Public and private health service in Norway: a comparison of patient characteristics and surgery criteria for patients with nerve root affections due to discus herniation.

PURPOSE: To compare sociodemographic, life style and clinical characteristics in patients operated for lumbar disc herniation in public and private clinics in Norway, and evaluate whether selection for surgery and surgical treatment were different across the two settings. METHODS: A cross-sectional multicenter study of patients who underwent elective surgeries for lumbar disc herniation at 41 (31 public and 10 private) hospitals. Data were included in the Norwegian Registry for Spine Surgery. RESULTS: Of the 5,308 elective surgical procedures, 3,628 were performed at public hospitals and 1,680 at private clinics. Patients in the private clinics were slightly younger, more likely to be man, have higher level of education, and more likely to be employed. Disability and retirement pensions were more than double in the public as compared to the private clinics. Mean duration of sick leave was 24 weeks (SD 36.4) in the public and 15 weeks (20.7) in the private clinics. There were minor differences in pain, disability and quality-of life, number of verified disc herniations and radiological findings. Number of days at hospital, total operation time and proportion of complications were significantly higher in the public than in the private clinics. CONCLUSION: Patients having elective surgery due to lumbar disc herniation in public and private clinics were different with respect to many sociodemographic and life style variables. There were minor differences with respect to clinical variables and selection of patients for surgery, but substantial differences related to aspects of the surgical treatment.

[What do Norwegian media communicate about back pain?]. / Hva skriver norske aviser og ukeblader om vond rygg?

BACKGROUND: Mass media influence peoples' attitudes and conduct. We set out to investigate what Norwegian mass media write about back pain and whether this information is in accordance with national interdisciplinary guidelines for low back pain (published in 2002). MATERIAL AND METHODS: Quantitative content analysis of 495 news stories from Norwegian newspapers and magazines published in 2001-03 and 2005-06. RESULTS: Most publications were about a single case. Risk factors for low back pain, examinations, treatment and prevention were frequent topics. No publication was in direct disagreement with the clinical guidelines. Dependent on the media type, 44 to 62 % of the publications supported the guidelines' main messages of regaining daily normal activities, including work and exercises, as soon as possible. INTERPRETATION: Norwegian mass media communicate evidence-based information about low back pain to a large extent. We regard these media as collaborators in the communication of important recommendations in guidelines about low back pain.

[Low back pain--still a clinical challenge]. / Vond rygg--fortsatt en klinisk utfordring.

BACKGROUND: Low back pain is a challenge in daily clinical activity. The prognosis for single episodes of acute pain is good, but many patients have persistent/recurrent illness, often characterized by a complex pattern of somatic, psychological and social factors. The aim of this article is to present the evidence-based recommendations in the Norwegian clinical guidelines and to discuss new knowledge. MATERIAL AND METHODS: The Norwegian guidelines for diagnosis and treatment of low back pain of 2007, are based on literature searches that were completed in 2005. This article presents the main content of those national guidelines and assessment of new knowledge based on more recent Cochrane reviews and relevant articles. RESULTS: Low back pain can be categorized according to development over time, etiology or a diagnostic triad with so-called red, green or yellow flags. Diagnostic imaging is recommended after four to six weeks duration without improval. A main treatment goal is to provide early and sufficient pain reduction. It is also important to regain normal daily activities as soon as possible. INTERPRETATION: Low back pain often resolves without treatment within a few weeks. Adequate diagnostic categorization and good pain alleviation is possible with simple means in most patients. Simple diagnostic measures can help to identify individuals with serious pathology.

Health care providers communicate less well with patients with chronic low back pain--a study of encounters at a back pain clinic in Denmark.

We aimed to study the quality of communication between health care providers and patients with low back pain with emphasis on information giving in a back pain clinic, including if characteristics of patients could be associated with communication quality. We videotaped 79 encounters in which 21 providers informed patients about the results of magnetic resonance imaging of the back. Background information about the patients was collected by questionnaires and interview after the encounter. Videotapes were analysed with the Four Habits Coding Scheme (4HCS) in which higher scores mean better communication. There were strong negative correlations between 4HCS scores and the duration of back pain, and patient age. The results were significant for all professional subgroups (doctors, physiotherapists, chiropractors). Communication quality in encounters with back pain patients is worse, the longer the patient has suffered pain. Poor communication quality also seems to be associated with patients being older.

Low back pain media campaign: no effect on sickness behaviour.

OBJECTIVE: To evaluate the effect of a media campaign on popular beliefs about LBP, and eventual changes in sick leave, imaging examinations, and surgery. METHODS: Quasi-experimental telephone survey of 1500 randomly chosen people before, during, and after a media campaign in two Norwegian counties, with residents of an adjacent county as the control group. Data on sickness absence, surgery rates for disc herniation and imaging examinations on LBP in the area were collected at the same intervals. RESULTS: The campaign led to a small but statistically significant shift in beliefs about LBP in the general public. In particular, beliefs about the use of X-rays, and the importance of remaining active and at work, seemed to have changed in response to the campaign messages. However, this change in attitude and understanding of the condition did not lead to any corresponding change in sickness behaviour. CONCLUSIONS: Although the media campaign seemed to somewhat improve beliefs about LBP in the general public, the magnitude of this was too small to produce any significant change in behaviour. PRACTICE IMPLICATIONS: A media campaign on LBP should not be limited to small areas and low-budget. A much larger investment is needed for a media campaign to have sufficient impact on public's beliefs on LBP to lead to altered sickness behaviour.

Peer support in an occupational setting preventing LBP-related sick leave.

BACKGROUND: Low back pain (LBP) is among the most frequent causes of sickness absence in Norway, and it is thought that it could be reduced by 30-50% if present day knowledge was implemented in the workplace. Evidence-based interventions in occupational settings to prevent sickness absence are still lacking. AIM: To evaluate whether peer support would be able to modify general beliefs about LBP, pain experiences, health care utilization and sickness absence due to back pain. METHODS: In addition to a media campaign in two Norwegian counties in 2002-05, aiming at improving beliefs about LBP in the general public, the 'Active Back' project trained a peer adviser in six participating workplaces. The task of this peer adviser was to provide information aimed at reducing fear of the pain, supportive advice and arrange for modifications of workloads, etc., for a limited period of time. RESULTS: The prevalence of back pain remained constant throughout the study period, but self-reported intensity of LBP decreased at the end. There was a small decline in use of health care professionals and significant improvements in beliefs, in line with the messages of the campaign. Total sickness absence decreased by 27% and the LBP-related sickness absence by 49%. CONCLUSION: The combination of peer support and modified workload seemed to have additional effects to the general media campaign, and resulted in decline in sickness absence and improvements in beliefs about back pain.

A randomized study of new sling exercise treatment vs traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims.

BACKGROUND: Many patients with chronic whiplash-associated disorders have reduced neuromuscular control of the neck and head. It has been proposed that a new sling exercise therapy may promote neuromuscular control of the neck. OBJECTIVES: To compare the effects of traditional physiotherapy vs traditional physiotherapy combined with a new sling exercise therapy on discomfort and function in patients with chronic whiplash-associated disorders who have unsettled compensation claims; and to investigate possible additional effects of guided, long-term home training. DESIGN: A randomized multi-centre trial with 4 parallel groups. METHODS: A total of 214 patients were assigned randomly to 4 treatment groups, and received either traditional physiotherapy with or without home training, or new sling exercise therapy with or without home training. Outcome measures were pain, disability, psychological distress, sick leave and physical tests. RESULTS: A total of 171 patients (80%) completed the study. There were no important statistical or clinical differences between the groups after 4 months of treatment. There was a small statistically significant effect at 12-month follow-up in both groups with home training regarding pain during rest (p = 0.05) and reported fatigue in the final week (p = 0.02). CONCLUSION: No statistically significant differences were found between the traditional physiotherapy group and the new sling exercise group, with or without home training. Since the groups were not compared with a control group without treatment, we cannot conclude that the studied treatments are effective for patients with whiplash-associated disorder, only that they did not differ in our study.

Prevalence of low back pain and sickness absence: a "borderline" study in Norway and Sweden.

AIMS: Low back pain (LBP) is a major public health problem in both Norway and Sweden. The aim of the study was to estimate the prevalence of LBP and sickness absence due to LBP in two neighbouring regions in Norway and Sweden. The two areas have similar socioeconomic status, but differ in health benefit systems. METHODS: A representative sample of 1,988 adults in Norway and 2,006 in Sweden completed questionnaires concerning LBP during 1999 and 2000. For this study only individuals in part or full time jobs, (n = 1,158 in Norway and n = 1,129 in Sweden) were included. RESULTS: In Norway the lifetime prevalence was 60.7% and in Sweden 69.6%, the one-year prevalence was 40.5% and 47.2%, and the point prevalence 13.4% and 18.2% respectively. There was a significantly higher risk of reporting LBP in Sweden, even after controlling for gender, age, education, and physical workload. There was no difference in risk of self-certified short-term sickness absence (1-3 days), but it was a 40% lower risk of sickness absence with medical sickness certification in Sweden compared with Norway. CONCLUSION: The prevalence of LBP was higher in the Swedish area than in the Norwegian. The risk of self-certified sickness absence, however, showed no differences and the risk of medically certified sickness absence was lower in the Swedish area. This contradiction might partly be explained by the economical "disincentives" in the Swedish health compensation system.

What is "the good back-consultation"? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists.

OBJECTIVE: To identify core elements of what patients with chronic low back pain perceive as good clinical communication and interaction with a specialist ("The Good Back-Consultation"). DESIGN: Qualitative study including observation of consultations and a subsequent patient interview. Quantitative data were also recorded. SUBJECTS: Thirty-five patients with chronic low back pain referred to a specialist. METHODS: Thirty-five consultations were observed with respect to history-taking, clinical examination and interaction between patient and doctor. Patients were subsequently interviewed about how they perceived the consultation. Fourteen specialists with various specialty branches and 35 patients (18 males) participated. For 3 of the specialists a positive effect (return to work) on patients with chronic low back pain had been documented in previous randomized controlled trials. Qualitative data analysis was performed using a template method. RESULTS: Most patients thought that the history-taking and clinical examination had been thorough and satisfactory. Patients emphasized the importance of being given an explanation during the examination of what was being done and found, of receiving understandable information on the causes of the pain, of receiving reassurance, discussing psychosocial issues and discussing what can be done. The most important characteristic of "The Good Back-Consultation" was that the specialist took the patient seriously. CONCLUSION: The findings may represent an important potential for enhancing clinical communication with patients.

Beliefs about low back pain in the Norwegian general population: are they related to pain experiences and health professionals?

STUDY DESIGN: A baseline study of the general population and the health care providers in 3 Norwegian counties. OBJECTIVE: To investigate if beliefs about low back pain (LBP) are related to personal experiences and profession sought for care. SUMMARY OF BACKGROUND DATA: Myths about LBP that are abandoned by health professionals are still alive in the public. Such myths represent pain avoidance beliefs and passive coping strategies that may hinder normal spontaneous recovery from an episode of LBP. METHODS: A sample of 1502 randomly selected people was interviewed by telephone, and all the 1105 physicians, physiotherapists, and chiropractors in the area were sent a questionnaire in April 2002. All respondents gave their responses in terms of degree of agreement to 6 statements reflecting beliefs about LBP. RESULTS: Personal back pain experiences were important for beliefs about LBP. People with a history of previous back pain had more faith in the 2 statements "Back pain recovers best by itself" (52.2%) and "In most cases back pain recovers by itself in a couple of weeks" (32.5%) than those with current pain (36.9% and 20.9%, respectively, P < 0.000). There were significant differences in beliefs between physicians and the chiropractors concerning the same 2 statements, and these differences were also reflected in the beliefs of patients treated by the different professional groups. CONCLUSIONS: Belief in spontaneous recovery from LBP seems to be positively correlated to previous experience with LBP without current pain. Patients of the various health care providers seem to have a faith in spontaneous recovery similar to that of their health care provider. These differences may frustrate the public and patients who visit more than one provider, and hinder collaboration among professional groups.

The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a randomized clinical trial.

STUDY DESIGN: A randomized clinical trial. OBJECTIVES: To examine the effects of a treatment program focusing on specific stabilizing exercises after a 2-year follow-up period. SUMMARY OF BACKGROUND DATA: An individualized treatment approach with specific stabilizing exercises is shown to be effective for women with pelvic girdle pain 1 year after delivery. No previous study has examined the long-term effects of treatment for women with postpartum pelvic girdle pain. METHODS: Eighty-one women with pelvic girdle pain postpartum were assigned randomly to 2 treatment groups for 20 weeks. Patient self-reported questionnaires measuring pain, disability, and health-related quality of life were collected after 20 weeks of treatment and 1 and 2 years postpartum. RESULTS: All 81 women returned the questionnaires for the 2-year follow-up. Sixteen were excluded from the analysis, mainly due to new pregnancies. The significant differences between the groups in functional status, pain, and physical health (SF-36) were maintained 2 years after delivery. Minimal disability was found in 85% of the specific stabilizing exercise group as compared to 47% in the control group. The control group showed significant improvement in functional status with median change score of 6.0 (Q1-Q3 of -12-0). Minimal evening pain was reported by 68% in the specific stabilizing exercise group versus 23% in the control group. However, the group differences disappeared for all measures when controlling for score level 1 year after delivery by regression analysis. CONCLUSION: The significant differences between the groups persisted with continued low levels of pain and disability in the specific stabilizing exercise group 2 years after delivery. Significant reduction in disability was found within the control group. Those with the highest level of disability and greatest potential for improvements recovered most, regardless of intervention group.

The Patient Perspective Survey (PPS): a new tool to improve consultation outcome and patient involvement in general practice patients with complex health problems. Psychometric testing and development of a final version.

The Patient Perspective Survey (PPS) is designed to enhance consultation outcome and patient participation among general practice patients with complex health problems. This article presents the final version of the survey. This version is more condensed, tested for psychometric and clinical properties, and with increased emphasis on coping. The development and testing was performed in two phases with two groups of GPs and patients. Indications for use and criteria for rejection of items were defined, based on comprehensive data analysis and clinical judgement. The number of items was reduced to 38 items. The majority of diagnoses were related to psychosocial or musculoskeletal disorders. For the survey's main dimensions (psychological and somatic items, everyday life situation and coping) sound psychometric properties were identified. Seven open-ended questions were found useful for obtaining important new information and stimulating processes, often related to coping aspects. The revised 38-item PPS represents a condensed and final version, with increased focus on coping, and sound psychometric properties.

The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial with stratified block design. OBJECTIVES: To evaluate a treatment program focusing on whether specific stabilizing exercises for patients with pelvic girdle pain after pregnancy reduce pain, improve functional status, and improve quality of life. SUMMARY OF BACKGROUND DATA. : The evidence of effectiveness of treatment for pelvic girdle pain is weak. Recent research has focused on the importance of activation of muscles for motor control and stability of the lumbopelvic region. To the authors' knowledge, the efficacy of applying these principles for pelvic girdle pain has not previously been evaluated in a randomized controlled trial. METHODS: Eighty-one women with pelvic girdle pain were assigned randomly to two treatment groups for 20 weeks. One group received physical therapy with a focus on specific stabilizing exercises. The other group received individualized physical therapy without specific stabilizing exercises. Assessments were administered by a blinded assessor, at baseline, after intervention and 1 year post partum. Main outcome measures were pain, functional status and quality of life. RESULTS: There were no dropouts. After intervention and at 1 year post partum, the specific stabilizing exercise group showed statistically and clinically significant lower pain intensity, lower disability, and higher quality of life compared with the control group. Group difference in median values for evening pain after treatment was 30 mm on the Visual Analog Scale. Disability was reduced by more than 50% for the exercise group; changes were negligible in the control group. Significant differences were also observed for physical tests, in favor of the specific exercise group. CONCLUSION: An individualized treatment approach with specific stabilizing exercises appears to be more effective than physical therapy without specific stabilizing exercises for women with pelvic girdle pain after pregnancy.

[Multidisciplinary outpatient clinics for back pain patients--a new treatment program]. / Tverrfaglige ryggpoliklinikker--et nytt behandlingstilbud.

Chronic low back pain (LBP) represents a major health problem, especially in Western Europe and North America. The aim of this study is to give an account of why a multidisciplinary treatment program in an outpatient spine clinic is the best treatment for many sub-acute and chronic LBP patients on long-term sick leave. We present an overview of documented treatment effects from multidisciplinary treatment programmes, an outline of the treatment in an outpatient spine clinic, and an account of why multidisciplinary programs are beneficial. The treatment of this patient group is also shown to be cost-effective when one differentiates between light and extensive multidisciplinary programmes. A future challenge rests in the fact that even after optimal treatment, approximately 20 % of patients still do not return to work.

Factors associated with high prescribing of benzodiazepines and minor opiates. A survey among general practitioners in Norway.

OBJECTIVE: To determine the factors associated with high-volume prescribing of benzodiazepines and minor opiates--background characteristics, personal prescribing habits and general attitudes to prescribing. DESIGN: A questionnaire survey. Descriptive statistics, bivariate analysis and multiple logistic regression. SETTING: General practitioners in Norway. SUBJECTS: Every third general practitioner from the list of members of the Norwegian Medical Association. MAIN OUTCOME MEASURES: Odds ratios for being a high prescriber. RESULTS: The main predictors of high-volume prescribing were: patients allowed to influence prescribing decisions, benzodiazepines and minor opiates prescribed without consultation, prescribing perceived as difficult and the doctor being male. CONCLUSION: Emotional and relational aspects play an important part in decisions on prescribing benzodiazepine and minor opiates. Our findings indicate that there is potential for improvement in prescribing practice; for instance, by investigating how and to what extent prescribing decisions are influenced by patients and how the difficulties experienced influence the decision process. Better practice routines could be considered such as not prescribing these drugs without consultation.