The effect of clinical guidelines on the utilisation of radiographs in chiropractic clinics in Denmark - an interrupted time series analysis.

BACKGROUND: In Denmark, chiropractors have a statutory right to use radiography and the government-funded national Health Insurance provides partial reimbursement. Danish National Clinical Guidelines recommends against routine use of imaging for uncomplicated spinal pain; however, it is not clear if clinical imaging guidelines recommendations have had an effect on the utilisation of spinal radiography. This study aimed to describe the utilisation rate of radiographs in Danish chiropractic clinics in the period from 2010 to 2020 and to assess the impact of clinical guidelines and policy changes on the utilisation of radiographs in Danish chiropractic clinics. METHODS: Anonymised data from January 1st, 2010, to December 31st, 2020, were extracted from the Danish Regions register on health contacts in primary care. Data consisted of the total number of patients consulting one of 254 chiropractic clinics and the total number of patients having or being referred for radiography. Data were used to investigate the radiography utilisation per month from 2010 to 2020. An 'interrupted time series' analysis was conducted to determine if two interventions, the dissemination of 1) Danish clinical imaging guidelines recommendations and policy changes related to referral for advanced imaging for chiropractors in 2013 and 2) four Danish clinical guidelines recommendations in 2016, were associated with an immediate change in the level and/or slope of radiography utilisation. RESULTS: In total, 336,128 unique patients consulted a chiropractor in 2010 of which 55,449 (15.4%) had radiography. In 2020, the number of patients consulting a chiropractor had increased to 366,732 of which 29,244 (8.0%) had radiography. The pre-intervention utilisation decreased by two radiographs per 10,000 patients per month. Little absolute change, but still statistically significant for Intervention 1, in the utilisation was found after the dissemination of the clinical guidelines and policy changes in 2013 or 2016. CONCLUSIONS: The proportion of Danish chiropractic patients undergoing radiography was halved in the period from 2010 to 2020. However, the dissemination of clinical imaging guidelines recommendations and policy changes related to referrals for advanced imaging showed little meaningful change in the monthly utilisation of radiographs in the same period.

Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program.

BACKGROUND: People with nonspecific low back pain (NSLBP) can also experience overlapping symptoms of lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. This study investigated differences in treatment outcomes for disability, back pain intensity, and leg pain intensity following an education and exercise therapy program for NSLBP patients with and without comorbid LSS symptoms. METHODS: This was a longitudinal analysis of 655 Danish participants in the GLA:D® Back program; an education and exercise therapy program for people with persistent NSLBP. Participants were classified as having comorbid LSS symptoms based on self-report. Linear mixed models were used to assess differences in change in disability (Oswestry Disability Index [0-100]) and back and leg pain intensity (Numeric Rating Scale [0-10]) at 3-, 6-, and 12-months between those with and without LSS symptoms. RESULTS: 28% of participants reported LSS symptoms. No certain differences in change in disability or back pain intensity improvement were observed at any time-point between those with and without LSS symptoms. Participants with LSS symptoms had slightly greater improvement in leg pain intensity at 6- (-0.7, 95% CI -1.2 to -0.2) and 12-months (-0.6, 95% CI -1.2 to -0.1). CONCLUSION: Compared to those without LSS symptoms, patients with persistent NSLBP and LSS symptoms can expect similar improvements in disability and back pain intensity, and slightly greater improvements in leg pain intensity with treatment. Therefore, education and exercise therapy programs designed for NSLBP are likely helpful for those also experiencing LSS symptoms.

Surgical trends and regional variation in Danish patients diagnosed with lumbar spinal stenosis between 2002 and 2018: a retrospective registry-based study of 83,783 patients.

BACKGROUND: Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older people. However, surgery rates vary widely both internationally and nationally. This study compared patient and sociodemographic characteristics, geographical location and comorbidity between surgically and non-surgically treated Danish patients diagnosed with LSS from 2002 to 2018 and described variations over time. METHODS: Diagnostic ICD-10 codes identifying patients with LSS and surgical procedure codes for decompression with or without fusion were retrieved from the Danish National Patient Register. Patients ≥ 18 years who had been admitted to private or public hospitals in Denmark between 2002 and 2018 were included. Data on age, sex, income, retirement status, geographical region and comorbidity were extracted. A multivariable logistic regression model was used to calculate the relative risk for surgically versus non-surgically treated LSS patients using the total population and subsequently divided into three time periods. Variations over time were displayed graphically. RESULTS: A total of 83,783 unique patients with an LSS diagnosis were identified, and of these, 38,362 (46%) underwent decompression surgery. Compared to those who did not receive surgery, the surgically treated patients were more likely to be aged 65-74 years, were less likely to have comorbidities, had higher income and were more likely to reside in the northern part of Denmark. Patients aged 65-74 years remained more likely to receive surgery over time, although the difference between age groups eventually diminished, as older patients (aged ≥ 75) were increasingly more likely to undergo surgery. Large variations and differences in the relative risk of surgery were observed within and between the geographical regions. The likelihood of receiving surgery varied up to threefold between regions. CONCLUSION: Danish patients with LSS who receive surgery differ in a number of respects from those not receiving surgery. Patients aged 65 to 74 years were more likely to receive surgery than other age groups, and LSS surgical patients were healthier, more often retired and had higher incomes than those not undergoing surgery. There were considerable variations in the relative risk of surgery between and within geographical regions.

Patient expectations and levels of satisfaction in chiropractic treatment for lumbar radiculopathy. A mixed methods study.

BACKGROUND: Chiropractic patients are generally satisfied with the care received. It is unclear if this also applies to Danish patients with lumbar radiculopathy included in a standardised chiropractic care package (SCCP). This study aimed to investigate patient satisfaction and explore perspectives on the SCCP for lumbar radiculopathy. METHODS: An explanatory sequential mixed methods design with three separate phases was used. Phase one was a quantitative analysis based on a survey in a prospective cohort of patients with lumbar radiculopathy in an SCCP from 2018 to 2020. Patients rated their satisfaction with the examination, information, treatment effect, and overall management of their problem on a 0-10 scale. In phase two, six semi-structured interviews conducted in 2021 were used to gain further explanatory insights into the findings from phase one. Data were analysed using systematic text condensation. In phase three, the quantitative and qualitative data were merged in a narrative joint display to obtain a deeper understanding of the overall results. RESULTS: Of 303 eligible patients, 238 responded to the survey. Of these, 80-90% were very satisfied (≥ 8) when asked about the examination, information, and overall management, whereas 50% were very satisfied with the treatment effect. The qualitative analysis led to the emergence of four themes: 'Understanding the standardised care packages', 'Expectations regarding consultation and treatment effect', 'Information about diagnosis and prognosis', and 'Interdisciplinary collaboration'. The joint display analysis showed that high patient satisfaction with the examination could be explained by the patients' feeling of being carefully and thoroughly examined by the chiropractor and by referrals to MRI. Advice and information given to patients on variations in symptoms and the expected prognosis were considered reassuring. Satisfaction with the chiropractor's coordination of care and with referral to other healthcare professionals was explained by the patients' positive experiences of coordinated care and their sense of alleviated responsibility. CONCLUSION: Overall, patients were satisfied with the SCCP for lumbar radiculopathy. From a patient's perspective, the consultation should include a thorough examination and a focus on communication and information relating to symptoms and prognosis, while expectations regarding the content and efficacy of the treatment should be addressed and aligned.

Characteristics associated with comorbid lumbar spinal stenosis symptoms in people with knee or hip osteoarthritis: an analysis of 9,136 good life with osteoArthritis in Denmark (GLA:D®) participants.

BACKGROUND: Previous studies have found that lumbar spinal stenosis (LSS) often co-occurs with knee or hip OA and can impact treatment response. However, it is unclear what participant characteristics may be helpful in identifying individuals with these co-occurring conditions. The aim of this cross-sectional study was to explore characteristics associated with comorbid symptoms of lumbar spinal stenosis (LSS) in people with knee or hip osteoarthritis (OA) enrolled in a primary care education and exercise program. METHODS: Sociodemographic, clinical characteristics, health status measures, and a self-report questionnaire on the presence of LSS symptoms was collected at baseline from the Good Life with osteoArthritis in Denmark primary care program for knee and hip OA. Cross-sectional associations between characteristics and the presence of comorbid LSS symptoms were assessed separately in participants with primary complaint of knee and hip OA, using domain-specific logistic models and a logistic model including all characteristics. RESULTS: A total of 6,541 participants with a primary complaint of knee OA and 2,595 participants with a primary complaint of hip OA were included, of which 40% and 50% reported comorbid LSS symptoms, respectively. LSS symptoms were associated with similar characteristics in knee and hip OA. Sick leave was the only sociodemographic variable consistently associated with LSS symptoms. For clinical characteristics, back pain, longer symptom duration and bilateral or comorbid knee or hip symptoms were also consistently associated. Health status measures were not consistently related to LSS symptoms. CONCLUSION: Comorbid LSS symptoms in people with knee or hip OA undergoing a primary care treatment program of group-based education and exercise were common and associated with a similar set of characteristics. These characteristics may help to identify people with co-occurring LSS and knee or hip OA, which can be used to help guide clinical decision-making.

The clinical relevance of magnetic resonance imaging of the lower back.

Magnetic resonance imaging (MRI) is commonly used in the management of low back pain (LBP). This review provides an overview of the clinical relevance of degenerative MRI findings in the lumbar spine. The association between degenerative MRI findings and LBP is relatively consistent at population level, but very little research exists on the prognostic value of MRI findings and based on the current evidence, MRI cannot be used to guide treatment. Lumbar spine MRI is only recommended for patients with progressive neurological deficits, suspicion of specific pathology or in absence of progress of conservative treatment.

Associations between comorbid lumbar spinal stenosis symptoms and treatment outcomes in 6,813 patients with knee or hip osteoarthritis following a patient education and exercise therapy program.

Objective: People with knee or hip osteoarthritis (OA) can experience comorbid lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. The aim of this study was to investigate associations between comorbid LSS symptoms and changes in pain, function, and quality of life following a patient education and exercise therapy program. Design: This was a longitudinal analysis of 6813 participants in the Good Life with osteoArthritis in Denmark (GLA:D®) program; a structured patient education and exercise therapy program for knee and hip OA. Participants were classified as having comorbid LSS symptoms based on self-report symptom items. Linear mixed models were used to assess differences in change in pain, function, and quality of life outcomes (0 worst to 100 best) at 3- and 12-month follow-up. Results: 15% and 23% of knee and hip OA participants had comorbid LSS symptoms, respectively. Knee participants with comorbid LSS symptoms had smaller improvement in pain at 3-months (-1.7, 95% CI -3.3 to -0.1) and hip participants with comorbid LSS symptoms had greater improvement in function at 3- (2.5, 95% CI 0.5 to 5.0) and 12-months (3.8, 95% CI 0.9 to 6.6), when compared to those without LSS symptoms. These differences were not clinically significant and no differences in other outcomes were observed. Conclusion: Knee or hip OA patients with comorbid LSS symptoms should expect similar improvements in knee- or hip-related pain, function, and quality of life outcomes when undergoing a patient education and exercise therapy program compared to those without LSS symptoms.

The utilisation of regulated standardised care packages by Danish chiropractors: a mixed methods study.

BACKGROUND: In Denmark, chiropractors in primary care work as independent private contractors regulated by the Danish National Health Authorities. The regulation includes partial reimbursement intended for standardised care packages for lumbar and cervical radiculopathy and lumbar spinal stenosis. Random checks have shown lower use than expected. This study aimed to describe and explore the utilisation of standardised chiropractic care packages and identify barriers to uptake. METHODS: A convergent mixed-method design was conceptualised. The use of standardised care packages was collected by register data. Potential determinants of difference in utilisation were assessed using a modified version of the Determinants of Implementation Behaviour Questionnaire (DIBQ) divided into 13 domains and sent to chiropractors in private clinics in Denmark in 2019. An open-ended question was added to the questionnaire, and thematic content analysis was applied. Qualitative findings were used to expand on the DIBQ data providing further insight into the clinicians' perspective on standardised care packages. RESULTS: Registry data of 244 included chiropractic clinics showed limited and inconsistent use of the standardised chiropractic care packages. A total of 269 chiropractors (44%) answered the DIBQ, and 45 provided data for the qualitative analyses. At least 60% of the clinicians answered 'Strongly agree' or 'Agree' in 10 out of 13 DIBQ domains suggesting a positive attitude towards using the standardised care packages. Three domains were identified as 'problematic' as more than 20% of clinicians disagreed or strongly disagreed: 'Socio-political context', 'Goals' and 'Innovation'. Qualitative findings indicated that lack of usage of the standardised care packages was mainly related to the practical organization of standardised care, the chiropractor's role when managing patients, and the patient population of interest to the clinic (e.g., children, athletes). CONCLUSION: In general, Danish chiropractors displayed positive attitudes towards standardised packages of care. However, considerable variation in the use of the standardised care programs was observed. Low utilisation seemed mainly related to logistics, the chiropractor's role, collaboration with GPs, and the patient population of interest to the clinic. These findings should be further explored in more extensive qualitative studies to inform implementation initiatives to increase and rectify utility.

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee or hip osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Musculoskeletal multimorbidity is common and coexisting lumbar spinal stenosis (LSS) with knee or hip osteoarthritis (OA) has been reported. The aim of this review was to report the prevalence of multimorbid degenerative LSS with knee or hip OA based on clinical and/or imaging case definitions. METHODS: Literature searches were performed in MEDLINE, EMBASE, CENTRAL, and CINAHL up to May 2021. Studies involving adults with cross-sectional data to estimate the prevalence of co-occurring LSS with knee or hip OA were included. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Results were stratified according to index and comorbid condition, and by case definitions (imaging, clinical, and combined). RESULTS: Ten studies from five countries out of 3891 citations met the inclusion criteria. Sample sizes ranged from 44 to 2,857,999 (median 230) and the mean age in the included studies range from 61 to 73 years (median 66 years). All studies were from secondary care or mixed settings. Nine studies used a combined definition of LSS and one used a clinical definition. Imaging, clinical, and combined case definitions of knee and hip OA were used. The prevalence of multimorbid LSS and knee or hip OA ranged from 0 to 54%, depending on the specified index condition and case definitions used. Six studies each provided prevalence data for index LSS and comorbid knee OA (prevalence range: 5 to 41%) and comorbid hip OA (prevalence range: 2 to 35%). Two studies provided prevalence data for index knee OA and comorbid LSS (prevalence range 17 to 54%). No studies reporting prevalence data for index hip OA and comorbid LSS were found. Few studies used comparable case definitions and all but one study were rated as high risk of bias. CONCLUSIONS: There is evidence that multimorbid LSS with knee or hip OA occurs in people (0 to 54%), although results are based on studies with high risk of bias and surgical populations. Variability in LSS and OA case definitions limit the comparability of studies and prevalence estimates should therefore be interpreted with caution. REVIEW REGISTRATION: PROSPERO ( CRD42020177759 ).

Appropriateness of referrals from primary care for lumbar MRI.

BACKGROUND: International guidelines do not recommend routine imaging, including magnetic resonance imaging (MRI), and seek to guide clinicians only to refer for imaging based on specific indications. Despite this, several studies show an increase in the use of MRI among patients with low back pain (LBP) and an imbalance between appropriate versus inappropriate use of MRI for LBP. This study aimed to investigate to what extent referrals from general practice for lumbar MRI complied with clinical guideline recommendations in a Danish setting, contributing to the understanding and approaches to lumbar MRI for all clinicians managing LBP in the primary sector. MATERIALS AND METHODS: From 2014 to 2018, all referrals for lumbar MRI were included from general practitioners in the Central Denmark Region for diagnostic imaging at a public regional hospital. A modified version of the American College of Radiology Imaging Appropriateness Criteria for LBP was used to classify referrals as appropriate or inappropriate, based on the unstructured text in the GPs' referrals. Appropriate referrals included fractures, cancer, symptoms persisting for more than 6 weeks of non-surgical treatment, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals were sub-classified as lacking information about previous non-surgical treatment and duration. RESULTS: Of the 3772 retrieved referrals for MRI of the lumbar spine, 55% were selected and a total of 2051 referrals were categorised. Approximately one quarter (24.5%) were categorised as appropriate, and 75.5% were deemed inappropriate. 51% of the inappropriate referrals lacked information about previous non-surgical treatment, and 49% had no information about the duration of non-surgical treatment. Apart from minor yearly fluctuations, there was no change in the distribution of appropriate and inappropriate MRI referrals from 2014 to 2018. CONCLUSION: The majority of lumbar MRI referrals (75.5%) from general practitioners for lumbar MRI did not fulfil the ACR Imaging Appropriateness Criteria for LBP based on the unstructured text of their referrals. There is a need for referrers to include all guideline-relevant information in referrals for imaging. More research is needed to determine whether this is due to patients not fulfilling guideline recommendations or simply the content of the referrals.

Digging deeper: exploring chiropractors online claims about non-musculoskeletal disorders.

BACKGROUND: Some chiropractors suggest that chiropractic treatment is appropriate for health issues other than musculoskeletal problems. The prevalence of such claims on individual clinic websites has previously been reported as approximately one-in-four in Denmark. The underlying rationales for such claims may reflect convictions about traditional chiropractic subluxations paradigms, but are not self-evident and has not previously been studied. METHODS: An exploratory qualitative case interview study of Danish chiropractors with websites which contain claims about chiropractic efficacy in the treatment of non-musculoskeletal disorders. Websites were identified from a nation wide random sample (57%) of all chiropractic clinic websites. RESULTS: Of the original 139 websites, 36 were identified as mentioning non-MSK conditions. When revisited, 19 of those clinic websites still mentioned non-MSK disorders and were contacted. Eleven (11) declined our invitation to participate. Interviews were conducted with the responsible chiropractor from each of the remaining 8 clinics. Five distinct themes were identified in the rationales for treating non-musculoskeletal disorders: 'Positive side-effects,' 'Experience,' 'Web page,' 'Communication' and 'Conviction.' CONCLUSIONS: A minority of Danish chiropractic websites suggest that non-musculoskeletal disorders are within the chiropractic scope of practice. Those that do, do so for varying reasons-poor communication and website maintenance were commonly cited problems. An explicitly stated adherence to traditional chiropractic subluxations concepts was uncommon. By contrast, a more tempered rationale that suggested a potential beneficial side-effect of chiropractic on non-musculoskeletal health issues were more common and was typically presented in softer-language and/or with some reservations.

Chiropractic website claims related to non-musculoskeletal conditions: a cross-sectional study.

BACKGROUND: Chiropractors frequently use spinal manipulation therapy as a treatment modality in the management of musculoskeletal (MSK) conditions such as spinal pain and sometimes in the treatment of non-MSK disorders. The latter is not supported by evidence. This study aimed to investigate the extent of non-MSK website claims from French chiropractors to assess if websites were aligned with current recommendations on evidence-based practice. METHODS: This was a cross-sectional study of a representative sample of French chiropractors. Information on non-MSK conditions was collected from chiropractic professional websites by two independent observers in June 2020. For each non-MSK condition, it was noted whether a clarifying explanation justifying the mentioning of the condition was available. In addition, data on professional association affiliation status, country of education, years since graduation, and special clinical focus (e.g., seniors, children) were collected. RESULTS: A total of 287 randomly selected websites were included in the study corresponding to 22% of all chiropractors registered in France. One or more of 42 different non-MSK conditions were identified on 231 websites, of which 5 (2.2%) provided a clarifying explanation. 226 (79%) websites mentioned a non-MSK condition without a clarifying explanation. The non-MSK conditions most often mentioned were sleep problems, constipation/digestive problems, unease/discontent in children and menstrual cramps/pains. A larger proportion of the websites advertising treatment for non-MSK disorders was found among those claiming a special clinical focus on infants/children, seniors, pregnant women or athletes compared to those that did not. Also, a larger proportion of chiropractors who were affiliated with a professional association were advertising treatment for non-MSK disorders compared to those who were not affiliated. CONCLUSIONS: Eight out of ten chiropractic websites mentioned one or more non-MSK diagnoses or symptoms. It is unclear if this reflects inaccurate communication or if treatments for non-MSK conditions are provided by the chiropractors.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline.

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study.

BACKGROUND: Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals' appropriateness. METHODS: Four inexperienced students (chiropractic master's students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or "other reasons" for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison. RESULTS: Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55-0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58-0.91) and 0.82 (95% CI: 0.72-0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters' results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84-92%, respectively, for the pairwise comparisons. CONCLUSION: The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

The Association Between Early Postoperative Leg Pain Intensity and Disability at 1-Year and 2-Year Follow-Up After First-Time Lumbar Discectomy.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To investigate whether a cutoff point in leg pain intensity measured preoperatively or at early follow-up could identify patients at risk of poor outcomes in terms of disability at 1-year and 2-year follow-up after first-time lumbar discectomy, and to identify the characteristics associated with early postoperative leg pain intensity. METHODS: From 2010 to 2013, 556 patients underwent lumbar discectomy. Leg pain intensity was measured preoperatively and at early postoperative follow-up and dichotomized according to an established cutoff point on a 0 to 100 visual analogue scale (mild <30, moderate/severe ≥30). The outcome measurement was Oswestry Disability Index (ODI). Generalized estimating equations modelling established the association between leg pain intensity and ODI. Characteristics associated with early postoperative leg pain intensity were identified using common hypothesis tests. RESULTS: Moderate/severe leg pain intensity at early follow-up showed a statistically significant association with higher ODI at 1-year and 2-year follow-up compared to mild leg pain intensity (median [interquartile range]: 24 [26] and 26 [26] versus 12 [18] and 10 [20], respectively). Patients reporting moderate/severe leg pain intensity were more often smokers, were more prone to receive social benefits, and were more prone to have chronic back pain. The preoperative measurement of leg pain intensity showed inferior associations. CONCLUSION: The proposed cutoff point in leg pain intensity at early follow-up can identify patients at risk of disability at both 1-year and 2-year follow-up after first-time discectomy. Future research should be undertaken to investigate whether patients with moderate/severe leg pain intensity at early postoperative follow-up could benefit from additional or more intensive postoperative interventions.

Diagnostic Screening for Lumbar Spinal Stenosis.

PURPOSE: To develop a self-administered diagnostic screening questionnaire for lumbar spinal stenosis (LSS) consisting of items with high content validity and to investigate the diagnostic value of the questionnaire and the items. PATIENTS AND METHODS: A self-reported diagnostic LSS screening questionnaire was developed based on items from the existing literature describing key symptoms of LSS. The screening questionnaire (index test) was to be tested in a cohort of patients with persistent lumbar and/or leg pain recruited from a Danish publicly funded outpatient secondary care spine clinic with clinicians performing the reference test. However, to avoid unnecessary collection of data if the screening questionnaire proved to be of limited value, a case-control design was incorporated into the cohort design including an interim analysis. Additional cases for the case-control study were recruited at two Danish publicly funded spine surgery departments. Prevalence, sensitivity, specificity and diagnostic odds ratio (OR) were calculated for each individual item, and AUC (area under the curve) was calculated to examine the performance of the full questionnaire. RESULTS: A 13-item Danish questionnaire was developed and tested in 153 cases and 230 controls. The interim analysis was not in favour of continuing the cohort study, and therefore, only results from the case-control study are reported. There was a positive association for all items except the presence of back pain. However, the association was only moderate with ORs up to 3.3. When testing the performance of the whole questionnaire, an AUC of 0.72 was reached with a specificity of 20% for a fixed sensitivity of 95%. CONCLUSION: The items were associated with LSS and therefore have some potential to identify LSS patients. However, the association was not strong enough to provide sufficient accuracy for a diagnostic tool. Additional dimensions of symptoms of LSS need identification to obtain a reliable questionnaire for screening purposes.

A cross-sectional study of website claims related to diagnoses and treatment of non-musculoskeletal conditions.

BACKGROUND: The Danish Authorisation Act sets out the chiropractic scope of practice. Under this legislation the scope of practice is diagnostics, prevention and treatment of biomechanical disorders of the spine, pelvis and extremities. Despite this and an international movement toward a scientifically active, evidence-based profession with a focus on treatment of musculoskeletal disorders, a large proportion of chiropractors still offer treatment of non-musculoskeletal disorders. This study aimed to investigate the content and characteristics of website claims by chiropractors in Denmark on non-musculoskeletal conditions and to assess whether these were aligned with the Danish Authorisation Act of the chiropractic scope of practice. METHODS: In this cross-sectional study data on a representative sample were collected from chiropractic clinic websites in Denmark. Information on non-musculoskeletal conditions from the websites was categorised. For each non-musculoskeletal condition, it was noted whether a clarifying explanation justifying the presence of the diagnosis was available and what it said. These explanations were assessed and categorised according to agreement or disagreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. In addition, data on geographic location, clinic size, reimbursement coverage, country of education and special clinical focus (children, athletes, etc) were collected. Differences in characteristics of the clinics and the frequency of reporting non-musculoskeletal conditions were tested using Pearson's chi-squared or Fisher's exact test. RESULTS: A geographically stratified, random sample of 139 (57%) websites was included from chiropractic clinics in Denmark. In total, 36 (26%) of the sampled websites mentioned conditions of non-musculoskeletal origin that was not accompanied by a clarifying explanation in agreement with the chiropractic scope of practice. A positive association between advertising infant or children's care and advertising treatment for non-musculoskeletal disorders (without adequate explanation) was observed. CONCLUSIONS: A total of 36 (26%) of the sampled chiropractic websites in Denmark mentioned diagnoses or symptoms of non-musculoskeletal origin on their websites without presenting an adequate clarifying explanation in agreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. This could be misleading for patients seeking care for non-musculoskeletal conditions and consequently lead to inappropriate treatment.

Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis.

PURPOSE: To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. METHODS: Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. RESULTS: In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care. CONCLUSIONS: The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.

Returning to Work Within Two Years After First-Time, Single-Level, Simple Lumbar Discectomy: A Multifactorial, Predictive Model.

Purpose Continued inability to work has societal and individual consequences. Thus, the factors associated with sustained return to work after lumbar discectomy should be identified. Prior studies of the biopsychosocial factors associated with sustained RTW were primarily based on patient-reported outcome data and have shown conflicting results because of small study samples. In patients undergoing first-time, single-level, simple lumbar discectomy, we describe the time to sustained return to work within 2 years after surgery using outcome data from a national database and identify the pre- and peri-operative factors associated with sustained return to work within 2 years by developing and validating a predictive multivariable model. Methods The time to a sustained return to work within the study period was described using a Kaplan-Meier plot. A temporal validated Cox proportional hazards model examined associations between biopsychosocial factors and return to work. Results In the derivation cohort made up by 351 operated patients who were on sick-leave for more than 3 weeks around the time of surgery, 62% returned to work (median 15 weeks). The probability of sustained return to work was associated with a high education level, positive expectations towards future labor market attachment, pre-operative stable labor market attachment, pre-operative higher physical quality of life, and less disability. Conclusions Through the development and validation of a predictive model, this study identifies a number of patient-related factors associated with sustained return to work after lumbar discectomy, while revealing that most disease-related clinical findings were not associated with the outcome.