Clinical course of patients with low back pain following an emergency department presentation: a systematic review and meta-analysis.

INTRODUCTION: Low back pain, and especially non-specific low back pain, is a common cause of presentation to the emergency department (ED). Although these patients typically report relatively high pain intensity, the clinical course of their pain and disability remains unclear. Our objective was to review the literature and describe the clinical course of non-specific low back pain after an ED visit. METHODS: Electronic searches were conducted using MEDLINE, CINAHL and EMBASE from inception to March 2019. We screened for cohort studies or randomised trials investigating pain or disability in patients with non-specific low back pain presenting to EDs. We excluded studies that enrolled participants with minimal pain or disability scores at baseline. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias and quality of evidence. Estimates of pain and disability were converted to a common 0-100 scale. We estimated pooled means and 95% CIs of pain and disability as a function of time since ED presentation. RESULTS: Eight studies (nine publications) with a total of 1994 patients provided moderate overall quality evidence of the expected clinical course of low back pain after an ED visit. Seven of the eight studies were assessed to have a low risk of bias. At the time of the ED presentation, the pooled estimate of the mean pain score on a 0-100 scale was 71.0 (95% CI 64.2-77.9). This reduced to 46.1 (95% CI 37.2-55.0) after 1 day, 41.8 (95% CI 34.7 to 49.0) after 1 week and 13.5 (95% CI 5.8-21.3) after 26 weeks. The course of disability followed a similar pattern. CONCLUSIONS: Patients presenting to EDs with non-specific low back pain experience rapid reductions in pain intensity, but on average symptoms persisted 6 months later. This review can be used to educate patients so they can have realistic expectations of their recovery.

Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials.

BACKGROUND: Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit. METHODS: Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (≥18 years) with non-specific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence. RESULTS: Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30 min (mean difference (MD) -15.0, 95% confidence interval (CI) -21.0 to -9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD -15.7, 95% CI -19.8 to -11.6) and intravenous morphine (MD -11.4, 95% CI -21.6 to -1.2) were both superior to placebo at 30 min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95% CI -0.71 to 18.7) or sciatica (MD -6.8, 95% CI -24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating non-pharmacological treatments (low quality evidence). CONCLUSION: Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.

Correction: A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study.

[This corrects the article DOI: 10.2196/50146.].

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study.

BACKGROUND: Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia. OBJECTIVE: The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model. METHODS: This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes. RESULTS: As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024). CONCLUSIONS: This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50146.

Clinicians' Perspective on Implementing Virtual Hospital Care for Low Back Pain: Qualitative Study.

BACKGROUND: Alternate "hospital avoidance" models of care are required to manage the increasing demand for acute inpatient beds. There is currently a knowledge gap regarding the perspectives of hospital clinicians on barriers and facilitators to a transition to virtual care for low back pain. We plan to implement a virtual hospital model of care called "Back@Home" and use qualitative interviews with stakeholders to develop and refine the model. OBJECTIVE: We aim to explore clinicians' perspectives on a virtual hospital model of care for back pain (Back@Home) and identify barriers to and enablers of successful implementation of this model of care. METHODS: We conducted semistructured interviews with 19 purposively sampled clinicians involved in the delivery of acute back pain care at 3 metropolitan hospitals. Interview data were analyzed using the Theoretical Domains Framework. RESULTS: A total of 10 Theoretical Domains Framework domains were identified as important in understanding barriers and enablers to implementing virtual hospital care for musculoskeletal back pain. Key barriers to virtual hospital care included patient access to videoconferencing and reliable internet, language barriers, and difficulty building rapport. Barriers to avoiding admission included patient expectations, social isolation, comorbidities, and medicolegal concerns. Conversely, enablers of implementing a virtual hospital model of care included increased health care resource efficiency, clinician familiarity with telehealth, as well as a perceived reduction in overmedicalization and infection risk. CONCLUSIONS: The successful implementation of Back@Home relies on key stakeholder buy-in. Addressing barriers to implementation and building on enablers is crucial to clinicians' adoption of this model of care. Based on clinicians' input, the Back@Home model of care will incorporate the loan of internet-enabled devices, health care interpreters, and written resources translated into community languages to facilitate more equitable access to care for marginalized groups.

Continued opioid use following an emergency department presentation for low back pain.

OBJECTIVE: To investigate the proportion of patients with low back pain who receive an opioid analgesic prescription on hospital discharge, the proportion using opioid analgesics 4 weeks after discharge, and to identify predictors of continued opioid analgesic use at 4 weeks after an ED presentation in opioid-naïve patients. METHODS: An observational cohort study nested within a randomised controlled trial in four EDs in New South Wales, Australia. Participants were adults who presented to the ED with non-specific low back pain or low back pain with lower limb neurological signs and symptoms. Electronic medical records supplemented the patient-reported pain and use of opioid analgesics at 4-week follow up. RESULTS: Of the 104 patients included, 33 (31.7%, 95% confidence interval [CI] 22.9-41.6) received an opioid analgesic prescription at hospital discharge and 38 (36.5%, 95% CI 27.3-46.6) reported taking an opioid analgesic for pain 4 weeks after the ED presentation. Among opioid-naïve patients (n = 85), older age (odds ratio [OR] 1.04, 95% CI 1.00-1.08, P = 0.031) was the only predictor for continued opioid analgesic use at 4 weeks post-ED presentation. CONCLUSION: About one-third of patients who present to the ED with low back pain receive an opioid analgesic prescription on discharge and are taking an opioid analgesic 4 weeks later. These findings justify future research to identify strategies to reduce the risk of long-term opioid use in patients who present to the ED with low back pain.

Feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth') for patients with low back pain: protocol for a feasibility and pilot randomised controlled trial.

INTRODUCTION: Long waiting time is an important barrier to accessing recommended care for low back pain (LBP) in Australia's public health system. This study describes the protocol for a randomised controlled trial (RCT) that aims to establish the feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth'), which aims to reduce waiting times for LBP. METHODS AND ANALYSIS: We will conduct a single-centre feasibility and pilot RCT with nested qualitative interviews. Sixty participants with LBP newly referred to a hospital outpatient clinic will be randomised to receive Rapid Stratified Telehealth or usual care. Rapid Stratified Telehealth involves matching the mode and type of care to participants' risk of persistent disabling pain (using the Keele STarT MSK Tool) and presence of potential radiculopathy. 'Low risk' patients are matched to one session of advice over the telephone, 'medium risk' to telehealth physiotherapy plus App-based exercises, 'high risk' to telehealth physiotherapy, App-based exercises, and an online pain education programme, and 'potential radiculopathy' fast tracked to usual in-person care. Primary outcomes include the feasibility of delivering Rapid Stratified Telehealth (ie, acceptability assessed through interviews with clinicians and patients, intervention fidelity, appointment duration, App useability and online pain education programme usage) and evaluating Rapid Stratified Telehealth in a future trial (ie, recruitment rates, consent rates, lost to follow-up and missing data). Secondary outcomes include waiting times, number of appointments, intervention and healthcare costs, clinical outcomes (pain, function, quality of life, satisfaction), healthcare use and adverse events (AEs). Quantitative analyses will be descriptive and inform a future adequately-powered RCT. Interview data will be analysed using thematic analysis. ETHICS AND DISSEMINATION: This study has received approval from the Ethics Review Committee (RPAH Zone: X21-0221). Results will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001104842.

Healthcare costs due to low back pain in the emergency department and inpatient setting in Sydney, Australia.

BACKGROUND: Low back pain is the leading cause of disability worldwide and a common presentation to emergency departments, often resulting in subsequent admissions to hospital. There have been several studies investigating the cost of low back pain to society, but few specific to the emergency department and inpatient setting, especially in Australia. The aim was to describe the cost of low back pain in Australian public hospital emergency departments, and inpatient settings, and explore healthcare costs associated with different care pathways. METHODS: In this retrospective observational study, we explored the costs associated with an episode of care for low back pain in adults that attended three emergency departments in Sydney between 1 July 2014 and 30 June 2019. Systematised Nomenclature of Medicine-Clinical Terms (SNOMED) diagnosis codes were used to identify episodes of care where the patients had been diagnosed with non-specific low back pain or lumbosacral radicular syndromes. Serious spinal pathologies were excluded. We determined the costs for different treatment pathways involving the ambulance service, emergency department and inpatient ward care. Hospital costs were adjusted for inflation to 2019 Australian dollars (AUD). FINDINGS: There were 12,399 non-serious low back pain episodes of care during the study period. 4006 (32%) arrived by ambulance and 2067 (17%) were admitted for inpatient care. The total costs of inpatient and emergency department care across the 5-year period were AUD$36.7 million, with a mean of AUD$2959 per episode of care. The mean cost for a patient who had a non-ambulance presentation to the emergency department and was discharged was AUD$584. Patients presenting to the emergency department via ambulance and were discharged had a mean cost of AUD$1022. Patients who presented without the need of an ambulance and were admitted had a mean cost of $13,137. The most expensive care pathway was for patients arriving by ambulance with subsequent admission, with a mean cost of AUD$14,949. INTERPRETATION: The common practice of admitting patients with non-serious low back pain for inpatient care comes at great cost to the healthcare system. In a resource constrained environment, our data highlights the economic need to implement innovative, evidence-based strategies to reduce the inpatient management of these patients. FUNDING: Nil.

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial.

BACKGROUND: Overuse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department. METHODS: We conducted a stepped-wedge, cluster-randomised trial in four EDs in New South Wales, Australia. After a 13-month control phase of usual care, the EDs received a multifaceted intervention to support guideline-endorsed care in a random order, based on a computer-generated random sequence, every 4 weeks over a 4-month period. All sites were followed up for at least 3 months. The primary outcome was the proportion of low back pain presentations receiving lumbar imaging. Secondary healthcare utilisation outcomes included prescriptions of opioid and non-opioid pain medicines, inpatient admissions, length of ED stay, specialist referrals and re-presentations. Clinician beliefs and knowledge about low back pain care were measured before and after the intervention. Patient-reported pain, disability, quality of life and satisfaction were measured at 1, 2 and 4 weeks post ED presentation. RESULTS: A total of 269 ED clinicians and 4625 episodes of care for low back pain (4491 patients) were included. The data did not provide clear evidence that the intervention reduced lumbar imaging (OR 0.77; 95% CI 0.47 to 1.26; p=0.29). It did reduce opioid use (OR 0.57; 95% CI 0.38 to 0.85; p=0.006) and improved clinicians' beliefs (mean difference (MD), 2.85; 95% CI 1.85 to 3.85; p<0.001; on a scale from 9 to 45) and knowledge about low back pain care (MD, 0.48; 95% CI 0.13 to 0.83; p<0.01; on a scale from 0 to 11). There was no difference in pain scores at 1-week follow-up (MD, 0.04; 95% CI -1.00 to 1.08; p=0.94; on a scale from 0 to 10). A similar trend was observed for all other patient-reported outcomes and time points. This study found no effect on the other secondary healthcare utilisation outcomes. CONCLUSION: It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED; however, it did reduce opioid prescriptions without adversely affecting patient outcomes. Trial registration number ACTRN12617001160325.