Evaluation of a Canadian back pain mass media campaign.

STUDY DESIGN: Quasi-experimental before-and-after design with control group. OBJECTIVE: We evaluated a back pain mass media campaign's impact on population back pain beliefs, work disability, and health utilization outcomes. SUMMARY OF BACKGROUND DATA: Building on previous campaigns in Australia and Scotland, a back pain mass media campaign (Don't Take it Lying Down) was implemented in Alberta, Canada. A variety of media formats were used with radio ads predominating because of budget constraints. METHODS: Changes in back pain beliefs were studied using telephone surveys of random samples from intervention and control provinces before campaign onset and afterward. The Back Beliefs Questionnaire (BBQ) was used along with specific questions about the importance of staying active. For evaluating behaviors, we extracted data from governmental and workers' compensation databases between January 1999 and July 2008. Outcomes included indicators of number of visits to health care providers, use of diagnostic imaging, and compensation claim incidence and duration. Analysis included time series analysis and ANOVA testing of the interaction between province and time. RESULTS: Belief surveys were conducted with a total of 8566 subjects over the 4-year period. Changes on BBQ scores were not statistically significant, however, the proportion of subjects agreeing with the statement, "If you have back pain you should try to stay active" increased in Alberta from 56% to 63% (P = 0.008) with no change in the control group (consistently approximately 60%). No meaningful or statistically significant effects were seen on the behavioral outcomes. CONCLUSION: A Canadian media campaign appears to have had a small impact on public beliefs specifically related to campaign messaging to stay active, but no impact was observed on health utilization or work disability outcomes. Results are likely because of the modest level of awareness achieved by the campaign and future campaigns will likely require more extensive media coverage.

Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.

STUDY DESIGN: Literature review, expert panel, and a workshop during the "VIII International Forum on Primary Care Research on Low Back Pain" (Amsterdam, June 2006). OBJECTIVE: To develop practical guidance regarding the minimal important change (MIC) on frequently used measures of pain and functional status for low back pain. SUMMARY OF BACKGROUND DATA: Empirical studies have tried to determine meaningful changes for back pain, using different methodologies. This has led to confusion about what change is clinically important for commonly used back pain outcome measures. METHODS: This study covered the Visual Analogue Scale (0-100) and the Numerical Rating Scale (0-10) for pain and for function, the Roland Disability Questionnaire (0-24), the Oswestry Disability Index (0-100), and the Quebec Back Pain Disability Questionnaire (0-100). The literature was reviewed for empirical evidence. Additionally, experts and participants of the VIII International Forum on Primary Care Research on Low Back Pain were consulted to develop international consensus on clinical interpretation. RESULTS: There was wide variation in study design and the methods used to estimate MICs, and in values found for MIC, where MIC is the improvement in clinical status of an individual patient. However, after discussion among experts and workshop participants a reasonable consensus was achieved. Proposed MIC values are: 15 for the Visual Analogue Scale, 2 for the Numerical Rating Scale, 5 for the Roland Disability Questionnaire, 10 for the Oswestry Disability Index, and 20 for the QBDQ. When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures. CONCLUSION: For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients. It is hoped that these proposals facilitate the use of these measures in clinical practice and the comparability of future studies. The proposed MIC values are not the final answer but offer a common starting point for future research.

A consensus approach toward the standardization of back pain definitions for use in prevalence studies.

STUDY DESIGN: A modified Delphi study conducted with 28 experts in back pain research from 12 countries. OBJECTIVE: To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. SUMMARY OF BACKGROUND DATA: Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. METHODS: Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. RESULTS: Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. CONCLUSION: These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Work and common health problems.

This paper reviews the evidence on the relationship between work and health. It concludes that, overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term worklessness. That contrasts with increasing trends of sickness absence, long-term incapacity and ill-health retirement attributed to common health problems. It suggests that there needs to be a fundamental shift in how we think about common health problems and work--in health care, the workplace and society.

Working Backs Scotland: a public and professional health education campaign for back pain.

STUDY DESIGN: Public and professional health education campaign. OBJECTIVE: To change public beliefs about the management of back pain. SUMMARY OF BACKGROUND DATA: Within the past decade, there has been a reversal in the strategy of management of back pain, from rest to staying active. There is only one previous public health education campaign on back pain, in a workers compensation setting in Australia. METHODS: A multimedia campaign was based around 1777 radio advertisements, which were heard by 60% of adults. Information leaflets were prepared for people with back pain, for all health professionals who treat back pain, and for employers. A Web site was set up: www.workingbacksscotland.com. Structured monthly samples of 1000 adults were surveyed on their beliefs about rest or staying active, professional help sought and advice received for 2 months before the campaign and over the following 3 years. Royal Mail sickness absence rates and new awards of social security benefits for back pain were compared in Scotland versus the rest of the United Kingdom, before and after the campaign. RESULTS: There was a significant (P < 0.001) change in the balance of beliefs, from about 55% rest versus 40% staying active to about 30% rest versus 60% staying active. This occurred within 1 month of the launch and was maintained over 3 years. There was a comparable change in professional advice. There was no change in advice about work or the number who said they stayed off work. There was no effect on sickness absence or new awards of social security benefits for back pain. CONCLUSION: There was a major shift in public beliefs and professional advice but no change in work-related outcomes.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review.

STUDY DESIGN: An updated Cochrane Review. OBJECTIVES: To assess the effects of surgical interventions for the treatment of lumbar disc prolapse. SUMMARY OF BACKGROUND DATA: Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions. METHODS: Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007. RESULTS: Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy. CONCLUSION: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.

Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?

BACKGROUND: In many countries, community pharmacists can be consulted without appointment in a large number of convenient locations. They are in an ideal position to give advice to patients at the onset of low back pain and also reinforce advice given by other healthcare professionals. There is little specific information about the quality of care provided in the pharmacy for people with back pain. The main objectives of this survey were to determine the attitudes, knowledge and reported practice of English pharmacists advising people who present with acute or chronic low back pain. METHODS: A questionnaire was designed for anonymous self-completion by pharmacists attending continuing education sessions. Demographic questions were designed to allow comparison with a national pharmacy workforce survey. Attitudes were measured with the Back Beliefs Questionnaire (BBQ) and questions based on the Working Backs Scotland campaign. Questions about the treatment of back pain in the community pharmacy were written (or adapted) to reflect and characterise the nature of practice. In response to two clinical vignettes, respondents were asked to select proposals that they would recommend in practice. RESULTS: 335 responses from community pharmacists were analysed. Middle aged pharmacists, women, pharmacy managers and locums were over-represented compared to registration and workforce data. The mean (SD) BBQ score for the pharmacists was 31.37 (5.75), which was slightly more positive than in similar surveys of other groups. Those who had suffered from back pain seem to demonstrate more confidence (fewer negative feelings, more advice opportunities and better advice provision) in their perception of advice given in the pharmacy. Awareness of written information that could help to support practice was low. Reponses to the clinical vignettes were generally in line with the evidence base. Pharmacists expressed some caution about recommending activity. Most respondents said they would benefit from more education about back pain. CONCLUSION: Those sampled generally expressed positive attitudes about back pain and were able to offer evidence based advice. Pharmacists may benefit from training to increase their ability and confidence to offer support for self-care in back pain. Further research would be useful to clarify the representativeness of the sample.

Preventing incapacity in people with musculoskeletal disorders.

Musculoskeletal disorders are among the most common causes of sickness absence, long-term incapacity for work and ill-health retirement. The number of Incapacity Benefit (IB) recipients in the United Kingdom has trebled since 1979, despite improvement in objective measures of health. Most of the trend is in non-specific conditions (largely subjective complaints, often with little objective pathology or impairment). Understanding incapacity requires a biopsychosocial model that addresses all the physical, psychological and social factors involved in human illness and disability. Rehabilitation should be directed to overcome biopsychosocial obstacles to recovery and return to work. These principles are fundamental to better clinical and occupational management and minimizing incapacity. Sickness absence and incapacity from non-specific musculoskeletal conditions could be reduced by 33-50%, but that depends on getting all stakeholders onside and a fundamental shift in thinking about these conditions-in health care, in the workplace and in society.

A population-based survey of back pain beliefs in Canada.

STUDY DESIGN: Population-based survey. OBJECTIVES: To assess the back pain beliefs in 2 provinces in Canada to inform a population-based educational campaign. SUMMARY OF BACKGROUND DATA: Beliefs, attitudes, and recovery expectations appear to influence recovery from back pain, yet prevailing public opinions about the condition have been little studied. METHODS: Telephone surveys were conducted with 2400 adults in 2 Canadian provinces. Surveys included the Back Beliefs Questionnaire, and additional questions concerning age, gender, recent and lifetime back pain, coping strategies for back pain, and awareness and persuasiveness of media information concerning back pain. RESULTS: A high prevalence of back pain was reported, with a lifetime prevalence of 83.8%, and 1-week prevalence of 34.2%. Generally, a pessimistic view of back pain was held. Most agreed that back pain makes everything in life worse, will eventually stop one from working, and will become progressively worse with age. Mixed opinions were observed regarding the importance of rest and staying active. A significant minority (12.3%) reported taking time off from work for their last back pain episode. Those individuals taking time off from work held more negative back pain beliefs, including the belief that back pain should be rested until it gets better. CONCLUSIONS: Public back pain beliefs in the 2 Canadian provinces sampled are not in harmony with current scientific evidence for this highly prevalent condition. Given the mismatch between public beliefs and current evidence, strategies for reeducating the public are needed.

Surgery for degenerative lumbar spondylosis: updated Cochrane Review.

STUDY DESIGN: An updated Cochrane review. OBJECTIVE: To review current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis. SUMMARY OF BACKGROUND DATA: There is still limited scientific evidence on spinal surgery. METHODS: Use of standard Cochrane review methods to analyze all randomized controlled trials published to March 31, 2005. RESULTS: A total of 31 randomized controlled trials were identified. Most of the earlier trials reported mainly surgical outcomes; more of the recent trials also reported patient-centered outcomes of pain or disability. There is still very little information on occupational outcomes or long-term outcomes beyond 2-3 years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis, and nerve compression permitted limited conclusions. There were two new trials on fusion that showed conflicting results. One trial showed that fusion gave better clinical outcomes than conventional physiotherapy, and the other showed that fusion was no better than a modern exercise and rehabilitation program. There were 8 trials that showed that instrumented fusion produces a higher fusion rate, but any improvement in clinical outcomes is probably marginal. CONCLUSIONS: No conclusions are possible about the relative effectiveness of anterior, posterior, or circumferential fusion. The preliminary results of three small trials of intradiscal electrotherapy suggest it is ineffective, except possibly in highly selected patients. Preliminary data from three trials of disc arthroplasty do not permit firm conclusions.

Concepts of rehabilitation for the management of low back pain.

This chapter develops rehabilitation principles for the clinical and occupational management of non-specific low back pain (LBP). Rehabilitation has traditionally been a secondary intervention, which focused on permanent impairment, but this is inappropriate for LBP. Most patients with LBP do not have any irremediable impairment and long-term incapacity is not inevitable: given the right care, support and opportunity, most should be able to return to work. Rehabilitation should then address obstacles to recovery and barriers to (return to) work. Rehabilitation should not be a separate, second stage after 'treatment' is complete: rehabilitation principles should be integral to clinical and occupational management. It should be possible to reduce sickness absence and long-term incapacity due to LBP by at least 30-50%, but this will require a fundamental shift in management culture.

Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the cochrane collaboration.

STUDY DESIGN: A systematic review of randomized controlled trials. BACKGROUND: Although several rehabilitation programs, physical fitness programs, or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy of these treatments, and there are still persistent fears of causing reinjury, reherniation, or instability. OBJECTIVES: The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery. METHODS: The authors searched the MEDLINE, Embase, and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, issue 3. Both randomized and nonrandomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included. Two independent reviewers performed the inclusion of studies, and two other reviewers independently performed the methodologic quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results. RESULTS: Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately postsurgery, mainly because of the lack of good quality studies. For treatments that start 4 to 6 weeks postsurgery, there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs, and there is strong evidence (level 1) that on long-term follow-up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs, there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There is also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months postsurgery, are more effective in improving low-back functional status as compared to physical agents, joint manipulations, or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately postsurgery or later. None of the investigated treatments seem harmful with regard to reherniation or reoperation. CONCLUSIONS: There is no evidence that patients need to have their activities restricted after first-time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks postoperative) and no evidence they increase the reoperation rate. It is unclear what the exact content of postsurgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately postsurgery or possibly 4 to 6 weeks later.

Public perceptions about low back pain and its management: a gap between expectations and reality?

OBJECTIVE: To compare public perceptions and patient perceptions about back pain and its management with current clinical guidelines. DESIGN: A survey using a quota sampling technique. SETTING: On-the-street in South Derbyshire in the UK. SUBJECTS: 507 members of the general population aged between 20 and 60 years, including a representative subsample of 40% who had experienced back pain in the previous year. SURVEY: To test knowledge and perceptions of back pain and its best management using statements based on The Back Book which was produced in conjunction with the Royal College of General Practitioners and based on best available evidence. In addition expectations of back pain management and outcome were investigated. RESULTS: Forty percent of this sample had experienced back pain during the previous year, more than half of whom had consulted their GP. More than half believed the spine is one of the strongest part of the body, but nearly two thirds incorrectly believed that back pain is often due to a slipped disc or trapped nerve. Two thirds expected a GP to be able to tell them exactly what was wrong with their back, although slightly fewer among those who had consulted. Most expected to have an X-ray, especially if they had consulted. Most recognised that the most important thing a GP can do is offer reassurance and advice. The responses were not related to age, gender or social class. Those who had consulted appeared to have slightly more misconceptions: this could be partly due to people with more severe problems or more misconceptions being more likely to consult, but also suggests either that GPs are still giving inaccurate information or at least failing to correct these misconceptions. CONCLUSIONS: The problem of managing back pain might be reduced by closing the gap between the public's expectations and what is recommended in the guidelines through the promotion of appropriate health education messages. Further professional education of GPs also appears to be needed to update them in the most effective approach to managing back pain.

A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.

Pilot studies and a literature review suggested that fear-avoidance beliefs about physical activity and work might form specific cognitions intervening between low back pain and disability. A Fear-Avoidance Beliefs Questionnaire (FABQ) was developed, based on theories of fear and avoidance behaviour and focussed specifically on patients' beliefs about how physical activity and work affected their low back pain. Test-retest reproducibility in 26 patients was high. Principal-components analysis of the questionnaire in 210 patients identified 2 factors: fear-avoidance beliefs about work and fear-avoidance beliefs about physical activity with internal consistency (alpha) of 0.88 and 0.77 and accounting for 43.7% and 16.5% of the total variance, respectively. Regression analysis in 184 patients showed that fear-avoidance beliefs about work accounted for 23% of the variance of disability in activities of daily living and 26% of the variance of work loss, even after allowing for severity of pain; fear-avoidance beliefs about physical activity explained an additional 9% of the variance of disability. These results confirm the importance of fear-avoidance beliefs and demonstrate that specific fear-avoidance beliefs about work are strongly related to work loss due to low back pain. These findings are incorporated into a biopsychosocial model of the cognitive, affective and behavioural influences in low back pain and disability. It is recommended that fear-avoidance beliefs should be considered in the medical management of low back pain and disability.

A comparison of cognitive measures in low back pain: statistical structure and clinical validity at initial assessment.

Four cognitive measures--MHLC, PLC, CSQ and PRSS/PRCS--were directly compared in 120 U.K. patients with chronic low back pain. 80% of the individual items in the PLC and 86% in the CSQ had satisfactory test-retest reliability, as had most of the scales of the CSQ and the PLC PC scale. The items and the scales of the MHLC and the PRSS/PRCS had lower reliability. The factor structures of the PLC and the PRSS/PRCS bore close similarity to the original descriptions. The CSQ structure was similar to the original but further investigation of its psychometric properties is required. The structure of the MHLC was not replicated. Considerable communality was found between the cognitive measures. The strongest relationship found in this study was between the CSQ and PRSS catastrophising scales and depressive symptoms. There was also a relationship among cognitive measures and both disability and work loss which persisted even after controlling for severity of pain and depressive symptoms. The present results suggest that the concept of catastrophising has greatest potential for understanding current low back symptoms and that the CSQ may be the most useful measure of this. Other work, however, suggests that the PLC may also be of value in following change and predicting response to treatment.

Clinical assessment and interpretation of abnormal illness behaviour in low back pain.

Patients with chronic low back pain present with a mixture of symptoms and signs. Some are a direct consequence of physical pathology whereas others are attributable to associated and appropriate psychological and behavioural changes. At times the latter may be out of keeping with the degree of physical pathology and thus have specific significance in terms of the affective and cognitive disturbances that are also present and which may be the basis for abnormal illness behaviour. In an attempt to demonstrate more clearly the relationship between physical, psychological and behavioural components of illness, this paper draws on two data sets in patients with low back pain. The first explores the relationship between behavioural symptoms and signs, objective physical impairment, pain and disability and psychometric measures of distress together with scales making up the illness behaviour questionnaire (IBQ) of Pilowsky and Spence. A second data set is used to assess the value of the IBQ in understanding how psychological distress and behavioural signs and symptoms are related to the outcome of surgical treatment. The results gained reveal that behavioural symptoms and signs are directly related to the physical severity of low back disorder, the patient's report of pain and disability and the outcome of surgical treatment. Scores on the IBQ were strongly related to measures of affective disturbance and psychological distress. More specifically the disease affirmation scale of the IBQ, incorporating scales for disease conviction and psychological versus somatic focussing was an important dimension in relation to the behavioural symptoms and signs, thereby confirming results gained by other workers. Disease conviction and lack of response to clinicians' reassurances regarding illness - a situation in which abnormal illness behaviour is often deemed to exist - should not be seen simply as a function of the disease process, but more as a psychological coping mechanism for certain individuals under stress. The significance of this observation is discussed in relation to decisions regarding the overall assessment of chronic pain patients and their treatment.

Psychometric construction and validity of the Pilowsky Illness Behaviour Questionnaire in British patients with chronic low back pain.

The psychometric construction and validity of the 62-item Illness Behaviour Questionnaire has been examined in a study of 200 British patients suffering from chronic low back pain. 25 of the 62 items were unsatisfactory. Three new scales (AHD, LD and SI) represented a statistical improvement on the original scales, but were of little additional value to established measures in the analysis of reported pain or disability. The results indicate the need to reconsider the nature of hypochondriasis and abnormal illness behaviour.