Change in number of pain sites - which factors are important? A 12-year prospective cohort study.

BACKGROUND: Pain in multiple body sites is common and often persistent. The purpose of this prospective study was to examine the change in the number of pain sites (NPS) over time and to evaluate to which extent clinical, demographic, lifestyle and health-related factors predict a change in NPS. METHODS: This was a population-based longitudinal cohort study of adults (n = 2,357). Data on pain, demographic, lifestyle, and health-related variables were collected by questionnaires in 2008 and 2020 and register data from 2006 to 2017. Data was analysed with linear regression. RESULTS: We found a mean decrease in NPS over the 12-year follow-up period (-0.36 (95% CI; -0.44; -0.27) and 56% of this sample reported no change or only one pain site increase/decrease over 12 years. While participants reporting pain for less than 3 months at baseline had almost no change in NPS (-0.04 (95% CI; -0.18; 0.10)), participants with pain for longer than 3 months decreased by -0.51 (95% CI; -0.62; -0.41). Age at baseline (20-49 years), pain intensity, and obesity (BMI ≥ 30) were associated with an increase in NPS over the follow-up period. CONCLUSIONS: NPS is relatively stable over time. We found a small mean decrease in NPS over 12 years varying between participants with pain for longer than 3 months and pain for less than 3 months respectively. The results also indicate that pain intensity, age, and obesity could be relevant factors to consider when predicting change in NPS.

The usefulness of the STarT back screening tool and single-item general health measures when predicting future disability in patients with low back pain treated in Danish primary care physiotherapy.

INTRODUCTION: The extent to which disease specific screening tools or other health measures add to the predictive value of common clinical factors (pain, disability and socio-demographics) has been sparsely investigated. The aim of this study was to investigate whether a disease specific screening tool and a single-item general health measure adds predictive value to basic information collected in primary physiotherapy care when predicting future disability in patients with low back pain. MATERIAL AND METHODS: This longitudinal cohort study included 354 patients with low back pain from Danish primary care physiotherapy. Information was collected on socio-demographics, common clinical factors, The STarT Back Screening Tool (SBT) and general health perceptions measured as a single item from the SF-36 (GH-1). Disability at 6-month follow-up, measured by the Roland-Morris Disability Questionnaire, was predicted using multiple linear regression models. RESULTS: Clinical factors and baseline disability level explained 28.3% of the variance in 6-month disability scores. With SBT and GH-1 added separately to the baseline model, the explained variance increased by 2.1% (p = 0.01) and 3.6% (p < 0.001), respectively. CONCLUSION: The added value of the disease specific screening tools or the single-item general measure when predicting disability in patients with low back pain was generally small. Moreover, the predictive value of the single-item general measure seems comparable to and slightly better than the disease specific screening tool. Overall these findings may question the clinical utility of such measures.

Musculoskeletal Health Climate Is a Prognostic Determinant of Sickness Absence Among Female Eldercare Workers: A Prospective Cohort Study.

OBJECTIVES: The present study investigated the association between musculoskeletal health climate, that is, the shared perceptions among workers concerning musculoskeletal health, and sickness absence. METHODS: Questionnaire data on two domains of musculoskeletal health climate, perceived management priority (PMP) and pain acceptance at work (PAW), were collected at baseline. Data on sickness absence were extracted at 1-year follow-up. Data were analyzed using negative binomial multivariable regression. RESULTS: The final study population comprised 390 female eldercare workers. Compared with participants with low PMP scores, participants with high PMP scores had lower risk of sickness absence (incidence rate ratio, 0.6; 95% confidence interval, 0.4-0.9). Participants with high PAW scores had higher risk of sickness absence than participants with low PAW scores (incidence rate ratio, 1.4; 95% confidence interval, 0.9-2.2). CONCLUSIONS: The results showed an association between the musculoskeletal health climate and sickness absence.

Primary Care Physical Therapists' Experiences When Screening for Serious Pathologies Among Their Patients: A Qualitative Study.

OBJECTIVE: A vital part of the initial examination performed by a physical therapist is to establish whether the patient would benefit from physical therapist intervention. This process includes knowledge about contraindications for treatment and screening for serious pathologies. However, little is known about the physical therapists' views and thoughts about their own practice when screening for serious pathologies. The purpose of this study was to explore the experience gained by physical therapists when screening for serious pathologies among their patients. METHODS: This was a qualitative study based on individual semi-structured interviews with 9 primary care physical therapists. The interviews were analyzed using reflexive thematic analysis, and generated themes were explained and reported with relevant quotes. RESULTS: Three overall themes were generated: (1) the role of physical therapists in the diagnostic process; (2) responsibility from the individual to the group; and (3) the difficult task of cooperation. The physical therapists described how they relied more on their clinical suspicion than on asking red-flag questions when screening for serious pathologies. They also questioned their differential diagnostic abilities. Finally, they saw a potential to further enhance their confidence in the area by reflecting on the matter with colleagues and by receiving more feedback about their clinical reasoning regarding serious pathologies from general practitioners. CONCLUSION: These findings suggest that physical therapists primarily rely on their clinical suspicion when screening for serious pathologies but at the same time are uncertain about their differential diagnostic abilities. IMPACT: These findings can inform future interventions targeting the physical therapists' abilities to detect serious pathology.

Primary care physiotherapists ability to make correct management decisions - is there room for improvement? A mixed method study.

BACKGROUND: With increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety. The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors. METHODS: The study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed. RESULTS: A total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics. CONCLUSION: The lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT's should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

The prevalence of serious pathology in musculoskeletal physiotherapy patients - a nationwide register-based cohort study.

INTRODUCTION: Musculoskeletal conditions are the single largest contributor to years lived with disability worldwide. Most musculoskeletal conditions can be managed in primary care, but for a small proportion of these patients the symptoms are caused by serious pathology. Although the general practitioner usually performs initial screening for serious pathology, evaluation and treatment by physiotherapists are often part of the treatment pathway. It is however unclear, how many patients in primary care physiotherapy have symptoms caused by serious pathology. OBJECTIVE: To estimate the prevalence of neoplasm, cauda equina syndrome, spinal fracture, infection and inflammatory pathology among patients referred for musculoskeletal physiotherapy. METHODS: The study was a nationwide register-based cohort study. The authors identified all referrals for primary care musculoskeletal physiotherapy in the Danish National Health Insurance Service Register from 2014 to 2017. Records of hospital contacts were extracted from the Danish National Patient Register within 180 days from first physiotherapy contact, identifying all diagnoses of serious pathology. Prevalence estimates of the serious pathology categories were reported. RESULTS: A total of 1568704 courses of treatment were included in the analysis. The overall prevalence of serious pathology was 2.30%. The prevalence of neoplasm was 2.11%, cauda equina syndrome 0.01%, fractures 0.13%, infections 0.01% and inflammatory pathology 0.06%. Higher prevalence's were observed among patients with a previous history of serious pathology, aged above 50 and with comorbidites. CONCLUSIONS: Although serious pathology among patients referred by the General Practitioner to musculoskeletal physiotherapy is rare, the present study found an overall prevalence of serious pathology which exceeded the guideline endorsed prevalence estimates.

The effects of the extended physiotherapy examination scheme for patients with low-back pain.

INTRODUCTION: The extended physiotherapy examination scheme (EES) was developed to assist general practitioners in their assessment of patients with complex low-back pain (LBP). The aim was to compare LBP patients in the EES and patients in current physiotherapy practice (CP) with respect to characteristics, healthcare utilisation and sick leave. METHODS: Data from three cohorts were included, one covering the EES and two covering CP for LBP patients in Danish primary care physiotherapy. Baseline questionnaire data were collected, and 78-week follow-up was conducted in Danish registries. Patients were stratified according to their risk profile by the STarT Back Tool, and regression analyses were used to analyse healthcare utilisation and sick leave. RESULTS: A total of 746 patients in the EES and 361 in CP were included. Patients in the EES had sick leave more often and were characterised by a longer pain duration and more disability than CP patients. The probability of contact to secondary care was doubled among patients in the EES with a high-risk profile and patients in the EES showed a trend towards a higher degree of sick leave. CONCLUSIONS: LBP patients in the EES are more burdened than patients in CP. Consequently, for some subgroups in the EES, a higher referral rate and more sick leave were detected. These findings may be the result of vague referral criteria, lack of appropriate screening tools or inadequate monitoring of the EES. FUNDING: This study was funded by the Central Denmark Region and the Region of Southern Denmark. TRIAL REGISTRATION: not relevant.

Socio-demographic, clinical and psychological predictors of healthcare utilization among patients with musculoskeletal disorders: a prospective cohort study.

BACKGROUND: Musculoskeletal disorders are common in the general population and a leading cause for care seeking. Despite the large number of patients with musculoskeletal disorders seeking care, little is known of the clinical course, pathways and predictors of healthcare utilization among these patients. The purposes of the study were to 1) describe the clinical course and related healthcare utilization in primary care physiotherapy and secondary healthcare among patients with neck, shoulder and low-back pain treated in physiotherapy practice, and 2) identify independent clinical, socio-demographic, psychological and general health predictors of healthcare utilization. METHODS: The study was a prospective cohort study of patients seeking physiotherapy treatment for neck, shoulder, or low-back pain in physiotherapy practices across Denmark. A total of 759 physiotherapy patients completed questionnaires containing information on clinical course and potential predictors of healthcare utilization. Healthcare utilization was obtained from the Danish National Health Service Register and National Patient Register. Associations between potential predictors and low/high primary care physiotherapy utilization and hospital contacts in relation to specific neck, shoulder or low-back disorders were analysed using binomial regression analyses and adjusted for age, sex, duration of pain and comorbidity. RESULTS: During 6 months follow-up, patients experienced clinically relevant improvements in pain, fear avoidance and psychological wellbeing. Patients with higher baseline pain and disability and who were on sickness leave were more likely to have high primary care physiotherapy utilization. Hospital contacts were predicted by higher levels of pain, disability and low psychological wellbeing. CONCLUSIONS: Clinical factors and sickness leave seems to be the main predictors of primary care physiotherapy utilization, whereas for secondary care contacts, psychological factors may also be of importance. The study contributes to the on-going research into clinical pathways and may identify future target areas to reduce healthcare utilization in patients with musculoskeletal disorders.

Responsiveness and minimal important change for the quick-DASH in patients with shoulder disorders.

BACKGROUND: Responsiveness and minimal important change (MIC) are central measurement properties when interpreting scores from health questionnaires. The aim of the study was to evaluate the responsiveness and MIC of the Danish version of the shortened version the Disabilities of the Arm, Shoulder and Hand questionnaire (Quick-DASH) in patients with shoulder disorders referred to primary care physiotherapy treatment. METHODS: The study included 261 patients who completed questionnaires at baseline and 3 and 6 months follow up. Absolute and relative change scores was analysed using receiver-operating-characteristics (ROC) curve analysis with the Patient Global Impression of Change (PGIC) as external anchor. RESULTS: At both 3 and 6 months follow up, the Area under the Curve (ROC AUC) exceeded 0.70 and MIC was 9.1 and 13.6 at 3 and 6 months respectively. CONCLUSION: The Danish version of the Quick-DASH demonstrated adequate ability to measure changes in disability over 3 and 6 months in patients with shoulder disorders undergoing primary care physiotherapy treatment.