ABSTRACT
STUDY DESIGN: Prospective study. PURPOSE: Yellow flags are psychosocial associated with a greater likelihood of progression to persistent pain and disability. These are referred to as obstacles to recovery. Despite their recognized importance, it is unknown how effective clinicians are in detecting them. The primary objective of this study was thus to determine the effectiveness of spine specialist clinicians in detecting the presence of yellow flags in patients presenting to an orthopedic outpatient clinic with low back-related disorders. OVERVIEW OF LITERATURE: Psychosocial factors have been previously studied as important predictors of prognosis in patients with low back pain. However, the ability of spinal specialist to identify them remains unknown. METHODS: A prospective, single-center, consecutive cohort study was conducted over a period of 30 months. All new patients with low back-related disorders regardless of pathology completed a Yellow Flag Questionnaire that was adapted from the psychosocial flags framework. Clinicians assessing these patients completed a standardized form to determine which and how many yellow flags they had identified during the consultation. RESULTS: A total of 130 patients were included in the analysis, and the clinicians reported an average of 5 flags (range, 0-9). Fear of movement or injury was the most frequently reported yellow flag, reported by 87.7% (n=114) of patients. Clinician sensitivity in detecting yellow flags was poor, correctly identifying only 2 flags, on average, of the 5 reported by patients, with an overall sensitivity of only 39%. CONCLUSIONS: The ability of spine specialists to identify yellow flags is poor and can be improved by asking patients to complete a simple screening questionnaire.
ABSTRACT
STUDY DESIGN: Triple blind randomized controlled study. OBJECTIVE: To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Etanercept is a selective competitor of tumor necrosis factor-alpha which is a proinflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease. METHODS: Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on magnetic resonance imaging scan. Exclusions were previous back surgery, spinal stenosis and any contraindications to the use of etanercept such as immunosuppression. The patient, the injector, and assessor were blinded to the agent being used. Follow-up was at 6 weeks and 3 months posttreatment. Oswestry disability index and visual analog scores were among the assessment criteria. RESULTS: Fifteen patients were recruited in a 4 years period with a 3 months follow-up of 80%. The etanercept group had 8 patients whereas the placebo group had 7. The average Oswestry disability index for the etanercept group preintervention was higher than that in the placebo group (53.6 vs. 50.4) and this remained the same after 6 weeks (46.1 vs. 31.2) and 3 months of follow-up (37 vs. 35). Visual analog score was also higher in the etanercept group versus placebo; preinjection (8.6 vs. 7.4), 6 weeks (5.0 vs. 3.8), and 3 months (4.8 vs. 4.5). CONCLUSIONS: Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of etanercept over placebo in the pharmacologic treatment of sciatica.
Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/administration & dosage , Immunoglobulin G/administration & dosage , Receptors, Tumor Necrosis Factor/administration & dosage , Sciatica/drug therapy , Tumor Necrosis Factor-alpha/antagonists & inhibitors , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Disability Evaluation , Double-Blind Method , Etanercept , Female , Humans , Immunoglobulin G/adverse effects , Inflammation/drug therapy , Inflammation/pathology , Inflammation/physiopathology , Intervertebral Disc Displacement/complications , Male , Pain Measurement , Placebos , Radiculopathy/drug therapy , Radiculopathy/pathology , Radiculopathy/physiopathology , Sample Size , Sciatica/etiology , Sciatica/physiopathology , Spinal Nerve Roots/drug effects , Spinal Nerve Roots/pathology , Spinal Nerve Roots/physiopathology , Spondylosis/complications , Treatment Failure , Tumor Necrosis Factor-alpha/metabolismABSTRACT
BACKGROUND: To reduce outpatient waiting times, a growing number of outpatient clinics for selected groups of patients are being provided by GPs with special interests (GPwSIs). AIM: To determine whether there are differences in patient satisfaction or clinical outcome among patients attending orthopaedic clinics provided by GPwSIs in hospital or community settings. DESIGN OF STUDY: Randomised controlled trial. SETTING: Hospital outpatient departments or general practices. METHOD: Three hundred and twenty-one patients with minor orthopaedic problems were referred by GPs to the orthopaedic surgery department of the University Hospitals of Leicester NHS Trust; 168 patients were randomised to care by GPwSIs in practices, and 153 were randomised to care by the same GPwSIs in clinics held at hospital outpatient departments. Patients completed the SF-36v2 and satisfaction questionnaires at their first appointment, and again 3 months later. RESULTS: There was no significant difference between the sites in changes in health. After the first clinic attendance, patients attending practice-based clinics were more satisfied with access to appointments and information received. CONCLUSION: For selected orthopaedic referrals seen by GPwSIs, there were no significant differences in clinical outcomes between practice-based and hospital-based clinics, but some features of practice-based clinics tend to be preferred by patients.
