Recurrence of low back pain: A difficult outcome to predict. Development and validation of a multivariable prediction model for recurrence in patients recently recovered from an episode of non-specific low back pain.

BACKGROUND: Recurrence of low back pain (LBP) is common. If clinicians could identify an individual's risk of recurrence, this would enhance clinical decision-making and tailored patient care. OBJECTIVE/DESIGN: To develop and validate a simple tool to predict the probability of a recurrence of LBP by 3- or 12-months following recovery. METHODS: Data utilised for the prediction model development came from a prospective inception cohort study of participants (n = 250) recently recovered from LBP, who had sought care from chiropractic or physiotherapy services. The outcome measure was a recurrence of activity-limiting LBP. Candidate predictor variables (e.g., basic demographics, LBP history, levels of physical activity, etc) collected at baseline were considered for inclusion in a multivariable Cox model. The model's performance was tested in a separate validation dataset of participants (n = 261) involved in a randomised controlled trial investigating exercise for the prevention of LBP recurrences. RESULTS: The final model included the number of previous episodes, total sitting time, and level of education. In the development sample, discrimination was acceptable (Harrell's C-statistic = 0.61, 95% CI, 0.59-0.62), but in the validation sample, discrimination was poor (0.56, 95% CI, 0.54-0.58). Calibration of the model in the validation dataset was acceptable at 3 months but was less precise at 12 months. CONCLUSION: The developed prediction model, which included number of previous episodes, total sitting time, and level of education, did not perform adequately in the validation sample to recommend its use in clinical practice. Predicting recurrence of LBP in clinical practice remains challenging.

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.

Bladder-sparing Radiotherapy for Muscle-invasive Bladder Cancer: A Qualitative Study to Identify Barriers and Enablers.

AIMS: Bladder-sparing radiotherapy for muscle-invasive bladder cancer (MIBC) may be underutilised in North America. To understand factors driving practice we used the Theoretical Domains Framework (TDF) to identify barriers and enablers of bladder-sparing radiotherapy utilisation. MATERIALS AND METHODS: A convenience sample of Canadian urologists, medical oncologists and radiation oncologists participated in individual semi-structured 1 h interviews. An interview guide was developed using the TDF to assess barriers and enablers of bladder-sparing radiotherapy use. Interviews were recorded and transcribed. Two investigators independently identified barriers and enablers and assigned them to specific themes. Participant recruitment continued until saturation. RESULTS: In total, 71 physicians were invited to participate and 34 (48%) agreed to be interviewed; 13 urologists, 11 radiation oncologists and 10 medical oncologists. We identified the following barriers to the use of bladder-sparing radiotherapy (relevant TDF domains in parentheses): (1) beliefs that radiotherapy has inferior survival compared with cystectomy (beliefs about consequences); (2) lack of referral from urology to radiation oncology (behavioural regulation; memory, attention and decision-making); (3) lack of 'champions' who advocate for radiotherapy (social and professional role); and (4) inadequate multidisciplinary collaboration (environmental context and resources). Predominant enablers to the use of bladder-sparing radiotherapy included: (1) 'champions' who believe in the value of radiotherapy (social and professional role); (2) beliefs by urologists that radiation oncologists should present radiotherapy options to all patients (social and professional role); (3) institutional policy that all MIBC patients should be seen by multiple specialists (environmental context and resources); (4) system facilitators of radiation oncology referral (i.e. nurse navigator) (environmental context and resources); and (5) patient-driven consultations seeking alternatives to cystectomy (social influences). CONCLUSIONS: These findings identify important barriers and enablers to the use of bladder-sparing radiotherapy in MIBC. Physician beliefs, access to multidisciplinary care and institutional context should be considered in efforts to increase the use of bladder-sparing radiotherapy.

Understanding patient beliefs regarding the use of imaging in the management of low back pain.

BACKGROUND: Imaging for low back pain (LBP) remains common despite guidelines recommending against routine imaging. Patient beliefs about imaging may contribute to the problem. This study aimed to quantitatively investigate patient beliefs regarding the need for imaging in managing LBP and to investigate whether personal characteristics, pain characteristics or back pain beliefs are associated with imaging beliefs. METHODS: A survey was performed of consecutive patients presenting to general medical practitioners in Sydney, Australia. Nine medical clinics were selected across varied socioeconomic regions. Survey questions assessed beliefs about the importance of imaging for LBP, collected demographic information, LBP history and general beliefs about back pain. Descriptive statistics and multivariate logistic regression were used to analyse findings. RESULTS: Three hundred completed surveys were collected with a 79.6% response rate. The mean age was 44 years and 60.7% of respondents were women. Exactly, 54.3% (95% CI: 48.7-58.9%) believed that imaging was necessary for the best medical care for LBP. Exactly, 48.0% (95% CI: 42.4-53.6%) believed that everyone with LBP should obtain imaging. Increased age, lower education level, non-European or non-Anglo-saxon cultural background, history of previous imaging and Back Beliefs Questionnaire scores were associated with beliefs that imaging was necessary. CONCLUSION: Approximately, half of all patients presenting to a medical doctor consider low back imaging to be necessary. This may have important implications for overutilization of low back imaging investigations. Knowledge of the factors associated with the patient's belief that imaging is necessary may be helpful in designing appropriate interventions to reduce unnecessary imaging for LBP.

Evidence-based practice in chiropractic practice: A survey of chiropractors' knowledge, skills, use of research literature and barriers to the use of research evidence.

BACKGROUND: Scant research has been undertaken regarding chiropractors' skills and knowledge associated with evidence-based practice (EBP), and their perceived barriers to EBP. These issues appear to have been examined in only one small qualitative study and one small study of chiropractors holding orthopaedic diplomas. The lack of research in this area suggests that additional studies are warranted to develop a better understanding of factors that affect chiropractors' use of research evidence in clinical practice. METHODS: We used a modified online questionnaire that captured information regarding EBP skills and knowledge, and barriers to EBP. Its adaption was informed by the use of a content validity panel. The questionnaire was disseminated through email by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring knowledge and skills with items measuring: age; years since registration; reading research literature; and use of research literature in clinical decision-making. RESULTS: 584 respondents returned questionnaires. About half of the respondents stated they had learned the foundations of EBP (56.6%) during their undergraduate training. Slightly more than two thirds of the respondents were confident in their ability to critically review literature (69.5%) and find relevant research to answer clinical questions (72.6%). The most common factors involved with reading more research, and increased use of research literature in clinical decision-making, were confidence in critical appraisal skills and confidence in finding relevant research literature. Conclusion Educational interventions should be implemented to enhance Australian chiropractors' fundamental EBP skills.

Superficial heat or cold for low back pain.

BACKGROUND: Heat and cold are commonly utilised in the treatment of low-back pain by both health care professionals and people with low-back pain. OBJECTIVES: To assess the effects of superficial heat and cold therapy for low-back pain in adults. SEARCH STRATEGY: We searched the Cochrane Back Review Group Specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005) and other relevant databases. SELECTION CRITERIA: We included randomised controlled trials and non-randomised controlled trials that examined superficial heat or cold therapies in people with low-back pain. DATA COLLECTION AND ANALYSIS: Two authors independently assessed methodological quality and extracted data, using the criteria recommended by the Cochrane Back Review Group. MAIN RESULTS: Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days (weighted mean difference (WMD) 1.06, 95% confidence interval (CI) 0.68 to 1.45, scale range 0 to 5) compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application (WMD -32.20, 95%CI -38.69 to -25.71, scale range 0 to 100). One trial of 100 participants with a mix of acute and sub-acute low-back pain examined the additional effects of adding exercise to heat wrap, and found that it reduced pain after seven days. There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain. AUTHORS' CONCLUSIONS: The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomised controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain.

OBJECTIVE: To assess the intraexaminer and interexaminer reliability of a multidimensional spinal diagnostic method commonly used by chiropractors. DESIGN: An intraexaminer and interexaminer Latin square, repeated measures reliability study. The techniques of diagnosis under investigation included visual postural analysis, pain description by the patient, plain static erect x-ray film of the lumbar spine, leg length discrepancy, neurologic tests, motion palpation, static palpation, and orthopedic tests. PARTICIPANTS: Three experienced chiropractors examined 19 patients, and 2 experienced chiropractors examined 10 and 9 patients, respectively, who were suffering from chronic mechanical low-back pain. RESULTS: Intraexaminer reliability of the decision to manipulate a certain spinal segmental level was moderate (kappa = 0.47). The interexaminer agreement pooled across all spinal joints indicated fair agreement (kappa = 0.27). Interexaminer reliability for individual examiner pairs for the L4/L5 segmental level was slight (kappa = 0.09). At the L5/S1 level, the interexaminer reliability was fair (kappa = 0.25). For the sacroiliac joints, interexaminer reliability was slight (kappa = 0.04 and 0.14). CONCLUSION: This study of commonly used chiropractic diagnostic methods in patients with chronic mechanical low-back pain to detect manipulable lesions in the lower thoracic spine, lumbar spine, and the sacroiliac joints has revealed that the measures are not reproducible. The implementation of these examination techniques alone should not be seen by practitioners to provide reliable information concerning where to direct a manipulative procedure in patients with chronic mechanical low-back pain.

Chiropractic and osteopathic education at Royal Melbourne Institute of Technology. A student perspective.

OBJECTIVE: To assess the attitudes of undergraduate chiropractic and osteopathic students at Royal Melbourne Institute of Technology (RMIT) in 1992 on the education they are receiving and on the effectiveness of chiropractic and osteopathic care. DESIGN: Cross-sectional descriptive survey. PARTICIPANTS: Undergraduate chiropractic and osteopathic students enrolled at RMIT School of Chiropractic and Osteopathy in 1992. RESULTS: This study surveyed 272 students, 196 who were chiropractic students and 76 who were osteopathic students from RMIT School of Chiropractic and Osteopathy in Melbourne, Australia. The students that responded represented 73.4% of chiropractic students and 85.4% of osteopathic students currently enrolled in their respective courses. Chiropractic and osteopathic students entered their respective courses from non-chiropractic/non-osteopathic families. More chiropractic students than osteopathic students (1.3:1.0) had their respective course as their first choice when applying for tertiary education. A majority (95.8 chiropractic students and 94.8% osteopathic students) of both groups surveyed were pleased with their choice of course. Students from both disciplines held considerable respect for each other in the care of certain conditions, but did not see the other profession's care as effective as their own. A greater percentage of osteopathic students believed there was sufficient difference between chiropractic and osteopathy to justify two separate professions (57.6% compared to 97.2%). DISCUSSION: High quality education is a major aim in our schools and colleges. For this standard to be maintained it requires continual re-evaluation and assessment. Surveys such as this should be performed regularly as a method of evaluating student attitude and how these attitudes change during the course. This would also allow administrators to determine whether they are achieving their academic intentions. An immediate follow up survey asking the same questions is suggested to ascertain whether the same attitudes exist today.

A CASE OF LEPTOMENINGEAL DISEASE PRESENTING AS A LUMBAR NERVE ROOT RADICULOPATHY: A Case Report.

Objective: To discuss a case of leptomenigeal disease mimicking a lower lumbar disc lesion and accompanying neurological deficit.Clinical Features: A 62 year old male presented with a 3-4 day history of left low back and left posterior thigh pain. The patient had a previous history of non-specific low back pain for approximately 10-25 years, which was relieved in the past by manual therapy. He was also currently being treated by a medical oncologist with chemotherapy for low grade non-Hodgkin's lymphoma, which was considered stable.Intervention and Outcome: After a favourable initial response to therapy, the patient developed a noticeable left-sided limp. Computed tomography scanning of the lumbar spine and pelvis was then performed, which revealed a mild posterior annular bulging of the intervertebral disc at the L4/5 level. The patient was then treated with axial lumbar spine traction but on review two days later had also developed a left sided facial droop, consistent with a Bell's palsy. A subsequent magnetic resonance imaging scan of the brain and lumbar spine revealed sites of abnormal enhancement of multiple cranial nerves, the cauda equina and the vertebral bodies L1 and L5. The findings were consistent with widespread leptomeningeal disease or leptomenigeal carcinomatosis and unfortunately the patient died as a direct consequence of the disease approximately three weeks after diagnosis.Conclusion: Although relatively rare, leptomenigeal disease must considered as a differential diagnosis in a patient with a history of carcinoma who presents with low back pain and/or any neurological signs and symptoms.

Health promotion in a primary health care setting. Neural tube defects and folate.

Primary care practitioners are ideally situated to carry out health promotion activities. Neural tube defects are of a fairly low incidence, but the consequences are tragic. They range from life long physical and often intellectual disabilities, to death at birth. Increased folate intake, either through eating folate rich foods or through supplementation, has been shown to reduce the incidence of neural tube defects in newborns by up to 75%. Encouraging all women of child-bearing age to increase their folate intake could thus prevent a significant number of neural tube defects occurring in the Australian population.

Sometimes they may be zebras: herpes zoster of the L2 spinal nerve. A case report.

This case report describes a relatively uncommon presentation of herpes zoster affecting the cutaneous distribution of the L2 spinal nerve. The coexistence of a previous history of leg pain, cortical thickening of the femoral shaft on plain film x-ray examination, and the absence, at the time of examination, of the tell tale rash of herpes zoster provided the clinician with a diagnostic challenge. Furthermore, this case stresses the importance of a thorough neurological and orthopaedic examination as well as careful visual inspection of the painful region.