Using medical storytelling to communicate problems and solutions in the low back pain conundrum: an evidence-based tale of twins.

OBJECTIVES: Low back pain (LBP) is the number one cause of disability world-wide. It is also the most expensive area in healthcare. Patient-centered innovations are needed. This paper uses medical storytelling to illustrate the common problems that often lead to unnecessary suffering for patients, and costs to society. We present innovative solutions, including narrative interventions. METHODS: We use medical storytelling to present a scenario in which hypothetical twin patients with identical LBP episodes enter the healthcare system, with one twin managed in an appropriate manner, and the other inappropriately. RESULTS: One twin becomes a chronic LBP sufferer, while the other experiences quick resolution, despite identical conditions. Recommendations are made to de-implement inappropriate action and to implement a more productive approach. CONCLUSIONS: Many patients with LBP descend into chronic pain. This is rarely inevitable based on clinical factors. Much of chronic LBP results from how the condition is handled within the healthcare system. Medical narrative may be one innovation to illustrate the problem of current LBP management, recommend solutions and foster changes in clinical behavior. PRACTICAL IMPLICATIONS: The starkly different outcomes for each identical twin are illustrated. Recommendations are made for reframing the situation to de-implement the inappropriate and to implement a more appropriate approach.

The primary spine practitioner as a new role in healthcare systems in North America.

BACKGROUND: In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies. MAIN BODY: The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly. CONCLUSION: Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Invasive Treatments for Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS: Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS: Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION: Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Non-Invasive and Minimally Invasive Management of Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Low Back Disorders Guideline reviews the evidence and recommendations developed for non-invasive and minimally invasive management of low back disorders. METHODS: Systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking. A total of 70 high-quality and 564 moderate-quality trials were identified for non-invasive low back disorders. Detailed algorithms were developed. RESULTS: Guidance has been developed for the management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 121 specific recommendations. CONCLUSION: Quality evidence should guide treatment for all phases of managing low back disorders.

Diagnostic Tests for Low Back Disorders.

OBJECTIVE: The aim of this study was to summarize evidence-based diagnostic guidelines for low back disorders. METHODS: A comprehensive literature review was conducted. A total of 101 articles of high or moderate quality addressing low back disorders diagnostic evaluation met the inclusion criteria. Evidence-based recommendations were developed and graded from (A) to (C) in favor and against the specific diagnostic test, with (A) level having the highest quality body of literature. Expert consensus was employed for insufficient evidence (I) to develop consensus guidance. RESULTS: Recommendations are given for these diagnostic tests: functional capacity evaluations, roentgenograms (x-rays), magnetic resonance imaging (MRI), computerized tomography, myelography, bone scans, single proton emission computed tomography, electromyography, surface electromyography, ultrasound, thermography, fluoroscopy, videofluoroscopy, lumbar discography, MRI discography, and myeloscopy. CONCLUSION: Diagnostic testing is not indicated for the majority of patients with low back pain.

Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial.

Importance: Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older US adults. There is an evidence gap about nonsurgical LSS treatment options. Objective: To explore the comparative clinical effectiveness of 3 nonsurgical interventions for patients with LSS. Design, Setting, and Participants: Three-arm randomized clinical trial of 3 years' duration (November 2013 to June 2016). Analysis began in August 2016. All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat. Interventions: Medical care, group exercise, and manual therapy/individualized exercise. Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors in senior community centers. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. Main Outcomes and Measures: Primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes). Results: A total of 259 participants (mean [SD] age, 72.4 [7.8] years; 137 women [52.9%]) were allocated to medical care (88 [34.0%]), group exercise (84 [32.4%]), or manual therapy/individualized exercise (87 [33.6%]). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care (-2.0; 95% CI, -3.6 to -0.4) or group exercise (-2.4; 95% CI, -4.1 to -0.8). Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates. Conclusions and Relevance: A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity. Trial Registration: ClinicalTrials.gov Identifier: NCT01943435.

Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No.

BACKGROUND: The purported relationship between cervical manipulative therapy (CMT) and stroke related to vertebral artery dissection (VAD) has been debated for several decades. A large number of publications, from case reports to case-control studies, have investigated this relationship. A recent article suggested that case misclassification in the case-control studies on this topic resulted in biased odds ratios in those studies. DISCUSSION: Given its rarity, the best epidemiologic research design for investigating the relationship between CMT and VAD is the case-control study. The addition of a case-crossover aspect further strengthens the scientific rigor of such studies by reducing bias. The most recent studies investigating the relationship between CMT and VAD indicate that the relationship is not causal. In fact, a comparable relationship between vertebral artery-related stroke and visits to a primary care physician has been observed. The statistical association between visits to chiropractors and VAD can best be explained as resulting from a patient with early manifestation of VAD (neck pain with or without headache) seeking the services of a chiropractor for relief of this pain. Sometime after the visit the patient experiences VAD-related stroke that would have occurred regardless of the care received. This explanation has been challenged by a recent article putting forth the argument that case misclassification is likely to have biased the odds ratios of the case-control studies that have investigated the association between CMT and vertebral artery related stroke. The challenge particularly focused on one of the case-control studies, which had concluded that the association between CMT and vertebral artery related stroke was not causal. It was suggested by the authors of the recent article that misclassification led to an underestimation of risk. We argue that the information presented in that article does not support the authors' claim for a variety of reasons, including the fact that the assumptions upon which their analysis is based lack substantiation and the fact that any possible misclassification would not have changed the conclusion of the study in question. CONCLUSION: Current evidence does not support the notion that misclassification threatens the validity of recent case-control studies investigating the relationship between CMT and VAD. Hence, the recent re-analysis cannot refute the conclusion from previous studies that CMT is not a cause of VAD.

Primary spine care services: responding to runaway costs and disappointing outcomes in spine care.

Efforts are underway to reform our health care system to improve efficiency, outcomes, patient satisfaction and costs. In no field is this more critical than that of spine- related disorders, where escalating costs combined with decreasing clinical benefits for patients has reached a breaking point. Traditionally, practitioners have grouped together based on their specialty (orthopedics, otolaryn- gology, etc.). There has been a recent movement to restructure health care delivery into a patient-centered model that teams professionals based on their ability to serve specific patient needs. This article introduces a new service line - primary spine care services - led by a new type of professional - the primary spine practitioner (PSP). This new practitioner type requires a refined and focused skill set and ideally functions within an integrated spine care pathway. The challenges and opportunities presented by primary spine care services are discussed. This service line has already been implemented in a variety of settings.

Neck and back pain specific outcome assessment questionnaires in the Spanish language: a systematic literature review.

BACKGROUND CONTEXT: Accurate measurement of functional improvement in clinical practice is becoming increasingly recognized as essential in demonstrating whether patients are deriving meaningful benefit from care. Several simple questionnaires have been developed for this purpose. The majority of these have been developed in English. In North America, there is a growing need for clinical tools, including outcome assessment tools that are available in the Spanish language. PURPOSE: The purpose of this study was to systematically review the literature regarding spine-specific outcome assessment questionnaires that are available in Spanish and to examine the evidence on their clinical utility. STUDY DESIGN: Systematic review. METHODS: The Medline, CINAHL, Embase, and MANTIS databases were searched for any studies on the topic of outcome assessment questionnaires in the Spanish language. Relevant articles were reviewed, and the data on reliability, validity, time to completion, and any other properties of the questionnaire was extracted. RESULTS: The search strategy identified 287 articles, of which 10 were deemed relevant. With regard to neck pain, data were found regarding Spanish translations of the Northwick Park Neck Pain Questionnaire, Neck Disability Index (NDI), and Core Outcome Measure for neck pain. With regard to low back pain, data were found regarding Spanish translations of the Oswestry Low Back Pain Disability Index (ODI), Roland Morris Disability Questionnaire (RMQ), and the North American Spine Society-American Academy of Orthopedic Surgeons questionnaire. CONCLUSIONS: Several reliable and valid outcome assessment questionnaires are available in the Spanish language. All were originally developed in English. It appears from the data reviewed that the most useful instruments are the NDI for neck pain patients and the ODI and RMQ for low back pain patients. The current trend is for the development of culturally adapted versions of these questionnaires that are specific to a particular country or region.

Application of a diagnosis-based clinical decision guide in patients with low back pain.

BACKGROUND: Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP. METHODS: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG. RESULTS: Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%. CONCLUSION: The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.

The usefulness of clinical measures of psychologic factors in patients with spinal pain.

OBJECTIVE: The purposes of this study were to investigate whether a screening procedure could capture important psychologic factors with minimum burden to the patient and to investigate whether correlations exist among the various psychologic factors. METHODS: A screening procedure consisting of the 11-item Tampa Scale for Kinesiophobia, a 2-question coping strategies screen, and the depression and anxiety subscales of the Bournemouth Disability Questionnaire was provided to consecutive patients with neck pain (NP) or low back pain (LBP) as part of the usual initial assessment process at a busy spine center, which includes chiropractic and physical therapy. Correlations and associations between these variables were determined. RESULTS: Data were collected on 95 patients with NP and 260 patients with LBP. Statistically significant correlations and associations were found between all measures in both cohorts with the exception of depression and coping in patients with NP. Statistically significant associations were found among all measures in both cohorts with the exception of depression and coping and coping and fear in patients with NP. CONCLUSION: This study showed that a screening procedure may provide useful clinical information regarding psychologic factors that are of potential relevance in patients with NP and LBP.

An investigation of neck muscle activity in asymptomatic participants who show different lumbar spine motion patterns during prone hip extension.

OBJECTIVE: The objective of the current study was to investigate whether any differences exist in the activity of the cervical erector spinae and upper trapezius (TRA) muscles between asymptomatic participants who show "normal" and "abnormal" lumbar spine motion patterns during the prone hip extension (PHE) test. METHODS: Twenty-six asymptomatic participants recruited from a chiropractic college participated in the study. Surface electromyography was used to record the activity of the cervical erector spinae and upper TRA muscles as each participant performed a set of 4 repetitions of PHE for each leg. An examiner observed the participant perform the movement and classified him/her as "positive" or "negative" based on the presence or absence (respectively) of 1 of 3 lumbar spine motion patterns. The mean activity levels of each muscle during the positive sets of PHE were compared with those during the negative sets. RESULTS: The mean activity of the upper TRA ipsilateral to the side of hip extension was significantly higher in the positive group compared with the negative group (difference, 13.3%; 95% confidence interval, 0.2%-24.4%; P = .0465). No other significant between-group differences were noted. CONCLUSION: The results of this study indicate that the presence of abnormal lumbar spine motion patterns during the PHE test may be associated with altered cervicothoracic motor control strategies in asymptomatic individuals. Similar investigations using patients with neck pain are required to comment further on the generalizability and potential clinical importance of these findings.

Application of a diagnosis-based clinical decision guide in patients with neck pain.

BACKGROUND: Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP. METHODS: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG. RESULTS: Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%. CONCLUSION: The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability, validity and efficacy of treatment based on the DBCDG.

The establishment of a primary spine care practitioner and its benefits to health care reform in the United States.

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.

Manual therapy and ear pain: a report of four cases.

PURPOSE: To report and discuss four cases of ear pain which were treated successfully with manual therapy. METHODS: Report of four cases. RESULTS: Four patients with ear pain were referred for chiropractic consult. They were all treated with a combination of manual therapy and exercise with resolution of their ear symptoms. CONCLUSIONS: The mechanism of idiopathic ear pain that may be amenable to manual therapy is not fully known. Further research is needed to investigate the etiology of this disorder and to determine whether manual therapy and exercise are viable options in some patients with idiopathic ear pain. In the meantime, it may be advantageous for otolaryngologists to seek input from physicians skilled in assessment and treatment of the musculoskeletal system in cases ear pain for which an otolarygologic etiology cannot be found.