The Need for Multidimensional Stratification of Chronic Low Back Pain (LBP).

MINI: The authors wanted to determine which existing primary-care low back pain stratification schema is associated with distinct subpopulations. Initial stratification by DMPP identified potentially distinct epidemiological groups. DMPP stratification resulted in discrimination beyond that provided by disability or chronicity risk stratification alone. STUDY DESIGN: A cross-sectional study of Canadian patients suffering from low back pain (LBP) seeking primary care. OBJECTIVE: The aim of this study was to determine which existing primary care LBP stratification schema is associated with distinct subpopulations as characterized by easily identifiable primary epidemiological factors. SUMMARY OF BACKGROUND DATA: LBP is among the most frequent reasons for visits to primary care physicians and a leading cause of years lived with disability. In an effort to improve treatment response/outcomes in LBP primary care, different classification systems have been proposed in an effort to provide more tailored treatment with the intent of improving outcomes. Group-specific risk factors and underlying etiology might suggest a need for, or inform, changes to treatment approaches to optimize LBP outcomes. METHODS: Stratification by dominant mechanical pain patterns; chronicity risk; disability severity. Multinomial logistic regression was used to identify the system showing greatest variability in associations with age, sex, obesity, and comorbidity. Once identified, the remaining schemas were incorporated into the model. RESULTS: N = 970; mean age: 50 years (range: 18-93); 56% female. Stratification by pain pattern revealed greater variability. Adjusted analysis: Increasing age was associated with greater odds of intermittent, extension-based back- or leg-dominant pain [odds ratio (OR): 1.02 and 1.06; P < 0.01]; being male with leg-dominant pain (ORs > 2; P < 0.01). Overweight/obesity was associated with extension-based leg-dominant pain (OR = 2.6; P < 0.02) and increasing comorbidity with extension-based back-dominant pain (OR = 1.3; P < 0.01). Severe disability was associated only with constant leg pain (OR = 3.9; P < 0.01), and high chronicity risk with extension-based leg-dominant pain (OR = 0.4; P = 0.03). CONCLUSION: Dominant mechanical symptom stratification resulted in further discrimination of an epidemiologically distinct and a large subgroup of LBP patients not identified by disability or chronicity risk stratification alone. Findings suggest a need for primary care initiated multidimensional stratification in chronic LBP. LEVEL OF EVIDENCE: 3.

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings.

BACKGROUND: The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings. METHODS: We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded. RESULTS: Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals. CONCLUSION: Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.

CONTEXTE: Les cliniques interprofessionnelles d'évaluation de la colonne vertébrale et d'éducation (Inter-professional Spine Assessment and Education Clinics [ISAEC]) ont été mises sur pied pour améliorer les soins primaires d'évaluation, d'éducation et de prise en charge des patients atteints de symptômes persistants ou récurrents de lombalgie. Cette étude a pour but d'évaluer l'effet des ISAEC sur l'accès à une évaluation chirurgicale et sur la pertinence et l'efficacité de la référence des patients en milieux ruraux, urbains et métropolitains répondant a priori aux critères de référence. MÉTHODES: Nous avons mené une étude rétrospective de données prospectives issues de cliniques du réseau des ISAEC situées à Thunder Bay, à Hamilton et à Toronto, en Ontario. Nous avons retenu pour l'étude les patients répondant aux critères de référence en chirurgie; pour chacun de ces patients, nous avons consigné le temps d'attente pour obtenir une évaluation chirurgicale, les images obtenues par résonance magnétique (IRM) aux fins de référence et la pertinence de la référence. RÉSULTATS: Au total, 422 patients, soit 10 % des patients des ISAEC au cours de la période étudiée, ont été dirigés en évaluation chirurgicale. Les temps d'attente moyens pour obtenir une évaluation chirurgicale étaient de 5,4 semaines, de 4,3 semaines et de 2,2 semaines dans les centres métropolitains, urbains et ruraux, respectivement. Le recours à l'IRM aux fins de référence a diminué de 31 % par rapport à la situation initiale. Parmi les patients référés en évaluation chirurgicale formelle, 80 % présentaient une douleur principalement localisée dans les jambes. La référence de 96 % des patients a été jugée adéquate. CONCLUSION: Même si les ressources en soins de santé sont concentrées en milieu métropolitain, c'est le milieu rural qui a connu la plus grande baisse du temps d'attente. La mise sur pied d'un modèle de soins partagés en réseau pour les patients aux prises avec des symptômes de lombalgie a amélioré l'accès aux évaluations chirurgicales de façon significative, malgré la variété géographique des milieux de pratique et les divers obstacles rencontrés. Les baisses les plus importantes ont été observées en milieu rural. De plus, des améliorations significatives de la pertinence et de l'efficacité des références ont été observées lors de la comparaison avec les rapports antérieurs, pour tous les sites de l'étude.