Does pain duration and other variables measured at baseline predict re-referral of low back pain patients managed on an evidence-based pathway? A cohort study.

OBJECTIVE: To explore the association between baseline pain duration and the likelihood of re-referral of patients with low back pain (LBP) managed on the evidence-based North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). STUDY DESIGN: Longitudinal, observational cohort study. METHODS: In all, 12,509 adults with LBP were identified as having been discharged from the pathway, between May 2015 and December 2019. To quantify any association between baseline pain duration and the likelihood of re-referral, two statistical modelling approaches, were used: logistic regression models for odds ratios and generalised linear models with a binomial link function in order to quantify risk differences. RESULTS: Twenty-five percent of patients with LBP, who were discharged, re-referred for management over a 4.5-year period. A large difference in pain duration of 2 SD days was statistically associated with re-referral, with an odds ratio of 1.22 (95% CI: 1.03, 1.44) and a risk difference of 3.6% (95% CI: 0.6, 6.6). Nevertheless, the predictive value of an individual's pain duration was found to be weak for re-referral. Higher baseline disability [odds ratio of 1.40 (95% CI: 1.07, 1.83)] and a younger age at baseline [odds ratio of 0.73 (95% CI 0.61, 0.86)] were also associated with an increased risk of re-referral. CONCLUSIONS: Baseline pain duration, disability and younger age are statistically associated with re-referral onto the NERBPP. However, the value of these variables for predicting an individual's risk of re-referral is weak. CONTRIBUTION OF PAPER.

The Association of Pain with Incident Falls in People with Chronic Obstructive Pulmonary Disease: Evidence from the English Longitudinal Study of Ageing.

People with chronic obstructive pulmonary disease (COPD) have a higher prevalence of pain and a greater risk of falls than their healthy peers. As pain has been associated with an increased risk of falls in older adults, this study investigated the association between pain and falls in people with COPD compared to healthy controls. Data from the English Longitudinal Study of Ageing were used to establish an association between pain and falls when modelled with a generalised ordinal logistic regression and adjusted for sex, age, wealth, and education (complete case analysis only; n = 806 COPD, n = 3898 healthy controls). The odds were then converted to the predicted probabilities of falling. The predicted probability of falling for people with COPD was greater across all pain categories than for healthy controls; for COPD with (predicted probability % [95%CI]), no pain was 20% [17 to 25], with mild pain was 28% [18 to 38], with moderate pain was 28% [22 to 34] with severe pain was 39% [30 to 47] and for healthy controls with no pain was 17% [16 to 18], mild pain 22% [18 to 27], moderate pain 25% [20 to 29] and severe pain 27% [20 to 35]. The probability of falling increased across pain categories in individuals with COPD, with the most severe pain category at a nearly 40% probability of falling, indicating a potential interaction between COPD and pain.

Long-term improvements following a residential combined physical and psychological programme for chronic low back pain.

OBJECTIVES: Evaluate the outcomes and explore experiences of patients undergoing a residential combined physical and psychological programme (CPPP) for chronic low back pain. DESIGN: A longitudinal observational cohort design, with a parallel qualitative design using semistructured interviews. SETTING: Residential, multimodal rehabilitation. PARTICIPANTS: 136 adults (62 male/74 female) referred to the CPPP, 100 (44 male/56 female) of whom completed the programme, during the term of the study. Ten (2 male/8 female) participated in the qualitative evaluation. INTERVENTION: A 3-week residential CPPP. OUTCOME MEASURES: Primary outcome measures were the STarT Back screening tool score; pain intensity-11-point Numerical Rating Scale; function-Oswestry Disability Index (ODI); health status/quality of life-EQ-5D-5L EuroQol five-Dimension-five level; anxiety-Generalised Anxiety Disorder-7; depression-Patient Health Questionnaire-9. Secondary outcome measures were the Global Subjective Outcome Scale; National Health Service Friends and Family Test;. RESULTS: At discharge, 6 and 12 months follow ups, there were improvements from baseline that were greater than minimum clinically important differences in each of the outcomes (with the sole exception of ODI at discharge). At 12 months, the majority of people considered themselves a lot better (57%) and were extremely likely (86%) to recommend the programme to a friend. The qualitative data showed praise for the residential nature of the intervention and the opportunities for interaction with peers and peer support. There were testimonies of improvements in understanding of pain and how to manage it better. Some participants said they had reduced, or stopped, medication they had been taking to manage their pain. CONCLUSIONS: Participants improved, and maintained long term, beyond minimum clinically important differences on a wide range of outcomes. Participants reported an enhanced ability to self-manage their back pain and support for the residential setting.

Exploring the origin of pain subclassification, with emphasis on low back pain: a scoping review.

OBJECTIVE: This scoping review aimed to explore the different working definitions for the duration of acute, subacute, and chronic pain, with emphasis on low back pain, and to establish where these definitions originated and the rationale provided for the time frames used. INTRODUCTION: From a global perspective, low back pain is a major social and economic problem. One of the most commonly used methods to stratify and manage low back pain is the traditional duration-based classification (acute, subacute, and chronic). Where these time points lie to differentiate these transitions continues to be debated within the scientific community, which may engender a degree of heterogeneity in study findings. Therefore, applying these findings to clinical practice may be somewhat challenging. This review encapsulates the historical origins of the different duration categories to provide an understanding of how these variations were derived. INCLUSION CRITERIA: Studies that included participants with low back pain were the focus of this review. Sources that included children or other specific pain pathologies, such as cancer pain, were excluded. The main concept of interest was that the publication proposed an original definition of the duration of acute, subacute, or chronic low back pain. All study designs were included provided they gave a rationale for the duration that they used. METHODS: The following databases were searched: MEDLINE, Embase, CINAHL, and PsycINFO, from the inception of each database until September 18, 2019. This review was limited to studies published in English. Two independent reviewers screened the retrieved articles against the eligibility criteria. Additional studies were searched from the reference lists of studies to find the original source. Some original sources overlapped with general pain duration literature. This led to a deviation from the scoping review protocol, which originally intended to focus on definitions of low back pain duration only. Data extraction was undertaken using a charting table developed specifically for the review objectives. The findings were presented using narrative synthesis. RESULTS: Nineteen records were included in this review, and comprised three book chapters, four review articles, four articles that arose following pain expert group discussions, seven primary research studies, and a spinal guideline. Data were extracted from the included studies and categorized into four themes based on the origin of the classification of the duration. The themes included i) work/employment setting, ii) empirical studies, iii) expert reasoning, and iv) pathophysiological explanation. CONCLUSIONS: This scoping review compiled the existing literature on the working definitions of the duration of acute, subacute, and chronic low back pain and found a wide variation. These ranged from seven days, 14 days, and seven weeks for the acute and subacute transition points, and seven weeks to three years for chronic low back pain. The duration definitions specifically referring to the general pain literature focused on three and/or six months for the transition to chronic. Better integration of reasoning between the identified themes could facilitate the establishment of more ideal duration definitions in the future. Although inconclusive, the definition most commonly cited, with most consensus, was three months for the transition to chronic low back pain.

Does Duration of Pain at Baseline Influence Longer-term Clinical Outcomes of Low Back Pain Patients Managed on an Evidence-Based Pathway?

STUDY DESIGN: Nonrandomized longitudinal observational study. OBJECTIVE: The aim of this study was to evaluate the association between baseline pain duration and medium-to-long term clinical outcomes, in low back pain (LBP) patients enrolled on the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). SUMMARY OF BACKGROUND DATA: The NERBPP is based upon National Institute for Health and Care Excellence (NICE) guidelines. These guidelines no longer differentiate management of LBP patients based on pain duration. Medium-to-long term data from the NERBPP is lacking. METHODS: Between May 2015 and December 2019, 786 and 552 LBP patients from the NERBPP returned 6-month and 12-month follow-up outcome measures, respectively. Outcomes included pain (Numerical rating scale), function (Oswestry Disability Index) and quality-of-life (EuroQol five-dimension, five-level questionnaire), analyzed using a series of covariate-adjusted models. Patients were categorized into four groups based upon baseline pain duration: <3 months, ≥3 to <6 months, ≥6 months to <12 months, ≥12 months. RESULTS: Patients with <3 months duration demonstrated clinically important improvements on all outcomes, at both follow-ups. The improvements in outcomes from this group were larger than those in the ≥12 month's duration group (P < 0.05), these group differences in change, in some cases surpassed our threshold for clinical relevance. Functional improvements in those with ≥12 month's duration were not clinically relevant at either follow-up. All patients, regardless of baseline pain duration, reported similar levels of readiness to self-manage at the 12-month follow-up. CONCLUSION: Baseline pain duration would appear to be of clinical importance. Patients with shorter baseline pain duration demonstrated better outcomes. Those with ≥12 month's duration of pain may need additional support during their management to achieve clinically relevant functional improvements in the medium-to-long term. These findings raise questions about the decision by NICE to move away from duration of pain to differentiate management of LBP patients.Level of Evidence: 3.

The Information Needs of Adolescent Idiopathic Scoliosis Patients and Their Parents in the UK: An Online Survey.

Patients' involvement in decision-making regarding their own health care is considered to be of great importance. However, their information needs are frequently reported to be unfulfilled. Few studies have investigated the knowledge, information and support needs of adolescent idiopathic scoliosis (AIS) patients and their families. Furthermore, previous studies have predominantly focussed on information needs relating to surgery. No previous studies have been conducted to specifically identify the information needs of AIS patients and their families. An online survey consisting of 18 questions was conducted to investigate the information needs of AIS patients and their families. Completed surveys of 83 participants (76 female, 7 male) from 44 differing postcode areas were analysed. The mean age of the respondents with scoliosis was 13.3 years (SD = 1.9; range = 10-18). Participants identified with feelings including worry, anxiety and being upset. The main information needs related to the cause and prognosis of the condition. Where participants had received information, there were contrasting views of the quality. The findings of this study stress the necessity for information materials to be accurate and applicable to each individual patient. Furthermore, the information should be presented in such a way as to be easily understandable, yet contain the necessary information required by AIS patients and their families.

Exploring the origin of low back pain sub-classification: a scoping review protocol.

OBJECTIVE: This scoping review aims to map the different working definitions currently being used for the duration of acute, subacute and chronic low back pain (LBP), and to establish where these definitions originated and the rationale provided for the timeframes used. INTRODUCTION: Low back pain is a major social and economic problem worldwide. One of the most commonly used approaches to classify and manage patients with LBP is the traditional duration-based classification (acute, subacute and chronic). There are significant differences between studies in the timeframes used for what constitutes acute, subacute and chronic LBP. These discrepancies lead to heterogeneity in study results, making it difficult to compare or summarize findings. INCLUSION CRITERIA: Studies that include participants with non-specific LBP, regardless of sex, will be considered. Studies that include children or participants with specific causes of LBP will be excluded. METHODS: The following electronic databases will be searched: MEDLINE, Embase, CINAHL and PsycINFO. All types of studies will be included, provided they give a rationale for the definition of duration that they use. Studies will be limited to those published in English. Two independent reviewers will screen the retrieved articles against the eligibility criteria for the scoping review. A narrative synthesis will describe the definitions used in the study and the rationale given for the timeframes reported. This scoping review will give an insight into the background of the variation of timeframes used for duration-based classification of LBP.

Does Duration of Pain at Baseline Influence Clinical Outcomes of Low Back Pain Patients Managed on an Evidence-based Pathway?

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To investigate the association between the duration of pain at baseline and the clinical outcomes of patients with low back pain (LBP) enrolled on the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). SUMMARY OF BACKGROUND DATA: The NERBPP is a clinical pathway based upon National Institute for Health and Care Excellence (NICE) guidelines (2009) for LBP of <1-year duration. Recent changes to NICE guidelines (2016) advocate the same management for all LBP patients regardless of pain duration. METHODS: Patients with LBP referred onto the NERBPP by their General Practitioner between May 2015 and January 2017 were included. Data from 667 patients, who provided pre- and post data for pain (Numerical rating scale), function (Oswestry Disability Index), quality-of-life (EuroQol five-dimension, five-level questionnaire), anxiety (the Generalized Anxiety Disorder Screener), and depression (the Patient Health Questionnaire), were analyzed using a series of covariate-adjusted models. Patients were categorized into four groups based upon baseline pain duration: <3 months, ≥3 to <6 months, ≥6 months to <12 months, ≥12 months. RESULTS: Each group showed improved outcomes greater than the minimal clinically important difference (MCID) for each measure as defined in NICE guidelines (2016). There was a trend toward better outcomes for those with shorter pain durations. The magnitude of the differences between the groups, in most instances, was below the MCID. For example, mean improvement in function for those with baseline pain duration <3 months was 20 points and 12 points for those of pain duration ≥12 months, both above the MCID of ≥10. CONCLUSION: Patients with different durations of LBP at baseline improved on the NERBPP, supporting the recent modification to NICE guidelines. However, those with shorter durations of pain may have superior outcomes in the short term, suggesting added benefit in getting patients onto the pathway in the early stages of LBP. LEVEL OF EVIDENCE: 3.

The association between displacement of sedentary time and chronic musculoskeletal pain: an isotemporal substitution analysis.

OBJECTIVES: Physical activity is an effective intervention for the prevention and management of chronic musculoskeletal pain (CMP). However, there is a lack of research to inform the intensity of physical activity that should be recommended. The aim of this study was to investigate the association between substituting 10minutes of sedentary time with either 10minutes of light physical activity (LPA) or moderate-to-vigorous physical activity (MVPA) and the CMP prevalence ratio. DESIGN: Secondary Analysis (November 2015) of data from the Health Survey for England (2008). PARTICIPANTS: 2313 adults (≥16years). MAIN OUTCOME MEASURES: Sedentary time, LPA and MVPA were measured using accelerometry. We used isotemporal models to quantify the prevalence ratio for CMP of replacing 10minutes of sedentary time with 10minutes of LPA or MVPA. RESULTS: The prevalence of CMP in this sample was 17%. The unadjusted prevalence ratio was 0.99 (95% CI: 0.97 to 1.01) for LPA and 0.76 (0.70 to 0.84) for MVPA. The fully adjusted prevalence ratio was 1.01 (95% CI: 0.99 to 1.02) for LPA and 0.89 (0.82 to 0.96) for MVPA. CONCLUSIONS: Substituting 10minutes of sedentary time with an equivalent period of LPA was not associated with a reduction in the prevalence ratio for CMP, whereas the equivalent replacement with MVPA showed a small protective relationship. Regarding CMP prevalence, physical activity intensity appears to be important, with MVPA rather than LPA showing a protective relationship. Prospective studies are needed to investigate causality.

The association between baseline persistent pain and weight change in patients attending a specialist weight management service.

OBJECTIVE: To quantify the influence of baseline pain levels on weight change at one-year follow-up in patients attending a National Health Service specialist weight management programme. METHODS: We compared one-year follow-up weight (body mass) change between patient sub-groups of none-to-mild, moderate, and severe pain at baseline. A mean sub-group difference in weight change of ≥5kg was considered clinically relevant. RESULTS: Of the 141 complete cases, n = 43 (30.5%) reported none-to-mild pain, n = 44 (31.2%) reported moderate pain, and n = 54 (38.3%) reported severe pain. Covariate-adjusted mean weight loss (95%CI) was similar for those with none-to-mild (8.1kg (4.2 to 12.0kg)) and moderate pain (8.3kg (4.9 to 11.7kg). The mean weight loss of 3.0kg (-0.4 to 6.4kg) for the severe pain group was 5.1kg (-0.6 to 10.7, p = 0.08) lower than the none-to-mild pain group and 5.3kg (0.4 to 10.2kg, p = 0.03) lower than the moderate pain group. CONCLUSIONS: Patients with severe pain upon entry to a specialist weight management service in England achieve a smaller mean weight loss at one-year follow-up than those with none-to-moderate pain. The magnitude of the difference in mean weight loss was clinically relevant, highlighting the importance of addressing severe persistent pain in obese patients undertaking weight management programmes.

Displacing Sedentary Time: Association with Cardiovascular Disease Prevalence.

PURPOSE: Isotemporal substitution analysis offers new insights for public health but has only recently been applied to sedentary behavior research. We aimed to quantify associations between the substitution of 10 min of sedentary behavior with 10 min of light physical activity (LPA) or moderate-to-vigorous physical activity (MVPA) and the prevalence of cardiovascular disease (CVD). Age was also explored as a potential effect modifier. METHODS: We completed a secondary analysis of data from 1477 adults from the Health Survey for England (2008). Sedentary time, LPA, and MVPA were measured using accelerometry. We applied isotemporal models to quantify the relationship with CVD prevalence of replacing 10 min of sedentary time with equivalent amounts of LPA or MVPA. Prevalence risk ratios (RR) with 95% confidence intervals (CI) are presented, adjusted for covariates. The role of age as an effect modifier was explored via age-MVPA and age-LPA interactions. CVD was defined as per the International Classification of Diseases. RESULTS: The prevalence of CVD was 24%. The RR was 0.97 (95% CI, 0.96-0.99) for LPA and 0.88 (0.81-0.96) for MVPA. Substitution of approximately 50 min of LPA would be required for an association equivalent to 10 min of MVPA. The beneficial association of MVPA was attenuated with age, with a decrease in the relative risk reduction of approximately 7% per decade. CONCLUSIONS: Isotemporal substitution of sedentary time with LPA was associated with a trivial relative risk reduction for CVD, whereas the equivalent replacement with MVPA had a small beneficial relationship. With respect to CVD prevalence, MVPA might become decreasingly important in older individuals. Prospective studies are needed to investigate causality.

An evaluation of web sites recommended by UK NHS consultants to patients with adolescent idiopathic scoliosis at the first point of diagnosis.

STUDY DESIGN: An Internet-based evaluation of Web sites using a validated assessment tool. OBJECTIVE: To evaluate the quality of information on scoliosis Web sites recommended by UK NHS consultants. SUMMARY OF BACKGROUND DATA: One of the most common sources of inquiry on the Web is for the purposes of health-related information. The number of Web sites in the field of scoliosis has increased, yet the quality of information is reported to continue to be of poor quality. The 2 previous studies in this area identified Web sites for evaluation through the use of a single search term, "scoliosis," on the 5 most popular search engines. METHODS: Seven Web sites were identified for inclusion in this study from the results of a survey of UK NHS consultants. These were independently evaluated by 3 reviewers using a validated information assessment tool, the DISCERN instrument. DISCERN scores were analyzed for correlation between reviewers. Web sites were also analyzed for the presence or absence of the quality assurance certification, Health On the Net code. RESULTS: Significant correlations between the DISCERN scores were found for reviewers 1 and 2 (τ = 0.878, P = 0.006) and reviewers 2 and 3 (τ = 0.732, P = 0.029). The highest mean cumulative score for all items achieved by any of the Web sites evaluated was 49 (maximum = 80, minimum = 15). Only one Web site was found to display the Health On the Net code. CONCLUSION: Healthcare professionals should be aware of the content of Web sites that they recommend to patients. Web sites should be designed so the content suits patient needs. Web sites should be maintained such that content is up to date, evidence based, impartial, and written in plain language. LEVEL OF EVIDENCE: N/A.