed to evaluate the underlying mechanisms of the identified associations. We found that depression and anxiety were the 2 most selected predictors for back pain in our model. Additionally, body mass index, spinal canal width and disc generation, medium and heavy physical work as well as cardiovascular factors were among the top 10 most selected predictors. Using mediation analysis, we found that the effects of anxiety and depression on the presence of back pain were mainly direct effects that were not mediated by spinal imaging. In summary, we found that psychological factors were the most important predictors of back pain in our cohort. This supports the notion that back pain should be treated in a personalized multidimensional framework. PERSPECTIVE: This article presents a wholistic approach to the problem of back pain. We found that depression and anxiety were the top predictors of back pain in our cohort. This strengthens the case for a multidimensional treatment approach to back pain, possibly with a special emphasis on psychological factors.

Effects of chiropractic use on medical healthcare utilization and costs in adults with back pain in Ontario, Canada from 2003 to 2018: a population-based cohort study.

BACKGROUND: Adults with back pain commonly consult chiropractors, but the impact of chiropractic use on medical utilization and costs within the Canadian health system is unclear. We assessed the association between chiropractic utilization and subsequent medical healthcare utilization and costs in a population-based cohort of Ontario adults with back pain. METHODS: We conducted a population-based cohort study that included Ontario adult respondents of the Canadian Community Health Survey (CCHS) with back pain from 2003 to 2010 (n = 29,475), followed up to 2018. The CCHS data were individually-linked to individual-level health administrative data up to 2018. Chiropractic utilization was self-reported consultation with a chiropractor in the past 12 months. We propensity score-matched adults with and without chiropractic utilization, accounting for confounders. We evaluated back pain-specific and all-cause medical utilization and costs at 1- and 5-year follow-up using negative binomial and linear (log-transformed) regression, respectively. We assessed whether sex and prior specialist consultation in the past 12 months were effect modifiers of the association. RESULTS: There were 6972 matched pairs of CCHS respondents with and without chiropractic utilization. Women with chiropractic utilization had 0.8 times lower rate of cause-specific medical visits at follow-up than those without chiropractic utilization (RR5years = 0.82, 95% CI 0.68-1.00); this association was not found in men (RR5years = 0.96, 95% CI 0.73-1.24). There were no associations between chiropractic utilization and all-cause physician visits, all-cause emergency department visits, all-cause hospitalizations, or costs. Effect modification of the association between chiropractic utilization and cause-specific utilization by prior specialist consultation was found at 1-year but not 5-year follow-up; cause-specific utilization at 1 year was lower in adults without prior specialist consultation only (RR1year = 0.74, 95% CI 0.57-0.97). CONCLUSIONS: Among adults with back pain, chiropractic use is associated with lower rates of back pain-specific utilization in women but not men over a 5-year follow-up period. Findings have implications for guiding allied healthcare delivery in the Ontario health system.

Demographics of and Costs to Users of Chiropractic Services in the United States with Neck or Back Pain not Meeting Guideline-Based Minimum Treatment Frequency Thresholds.

Context: Acceptance of chiropractic services as an effective therapy for neck or back pain has been well established with randomized controlled trials (RCTs); however, there have been limited observations made on the treatment frequency patterns seen in the real world. Objective: The purpose of this study is to identify chiropractic users with neck or back pain who did not meet recommended treatment frequency guidelines and examine their demographics and chiropractic costs. Design: In this cross-sectional retrospective study, the nationally representative 2017 Medical Expenditure Panel Survey database was used. Setting: This study used nationally representative US survey data. Participants: Inclusion criteria were adults aged 18 years and older with a diagnosis of neck or back pain with one or more chiropractic visits in 2017. Outcomes Measures: Chiropractic utilization was categorized as concordant or discordant with treatment frequency guidelines; concordant was defined as 5 or more visits to a chiropractor within any 2-month time frame or at least 12 total visits during the year. Discordant was defined as circumstances not meeting concordant criteria. The groups were compared by demographics including age, sex, race, region, years of education, health insurance coverage, employment status, family income, presence of headache diagnosis, Charlson Comorbidity Index score and the presence of any limitation of physical function. Comparisons were made between the two groups using Chi-squared tests. Logistic regression was used to adjust for covariates. Results: There were 159 and 310 adults classified as concordant and discordant, respectively (weighted total: 1 849 108 [31.44%] and 4 032 541 [68.56%], with significantly different mean chiropractic costs of $2555 and $434, respectively. Significant independent predictors of discordant chiropractic utilization were race, years of education, family income and the presence of any limitation of physical function. Conclusions: Most chiropractic users with diagnosed neck or back pain were considered discordant with treatment frequency guidelines, which may indicate inefficiencies in treatment and inefficient use of healthcare resources.

Back pain and body posture of non-professional Brazilian Jiu-Jitsu practitioners.

Background: The aim of the study was to assess the prevalence of back pain in non-professional Brazilian Jiu-Jitsu practitioners (NP-BJJ practitioners), and to assess the relationship between their back pain and postural disorders. Methods: The study involved 61 subjects (age: 30.7 ± 4.9 years old; body mass: 79.4 ± 12.9 kg; body height: 179.6 ± 8.4 cm; 8 woman and 53 man), 31 who trained Brazilian Jiu-Jitsu (BJJ) and 30 subjects who had never trained any combat sport. The mean time of training BJJ in the study population was 3.9 ± 4.1 years. Postural assessments were conducted with the use of the photogrammetric method. The assessment of back pain and injuries was conducted with the Oswestry Disability Index (ODI) and with our proprietary questionnaire. Results: Among both populations, 37 subjects reported back pain. There were no differences in back pain location between the two groups or in functional state on the ODI. Significant differences between the groups in the values of the postural parameters (spinal height, length of kyphosis, length of lordosis, pelvis inclination angle) were observed. Statistically significant differences between the NP-BJJ practitioners with and without back pain in the length of the thoracic kyphosis and the differences in the height of the waist triangles were found. Conclusions: Both in the study population and in the control group the spinal pain was minimal or moderate on the ODI. BJJ practitioners who reported back pain had characteristic postural changes in some of the analysed postural parameters in comparison to BJJ practitioners who did not report back pain.

Cross-sectoral Analysis of 1.4 Million AOK-insured Patients with Back Pain in Baden-Württemberg - What Influence does Outpatient Specialist Care Have? / Sektorenübergreifende Rückenschmerz-Versorgungsanalyse von 1,4 Mio. AOK-Versicherten in Baden-Württemberg ­ welchen Einfluss hat die ambulante fachärztliche Versorgung?

BACKGROUND: Back pain is one of the leading causes of disability globally and the most common musculoskeletal pain in Germany. The lifetime prevalence of back pain ranges from 74% to 85%, and the point prevalence ranges from 32% to 49%. One in five individuals with statutory health insurance visits a doctor at least once a year for back pain, and 1 in 20 individuals is on sick leave at least once a year. The question as to what extent can different outpatient care concepts substantially contribute to improving care and avoiding inpatient hospital treatment has repeatedly been the subject of controversial political discussions. This study aimed to present a description of the reality of care in Baden-Württemberg (BW), Germany, based on claims data. MATERIAL AND METHODS: Anonymised routine billing data of AOK Baden-Württemberg were analysed in compliance with data protection regulations. The billing data cover the outpatient and inpatient care sectors. All AOK patients in BW who received at least one ICD10 diagnosis from their physician in the first half of 2015 were considered for the analysis. Patients with at least one diagnosis of back pain were evaluated as patients with back pain, whereby the assignment to the diagnosis group of specific or non-specific back pain was made based on the code. RESULTS: In the first half of 2015, nearly 988 925 patients with back pain were registered in the 6696 primary care clinics in BW, approximately 302 524 patients in 1172 orthopaedic clinics and 17 043 patients in 89 neurosurgical clinics. Primary care clinics reported back pain diagnosis in 34.6%, orthopaedic clinics in 51.9% and neurosurgical clinics in 78.6% of cases. Primary care clinics diagnosed a specific cause in approximately one-third of patients with back pain, orthopaedic clinics in approximately 40% of their patients and neurosurgery clinics in one in two cases. Overall, approximately 1.2% of 1.3 million patients with back pain (January to December 2015 in BW) were hospitalised. Inpatient therapy consisted of surgical therapy and conservative therapy. Nucleotomy, decompression and spondylodesis were the three most common surgical procedures performed. Pain medication and remedy prescriptions decreased pain after spinal surgery. There are significant regional differences in referral and surgery rates. The mean inpatient referral rate was 535 of 100 000 AOK insurants, and the median was 536 of 100 000 AOK insurants. The mean surgery rate among all admitted patients with back pain was 49.9%, and the median was 49.8%. CONCLUSION: The vast majority of patients with back pain are treated as outpatients. Only approximately 1.2% of all patients with back pain were treated as inpatients in 2015. Of these, approximately half underwent surgery. Spinal surgeries led to a decrease in pain medication and remedy prescription postoperatively. The three most frequent surgical procedures were 'decompression', 'excision of disc tissue' and 'spondylodesis'. There were significant regional differences.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study.

OBJECTIVES: To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor). DESIGN: Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study. SETTING: Norwegian GP, PT and chiropractic primary care centres. PARTICIPANTS: Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor. PRIMARY AND SECONDARY OUTCOME MEASURES: For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses. RESULTS: Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05). CONCLUSION: Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations. TRIAL REGISTRATION NUMBER: NCT04261309.

Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon.

BACKGROUND: In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. OBJECTIVE: To examine changes in CAM utilization following the policy and variations in utilization across patient populations. DESIGN: A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. PARTICIPANTS: Adult Medicaid patients with back pain. INTERVENTION: The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). MAIN MEASURES: Use of CAM services. KEY RESULTS: Use of any CAM service increased from 7.9% (95% CI 7.6-8.2%) prior to the policy to 30.9% (95% CI 30.4-31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CONCLUSIONS: CAM service utilization increased among back pain patients following implementation of Oregon's policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.

A prospective observational study on trajectories and prognostic factors of mid back pain.

BACKGROUND: Although mid back pain (MBP) is a common condition that causes significant disability, it has received little attention in research and knowledge about trajectories and prognosis of MBP is limited. The purpose of this study was to identify trajectories of MBP and baseline risk factors for an unfavorable outcome in MBP patients undergoing chiropractic treatment. METHODS: This prospective-observational study analyzes outcome data of 90 adult MBP patients (mean age = 37.0 ± 14.6 years; 49 females) during one year (at baseline, after 1 week, 1 month, 3, 6 and 12 months) after start of chiropractic treatment. Patients completed an 11-point (0 to 10) numeric pain rating scale (NRS) at baseline and one week, one month, three, six and twelve months after treatment start and the Patient's Global Impression of Change (PGIC) questionnaire at all time points except baseline. To determine trajectories, clustering with the package kml (software R), a variant of k-means clustering adapted for longitudinal data, was performed using the NRS-data. The identified NRS-clusters and PGIC data after three months were tested for association with baseline variables using univariable logistic regression analyses, conditional inference trees and random forest plots. RESULTS: Two distinct NRS-clusters indicating a favourable (rapid improvement within one month from moderate pain to persistent minor pain or recovery after one year, 80% of patients) and an unfavourable trajectory (persistent moderate to severe pain, 20% of patients) were identified. Chronic (> 3 months) pain duration at baseline significantly predicted that a patient was less likely to follow a favourable trajectory [OR = 0.16, 95% CI = 0.05-0.50, p = 0.002] and to report subjective improvement after twelve months [OR = 0.19, 95% CI = 0.07-0.51, p = 0.001], which was confirmed by the conditional inference tree and the random forest analyses. CONCLUSIONS: This prospective exploratory study identified two distinct MBP trajectories, representing a favourable and an unfavourable outcome over the course of one year after chiropractic treatment. Pain chronicity was the factor that influenced outcome measures using NRS or PGIC.

Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: Longitudinal analysis of prospectively collected data. OBJECTIVE: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. METHODS: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). RESULTS: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. CONCLUSION: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. LEVEL OF EVIDENCE: 2.

Occurrence and impact of back pain on the quality of life of healthcare workers.

INTRODUCTION AND OBJECTIVE: Back pain affects specific occupational groups, among which healthcare workers are the most predisposed. Therefore, the aim of this study was to determine the interdependences between subjective disability and their correlation with pain intensity and quality of life assessment among professionally active medical workers, taking into account working, socio-demographic and health conditions. MATERIAL AND METHODS: The cross-sectional study enrolled 110 professionally active medical workers (nurses, midwives, paramedics and physiotherapists). The study was conducted by a diagnostic survey method using 4 questionnaires: Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), World Health Organization Quality of Life BREF (WHOQoL-BREF), and the authors' questionnaire. RESULTS: Back pain was reported by 103 respondents (94%) with the lumbar area indicated the most frequently (72.81%). Severe pain every day was reported by 49.51% of respondents and was associated with longer working time. ODI questionnaire confirmed III and IV degrees of disability in paramedics and nurses, who additionally obtained the lowest results in the quality of life assessment. Correlations between age and VAS were demonstrated (p=0.002), and between VAS and ODI pain (p<0.0001) and ODI disability (p<0.0001). CONCLUSIONS: Back pain associated with professional activities is the consequence of overload. Health care workers should be included in a preventive programme and attend systematic ergonomics courses. Health care facilities should be retrofitted with equipment enabling work in accordance with the principles of ergonomics. The ODI questionnaire, together with the VAS method and scales for testing the quality of life, are useful tools in the clinical assessment of individuals with back pain.

[Headache, abdominal and back pain in children and adolescents in Germany : Results from KiGGS Wave 2 and trends]. / Kopf­, Bauch- und Rückenschmerzen bei Kindern und Jugendlichen in Deutschland : Ergebnisse aus KiGGS Welle 2 und Trends.

BACKGROUND: Pain not only causes suffering in children and adolescents, but also leads to school absenteeism, medication intake, medical treatment, and an increased risk of recurrent pain in adulthood. OBJECTIVES: Based on data from the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017), the 3­month prevalence of recurrent headache, abdominal and back pain in girls and boys is reported, and is compared with the prevalence from the KiGGS baseline survey (2003-2006). The consequences of recurrent headache were also explored. MATERIALS AND METHODS: Data from >11,000 participants (KiGGS Wave 2) and from >12,000 (KiGGS baseline) participants aged between 3 and 17 years were analyzed. For 3­ to 10-year-olds, parents/guardians answered the questions, while 11- to 17-year-olds provided information themselves. RESULTS: In 3­ to 10-year-olds, recurrent abdominal pain was most prevalent, affecting one third of girls and one quarter of boys. Headache was the most frequent type of pain in 11- to 17-year-olds, affecting almost every second girl and about every third boy. The 3­month prevalence of recurrent headache, abdominal and back pain has increased in girls and boys, especially in the age groups 7 to 10 years and 11 to 13 years. Among recurrent headache sufferers, adolescents take medication almost twice as often as children. CONCLUSIONS: Headache, abdominal, and back pain are still and with increasing prevalence very common symptoms in children and adolescents in Germany. Their prevention requires a holistic view of children's health in the psychosocial living environment, and healthcare context.

Causes of Residual Back Pain at Early Stage After Percutaneous Vertebroplasty: A Retrospective Analysis of 1,316 Cases.

BACKGROUND: Percutaneous vertebroplasty (PVP) is now well accepted in the treatment of painful osteopathic vertebral compression fractures (OVCF), providing early pain relief and strengthening of the bone of the vertebrae. However, some patients still experienced severe back pain after PVP. OBJECTIVES: To analyze the possible reason for unsatisfactory back pain relief (UBPR) after PVP at early stage. STUDY DESIGN: Retrospective analysis. SETTING: Hong-Hui Hospital in Xi'an. METHODS: Between March 2013 and January 2015, a total of 1,316 patients with OVCF were treated by PVP at our Hospital. Demographics, clinical data, and surgical data were collected to analyze the factors associated with UBPR after PVP. RESULTS: Sixty cases complained of UBPR, and the prevalence was 4.6%. Univariate analyses showed that preoperative bone mineral density (BMD), number of fractures, cement distribution and volume injected per level, lumbodorsal fascia contusion, and depression were associated with UBPR after PVP (P < 0.001). Multivariate analysis revealed that preoperative BMD (odds ratio [OR], 3.577; P = 0.029), lumbodorsal fascia contusion (OR, 3.805; P = 0.002), number of fractures (OR, 3.440; P < 0.001), cement volume injected per level (OR, 0.079; P < 0.001), cement distribution (OR, 3.009; P = 0.013), and depression (OR, 3.426; P = 0.028) were independently associated with UBPR after PVP at the early postoperative stage. LIMITATIONS: A further prospective controlled study is needed to explore the association between the different degrees of the aforementioned factors and UBPR after PVP. CONCLUSIONS: Preoperative low BMD, lumbodorsal fascial injury, multiple segment PVP, insufficient cement injected volume, unsatisfactory cement distribution, and depression were strong risk factors associated with UBPR after PVP in patients with OVCF. KEY WORDS: Unsatisfactory back pain relief, residual back pain, percutaneous vertebroplasty.

Cost-Effectiveness of a Team-Based Integrative Medicine Approach to the Treatment of Back Pain.

OBJECTIVES: To report the results of health economic analyses comparing two treatment approaches for chronic low back pain (CLBP). DESIGN: Observational prospective cohort study comparing effectiveness and cost-effectiveness of CLBP care provided at an integrative care clinic with that provided in other clinics within the same hospital. CLBP-related medical utilization, function, quality of life, and days of work incapacity were self-reported at baseline, 3, 6, and 12 months. SETTINGS/LOCATION: Osher Clinical Center (OCC) based at a tertiary academic hospital (Brigham and Women's Hospital [BWH]) and other clinics at BWH. SUBJECTS: CLBP patients seeking care at OCC or non-OCC BWH clinics. INTERVENTIONS: Integrative or conventional care for CLBP as prescribed by the treating clinician(s). OUTCOME MEASURES: Quality-adjusted life years (QALYs) were estimated per treatment approach based on the SF-12. Cost per QALY gained was evaluated using an incremental cost-effectiveness ratio (ICER). ICERs based on CLBP-specific effectiveness measures (Roland Disability Questionnaire [RDQ] and bothersomeness of pain [BOP]) were exploratory outcomes. RESULTS: Total adjusted annual CLBP-related costs per patient were greater in the OCC versus non-OCC group ($11,526.73 vs. $6,810.63). Between group differences in QALYs were small and ICER estimate of cost per QALY gained was high ($436,676). However, unadjusted mean direct costs per patient decreased over time in the OCC group. Savings in direct costs of $391 (95% confidence interval: -1,078 to 1,861) were observed in the OCC group for the 6- to 12-month period, driven primarily by reduced medication usage. ICERs based on adjusted RDQ and BOP group differences showed cost of $2,073 and $4,203 for a one-point reduction per respective scale. CONCLUSIONS: When adjusted for baseline differences, self-reported costs were higher in the OCC group with only small effects on QALYs. However, trends toward decreased direct expenditures and medication usage over time warrant further investigation. Future studies evaluating potential benefits of integrative care models for the management of CLBP should employ randomized designs, longer observational periods, and explore multiple metrics of cost-effectiveness.

GLA:D® Back: implementation of group-based patient education integrated with exercises to support self-management of back pain - protocol for a hybrid effectiveness-implementation study.

BACKGROUND: Reassuring patient education and exercise therapy are widely recommended interventions for back pain in clinical guidelines. However, many patients are offered non-guideline endorsed options, and strategies for effective implementation of guideline-based care have not yet been developed. This protocol outlines the evaluation of a strategy for nationwide implementation of standardised patient education and exercise therapy for people with persistent or recurrent back pain in a hybrid implementation-effectiveness design. The strategy and the evaluation were planned using the framework of the Behaviour Change Wheel. METHODS: The main activity of the implementation strategy is a two-days course for physiotherapists and chiropractors in delivering patient education and exercise therapy that is aimed at supporting patient self-management. This comes with ready-to-use patient education materials and exercise programs. The clinical intervention is a group-based program consisting of two sessions of patient education and 8 weeks of supervised exercises. The program uses a cognitive-behavioural approach and the aim of the exercise component is to restore the patient's ability and confidence to move freely. The implementation process is evaluated in a dynamic process monitoring the penetration, adoption and fidelity of the clinical intervention. The clinical intervention and potential effect mechanisms will be evaluated at the patient-level using measures of knowledge, skills, beliefs, performance, self-efficacy and success in self-management. The education of clinicians will be evaluated via clinician-level outcomes, including the Pain Attitudes and Beliefs Scale, the Practitioner Confidence Scale, and the Determinants of Implementation Behaviour Questionnaire. Effects at a national level will be investigated via data from national registries of health care utilisation and sick-leave. DISCUSSION: This implementation-effectiveness study is designed to evaluate the process of implementing an evidence-based intervention for back pain. It will inform the development of strategies for implementing evidence-based care for musculoskeletal pain conditions, it will enhance the understanding of mechanisms for developing patient self-management skills, and it will demonstrate the outcomes that are achievable in everyday clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03570463 . Registered 27 June 2018.

Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey.

Background: The Keele STarT Back Screening Tool (SBT), a 9-item questionnaire, screens for pain, physical functioning, fear-avoidance beliefs, catastrophizing, anxious thoughts, low mood, and bothersomeness in persons with back pain. SBT scores designate low, medium, or high risk for developing persistent disabling back pain. The primary study aim was to report the prevalence of SBT-calculated risk for back pain disability in US patients seeking chiropractic care. Methods: The SBT questionnaire was administered to patients ≥18 years in 3 Chiropractic College outpatient teaching clinics in Iowa and Illinois (May 2017). Descriptive statistics were used to analyze respondent characteristics and prevalence of SBT-calculated risk subgroups. Binary logistic regression analysis was used to examine the relationship between respondent characteristics and SBT scores (including psychological subscores). Results: Of 550 respondents, 496 completed the SBT; 392 (79%) scored low-risk, 81 (16%) medium-risk, and 23 (5%) high-risk. Mean (SD) age was 44.8 (15.9), 56.9% were female, 88.2% white, 62.6% employed, mean current pain was 2.9 (2.1) out of 10, and 62% reported symptom duration > 3 months. Eighteen percent of respondents reported anxious thoughts, 32% low mood, 41% ≥ 1 and 21% ≥ 3 SBT psychological risk factors. Respondents reporting higher average pain (OR = 1.8 [1.4, 2.3]) and pain severity (OR = 1.3 [1.0 to 1.6]) were more likely to score with medium or high risk. Respondents reporting mid back versus low back pain (OR = 0.2 [0.1, 0.7]), and those employed less than full-time versus full-time (0.2 [01, 0.5]) were less likely to score with medium or high risk. Respondents reporting higher average pain were more likely to report ≥1 psychological factor (OR = 1.8 [1.5, 2.0]). Respondents employed part-time were less likely to report ≥1 psychological factor than those employed full-time (OR = 0.4 [0.2, 0.7]). Conclusion: The sample surveyed was less likely to score with medium or high risk for back pain disability than previous samples studied, perhaps due to differences in study design and sample characteristics. Rates of low mood and anxious thoughts indicate a need for future research to explore psychological factors among persons seeking chiropractic care.

Association of Geography and Access to Health Care Providers With Long-Term Prescription Opioid Use in Medicare Patients With Severe Osteoarthritis: A Cohort Study.

OBJECTIVE: To evaluate the variation in long-term opioid use in osteoarthritis (OA) patients according to geography and health care access. METHODS: We designed an observational cohort study among OA patients undergoing total joint replacement (TJR) in the Medicare program (2010 through 2014). The independent variables of interest were the state of residence and health care access, which was quantified at the primary care service area (PCSA) level as categories of number of practicing primary care providers (PCPs) and categories of rheumatologists per 1,000 Medicare beneficiaries. The percentage of OA patients taking long-term opioids (≥90 days in the 360-day period immediately preceding TJR) within each PCSA was the outcome variable in a multilevel, generalized linear regression model, adjusting for case-mix at the PCSA level and for policies, including rigor of prescription drug monitoring programs and legalized medical marijuana, at the state level. RESULTS: A total of 358,121 patients with advanced OA, with a mean age of 74 years, were included from 4,080 PCSAs. The unadjusted mean percentage of long-term opioid users varied widely across states, ranging from 8.9% (Minnesota) to 26.4% (Alabama), and this variation persisted in the adjusted models. Access to PCPs was only modestly associated with rates of long-term opioid use between PCSAs with highest (>8.6) versus lowest (<3.6) concentration of PCPs (adjusted mean difference 1.4% [95% confidence interval 0.8%, 2.0%]), while access to rheumatologists was not associated with long-term opioid use. CONCLUSION: We note a substantial statewide variation in rates of long-term treatment with opioids in OA, which is not fully explained by the differences in access to health care providers, varying case-mix, or state-level policies.

Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities.

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease that primarily affects the sacroiliac joints and spine. Delayed or inadequate treatment may decrease quality of life and lead to poor long-term outcomes, including irreversible loss of spinal function. In this review, we discuss clinical practice related to axSpA within the USA, including prevalence, diagnosis, reasons for delayed/missed diagnosis, and suggestions for making early diagnosis. The US population prevalence of axSpA (0.9-1.4%) is higher than the diagnostic prevalence (0.2-0.7%). Although the estimated diagnostic delay for axSpA is 14 years in the USA, the disease can be identified earlier if appropriately preselected patients are quickly referred to rheumatologists. Only 37% of patients with ankylosing spondylitis in the USA are diagnosed by rheumatologists; the remaining 63% are diagnosed by primary care (26%), chiropractic/physical therapy (7%), orthopedic surgery (4%), pain clinics (4%), acute care (3%), and other settings (19%). To help reduce diagnostic delay, non-rheumatologist-healthcare professionals are urged to refer patients with back pain and ≥ 1 of 3 SpA features (HLA-B27 positivity, current inflammatory back pain, or x-ray/MRI evidence of sacroiliitis) to a rheumatologist. Prevalence and diagnosis rates of axSpA are disparate in the USA due to the lack of awareness and knowledge among non-rheumatologists. Progress has been made in identifying hurdles causing diagnostic delays. Public health initiatives are needed to guide primary care physicians, physical therapists, chiropractors, and other specialists seeing patients with chronic back pain on methods for suspecting or identifying axSpA and early referral to rheumatologists.

Self-reported use of family physician, chiropractor and physiotherapy services among adult Canadians with chronic back disorders: an observational study.

BACKGROUND: Chronic back disorders (CBD) are prevalent, costly, and among the most common reasons for seeking primary care; however, little is known regarding the comparative use of family physician, chiropractic, and physiotherapy services among people with CBD in Canada. Elucidating these differences may identify potential gaps in access to care and inform the development of strategies to improve access. The research objectives were to investigate patterns of health care use and to profile factors associated with self-reported use of family physicians, chiropractors, and physiotherapists among adult Canadians with CBD. METHODS: The combined 2009 and 2010 Canadian Community Health Surveys conducted by Statistics Canada were used to investigate self-reported health care use among adults with CBD. This complex survey employs population weights and bootstrapping to be representative of the Canadian population. Following descriptive analyses, we used multiple logistic regression to profile self-reported health care use while statistically controlling for possible confounding effects. RESULTS: The majority of adult respondents with CBD sought care only with a family physician (53.8%), with 20.9% and 16.2% seeking care with combined family physician/chiropractor or family physician/physiotherapist, respectively. Few respondents sought care only with a chiropractor (2.5%) or physiotherapist (1.0%). After adjustment, differential patterns of utilization (p < 0.05) were evident between provider groups with respect to age, gender, socioeconomic status, rural/urban residence, functional limitations, and presence of co-morbidities. CONCLUSIONS: This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations.

The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women.

OBJECTIVES: The aims of this study were to (1) report the prevalence and explore the influence of spinal pain on quality of life and (2) assess the relationship between spinal pain and the type and number of comorbidities. METHODS: This cross-sectional study comprised 579 community-dwelling, older Australian women. Women had "spinal pain" if they marked "yes" to neck pain, upper back pain, mid-back pain, and/or lower back pain. Descriptive statistics and binary logistic regression were performed to report the prevalence and explore the relationship between spinal pain and the type and number of comorbidities. RESULTS: A majority of women (55.8%) who returned surveys had spinal pain. Women with spinal pain had significantly lower physical and mental quality of life scores than women without spinal pain (Medical Outcomes Study: 36 Item Short Form Survey [SF-36] physical component summary: 40.1 ± 11.1 vs 49.0 ± 9.0, and SF-36 mental component summary: 50.0 ± 10.5 vs 53.9 ± 8.2, respectively). Having spinal pain was significantly associated with overweight and obesity (odds ratio 1.98 [95% confidence interval 1.3-2.96] and 2.12 [1.37-3.28]), diabetes (1.93 [1.01-3.67]), pulmonary comorbidity (1.66 [1.04-2.65]), and cardiovascular comorbidity (1.57 [1.07-2.28]). More than half of the women with spinal pain reported 2 or more comorbidities, with comorbidities significantly more common among women with spinal pain than among women without spinal pain. The odds of having spinal pain increased with an increasing number of comorbidities (2 comorbidities: 2.44 [1.47-4.04], 3 comorbidities: 3.07 [1.66-5.67], 4 comorbidities: 5.05 [1.64-15.54]). CONCLUSIONS: Spinal pain is common in community-dwelling, older Australian women and is associated with greater disability and poorer quality of life. Diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain. There was an incremental increase in the risk of spinal pain associated with increasing comorbidity count.

Morbidity and Health Risk Factors Among New Mexico Miners: A Comparison Across Mining Sectors.

OBJECTIVE: This study examines differences in chronic health outcomes between coal, uranium, metal, and nonmetal miners. METHODS: In a cross-sectional study using data from a health screening program for current and former New Mexico miners, log-binomial logistic regression models were used to estimate relative risks of respiratory and heart disease, cancer, osteoarthritis, and back pain associated with mining in each sector as compared with coal, adjusting for other relevant risk factors. RESULTS: Differential risks in angina, pulmonary symptoms, asthma, cancer, osteoarthritis, and back pain between mining sectors were found. CONCLUSIONS: New Mexico miners experience different chronic health challenges across sectors. These results demonstrate the importance of using comparable data to understand how health risks differ across mining sectors. Further investigation among a broader geographic population of miners will help identify the health priorities and needs in each sector.