[General practice and occupational medicine: a dynamic exchange?] / Médecine générale, médecine du travail : quelle dynamique d'échange ?

GENERAL PRACTICE AND OCCUPATIONAL MEDICINE: A DYNAMIC EXCHANGE? Occupational physicians and general practitioners have different roles but share the common goal of maintaining and promoting the health of the population. Their collaboration is necessary, and both practitioners and employees are generally in favor of it. This collaboration is particularly necessary in several situations: the discovery of a pathology by the occupational physician, the need for temporary incapacity, or difficulties in maintaining employment. Especially in the case of musculoskeletal disorders and mental suffering at work. The pre-reinstatement visit is an important tool for achieving this collaboration. There are also several ways of improving these exchanges, such as the introduction of joint training courses.

MÉDECINE GÉNÉRALE, MÉDECINE DU TRAVAIL : QUELLE DYNAMIQUE D'ÉCHANGE ? Le médecin du travail et le médecin généraliste ont des places et des rôles différents mais pour objectif commun de maintenir et promouvoir la santé de la population. Leur nécessaire collaboration, à laquelle les praticiens comme les salariés se disent globalement favorables, est pourtant insuffisamment constatée sur le terrain. Cette collaboration est nécessaire dans plusieurs situations : découverte d'une pathologie par le médecin du travail, nécessité d'une inaptitude temporaire ou encore difficultés de maintien en emploi. C'est particulièrement le cas pour les situations de troubles musculo-squelettiques et de souffrance psychique au travail. La visite de préreprise est un outil important pour permettre cette collaboration. Il existe également plusieurs pistes d'amélioration de ces échanges, comme la mise en place de formations communes.

Physical activity advice given by French general practitioners for low back pain and the role of digital e-health applications: a qualitative study.

BACKGROUND: Low back pain is the fourth most common reason for consulting a general practitioner (GP) among people aged 40-50 years. Beyond the overall benefits of physical activity (PA) on health (psychological, cardiovascular, etc.), PA for low back pain seems to improve the prognosis in terms of pain, disability, and quality of life. The French National Health Insurance developed media campaigns to promote physical activity with low back pain and a smartphone application (app). Despite the known benefits and campaigns, GPs do not routinely provide advice about physical activity during low back pain consultations. To promote giving physical activity advice for low back pain, there is a need to understand how GPs currently provide this advice and whether technology could help. This study aims to explore the content of physical activity advice for low back pain that GPs provide in France, and their opinion about healthcare smartphone app provided electronically via the internet (e-health apps) as a support for this advice. METHODS: This qualitative study was conducted with semi-structured individual interviews among French GPs. The verbatim was double coded using a coding tree. Thematic analysis was performed using an inductive approach. RESULTS: Sixteen GPs from Maine et Loire, Sarthe, and Mayenne were included. The thematic analysis identified the following themes: GPs use a global patient-centred approach to physical activity advice for low back pain. The main goal is to enable patients to participate in their care. Advice was almost always general with little information about duration and frequency. The importance of patient-appropriate and easily achievable activities was emphasised. GPs referred patients to physiotherapists to reinforce regular physical activity, maintain motivation and improve patient adherence through supervision and follow-up. GPs knew little about e-health apps but felt they could be useful with young patients. The main barriers to their use included poor internet connection, lack of technical knowledge and no supervision meaning patients could injure themselves. CONCLUSIONS: This is one of the first studies to assess the contents of physical activity advice GPs provide for low back pain. Further research is needed into the implementation of e-health apps for low back pain management. TRIAL REGISTRATION: Not applicable.

Comparing physical activity prescription with verbal advice for general practice patients with cardiovascular risk factors: results from the PEPPER randomised controlled trial.

BACKGROUND: Regular physical activity improves health and quality of life for people with cardiovascular risk factors. However, few studies have demonstrated the applicability of strategies in health care to promote physical activity. OBJECTIVE: To evaluate if a written physical activity prescription combined with pedometer increases physical activity over one year compared with verbal advice in patients with cardiovascular disease risk in primary care. METHODS: The randomised-controlled, interventional, 12-month PEPPER study recruited patients aged 35 to 74 years, having quarterly followed-ups for hypertension, dyslipidaemia, or diabetes, and judged insufficiently active. Seventeen practices randomised patients into either the experimental group, who received a written, personalised prescription for daily step numbers, pedometer and logbook, or control group, who received verbal advice to do at least 15 min of rapid walking or equivalent daily. The primary outcome was the change in total weekly energy expenditure measured using an accelerometer at 3 months. The secondary outcomes were changes in step count, physical activity levels, quality of life, perceived obstacles to physical activity, and biomedical indicators at 3 and 12 months. RESULTS: One hundred and twenty-one participants were randomised. Although, weekly energy expenditure did not differ between the prescription and verbal instruction group, the estimated time spent doing moderate-intensity activity was significantly higher in the prescription group than the verbal group by an average of four minutes/week (p = 0.018)(95% CI [0.7 - 7.4]) reaching 48 min after 12 months (95% CI: 8 - 89). Similarly, this was associated with a clinically, higher average step number of 5256 steps/week increase over a year (95% CI: 660 - 9852). Among the most sedentary subgroup, walking less than 5000 steps/day at baseline, an 8868 steps/week (95% CI [2988 - 14700]) increase was observed in the prescription group. CONCLUSION: Prescribing physical activity did not significantly modify total weekly energy expenditure, but slightly increased moderate-intensity activity duration and step counts, particularly among the most sedentary participants. Prescribing personalised physical activity goals encourages sedentary patients to engage in physical activity. TRIAL REGISTRATION: The PEPPER trial is registered in the US National Institutes of Health Clinical Trials Registry under number NCT02317003 (15/12/2014).

Effectiveness of coordinated care to reduce the risk of prolonged disability among patients suffering from subacute or recurrent acute low back pain in primary care: protocol of the CO.LOMB cluster-randomized, controlled study.

Background: Low back pain (LBP) is a common musculoskeletal condition and, globally, a leading cause of years lived with disability. It leads to reduced social participation, impaired quality of life, and direct and indirect costs due to work incapacity. A coordinated approach focusing on psychosocial risk factors, active reeducation, and the early use of tools to maintain employment, may be effective for improving prognosis of patients with LBP. Primary care professionals and multidisciplinary teams, who see patients in the early stages of LBP may be in the best position to implement such a coordinated approach. We designed this study to assess a coordinated multi-faceted strategy in primary care for patients with subacute or recurrent acute LBP. Methods: The CO.LOMB study was designed as a multicentric, cluster-randomized, controlled study. Patients aged 18-60 years, with subacute or recurrent acute LBP are eligible. Patients also need to be employed (but can be on sick leave) with access to occupational health services. The clusters of GPs will be randomized (1:1) to either the Coordinated-care group or the Usual-care group. Patients will be assigned the group allocated to their GP. The healthcare professionals (GPs and associated physiotherapists) allocated to the Coordinated-care group will perform a 2-session study training. The following interventions are planned in the Coordinated-care group: exploration and management of psychosocial factors, active reeducation with a physiotherapist, the implementing of tools to maintain employment, and a reinforced cooperation between primary healthcare professionals. The primary objective is to assess the benefit of coordinated primary care to reduce disability in LBP patients at 12 months after enrollment: measure using the validated French version of the Roland Morris Disability Questionnaire. Secondary objectives include the evaluation of pain, work status, and quality of life at various time points. The study plans to enroll 500 patients in 20 GP clusters. Patients will be followed up for 12months. Discussion: This study will evaluate the benefit of a coordinated multi-faceted strategy in primary care for patients with LBP. Notably whether this approach will alleviate the associated disability, attenuate pain, and promote the maintenance or return to work. Clinical Trial Registration: NCT04826757.

Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study.

BACKGROUND: Non-specific low back pain is a frequent reason for consultation, yet little is known about how general practitioners manage it in France. OBJECTIVES: To describe the healthcare procedures general practitioners prescribe for low back pain in France. MATERIALS AND METHODS: This is an ancillary analysis of an observational, cross-sectional study (ECOGEN) conducted between November 2011 and April 2012 among 128 general practitioners. Adults younger than 65 years consulting for low back pain were included. Patient and general practitioner characteristics, consultation results (diagnosis) and healthcare procedures were collected and coded using the International Classification in Primary Care. Analyses focused on the initial or follow-up consultation, adjusting on age, gender, and socio-occupational category. RESULTS AND DISCUSSION: Out of 11510 consultations, 845 (7.3%) were for low back pain. Of these, 776 (79.5%) resulted in a clinical examination, 634 (73.4%) in medication prescription, and 203 (23.9%) were prescribed sick leave, but imaging and specialist referral were rare. Imaging was more frequent with radiating pain (adjusted odds ratio (aOR) = 1.61; 95% CI [1.07, 2.42]), as were specialist referrals (OR = 2.92; 95% CI [1.40, 6.09]) and sick leave prescription (aOR = 1.52; 95% CI [1.10, 2.09]), but physiotherapist referral was less frequent (aOR = 0.55; 95% CI [0.38, 0.82]). Clinical examinations (aOR = 2.75; 95% CI [1.98, 3.80]), imaging (aOR = 1.61; 95% CI [1.02, 2.31]) and medication prescriptions (aOR = 2.34; 95% CI [1.65, 3.30]) were more common in initial consultations, but specialist referral (aOR = 0.16; 95% CI [0.05, 0.47]) or sick leave prescription (aOR = 0.68; 95% CI [0.48, 0.97]) were rarer. CONCLUSION: Low back pain characteristics could influence healthcare procedures more markedly than patient or general practitioner characteristics.

To which non-physician health professionals do French general practitioners refer their patients to and what factors are associated with these referrals? Secondary analysis of the French national cross-sectional ECOGEN study.

BACKGROUND: Multiprofessional practice is a key component in primary care. Examining general practitioner (GP) referral frequency to non-physician health professionals (NPHP) can provide information about how primary care is organised and works which is useful for policymakers. Our study aimed to describe French GP referral frequency to various NPHPs in France and identify associated factors. METHODS: This is an ancillary study to the observational, cross-sectional (ECOGEN) study conducted in 2011/2012 in France among 128 GPs. Data about consultations using the standardised International Classification of Primary Care (ICPC-2), and patient and GP characteristics were collected from 20,613 GP consultations. Referrals were identified through inductive and deductive approaches using ICPC-2 codes, keywords, and deep, open manual searches. Referral frequency was described overall and per NPHP. Patient, GP, and consultation-related factors associated with referral rates were described for the three most frequently identified NPHPs. To minimise potential sources of bias, this observational study followed the STROBE guidelines. RESULTS: French GPs referred 6.8% of patients to NPHPs, with physiotherapists, podiatrists, and nurses accounting for 85.2% of referrals. Older patients, retired patients, multiple health problems managed, and longer consultation durations were found to be associated with higher referral rates (p < 0.001). Specific trends were observed for nurse, physiotherapist, and podiatrist referrals. Women (p < 0.001) and regular patients (p = 0.002) were more likely to receive physiotherapy referrals while people with no professional activity were less likely (p < 0.001). Female GPs and those working in urban practices were more likely to issue a physiotherapy referral (p < 0.001), while GPs working in rural practices (p < 0.001) and those with higher annual consultation numbers (p = 0.002) were more likely to refer to a nurse. Working in multiprofessional centres appeared to have little impact on referral rates, being only slightly associated with podiatrist referrals (p = 0.003). CONCLUSIONS: Referral frequency is more associated with patient characteristics and clinical situations than GP-related factors suggesting patients needing referral most are most often referred. Furthermore, the three NPHPs that GPs refer to the most are those for which a referral is required for reimbursement in France, suggesting that health system legislation and NPHP reimbursement are strong determinants for referrals.

Pre-return to work consultation and therapeutic part-time work: Cross-sectional study on level of knowledge and use by general practitioners in France.

BACKGROUND: In France, general practitioners (GPs) may use two tools specifically designed to help employees who experience difficulties in returning to work after sick leave: the pre-return-to-work (PRW) medical consultation and therapeutic part-time (TPT) work. OBJECTIVES: The objective was to investigate the level of knowledge and use of these two tools by GPs in Maine-et-Loire, France. METHODS: This cross-sectional study was performed using a telephone questionnaire to evaluate the level of knowledge of GPs and the use of these two tools in patients having difficulties returning to work. RESULTS: Among the 200 randomly selected GPs, 122 responded (response rate: 61%). More than half of the interviewed GPs declared they 'often' (46%) or 'always' (14%) contacted the occupational physician in these situations. Moreover, 62.2% and 32.7% believed that they had a 'vague' or 'very good' level of knowledge, and 41% and 51% declared either 'frequent' or 'regular' level of use of the PRW medical consultation, respectively. Regarding TPT work, 47% and 53% reported a 'very good' or 'vague' level of knowledge, and 41% and 51% a 'frequent' or 'regular' level of use, respectively. GPs who had a better level of knowledge of this tool reported a higher level of use (p < 0.001). CONCLUSION: This study shows that while the level of knowledge and use of the PRW medical consultation and TPT work is good, it is not optimal. This could be improved by organising training courses for GPs. Obstacles to their wider use could be investigated further in a qualitative study.

Factors influencing physiotherapists' attitudes and beliefs toward chronic low back pain: Impact of a care network belonging.

OBJECTIVES: To assess the attitudes and beliefs of physiotherapists (PTs) regarding the management of chronic LBP and to investigate the factors which influence them. METHODS: A cross-sectional study conducted in the French Loire Valley region by a questionnaire sent to the private PTs between June and September 2014. Demographic data and modalities of practices were collected in association with the Pain Attitudes and Beliefs Scale (PABS) which is a specific self-administered questionnaire designed to assess the "biomedical" or "behavioral" (i.e., biopsychosocial) management orientation of PTs toward chronic LBP. RESULTS: One hundred and sixty-eight of the 704 PTs entirely completed the questionnaire (63% of men, 58% >40 years of age) of whom 15 were involved in a LBP care network. A higher biomechanical score was observed with a higher age and lower with full-time employment, less than 20 years of length of practice and a recent LBP-specific training (p < 0.005). Belonging to a LBP care network was associated with a lower biomedical score (p < 0.01) and a higher biopsychosocial score (p < 0.005). CONCLUSIONS: Belonging to a LBP care network, which implies closer collaboration with multidisciplinary rehabilitation teams, was the most significant factor associated with higher biopsychosocial beliefs in PTs toward chronic LBP management.

State of knowledge on smartphone applications concerning contraception: A systematic review.

AIM: Women's knowledge of contraception is incomplete and a wide variety of information sources are used. Since the advent of smartphones, 325,000 healthcare apps have become available. Our aim is to conduct a literature review on smartphone applications for contraception. METHODS: 15 databases in English, Spanish and French were examined, which included studies published between 2007 and 2018 that describe or compare mobile applications for reversible contraceptive methods and interventional studies. The quality of the studies was assessed using the Cochrane scale or a scale created by the authors. RESULTS: 1786 articles were listed and 22 were included in the main text. In two randomised controlled trials, apps did not influence the choice of a contraceptive method. Two studies showed a significant improvement in knowledge after using an app. Comparative studies reported a large number of apps, the majority of which contained only incomplete information and few interactive features. CONCLUSION: Many applications deal with contraception, but few have reliable and exhaustive information. Further studies are needed to measure the impact of apps on observing compliance.

Interprofessional Communication Concerning Work-Related Musculoskeletal Disorders: A Qualitative Study.

Purpose Understanding and treating musculoskeletal disorders (MSDs) requires coordination between the numerous healthcare professionals involved, including occupational physicians (OPs), general practitioners (GPs) and social insurance physicians (SIPs). The main objective of this study was to assess communication between OPs, GPs and SIPs in the management of MSDs. Methods This is a qualitative study in the form of semi-structured interviews with OPs in the French region of Brittany. The interviews were conducted until data saturation was achieved. The interviews were fully coded and analysed thematically using NVivo® software. Results The interviews were carried out among 17 OPs from companies and external occupational healthcare services who treated employees from various activity sectors. Different communication channels were used depending on the interlocutor, though they were mainly contacted by mail or phone. Most of the communication passed through the patient, either verbally or in writing. No major failure was detected in communication between the various types of practitioners, but instances of communication were influenced by various factors such as differences in perception, representation and objectives, as well as by how well the physicians knew each other. A number of instances of non-communication were found. Conclusion This study showed that patients play a key role in the interactions between different practitioners. It also revealed that different types of professional relationships depend on the objectives of the various interlocutors, which in turn vary according to their roles and competences.

Efficiency of three treatment strategies on occupational and quality of life impairments for chronic low back pain patients: is the multidisciplinary approach the key feature to success?

OBJECTIVE: To compare the effectiveness of three treatment strategies for chronic low back pain with varying biomechanical intensity and multidisciplinary approach. METHODS: A monocentric randomized controlled trial with a 12-months follow-up, conducted in the French Valley Loire region from May 2009 to April 2013. Participants were working-aged patients with chronic low back pain referred to a French chronic low back pain care-network to support medical and occupational issues. Three treatment strategies, each for five weeks were compared: (i) intensive and multidisciplinary program conducted in a rehabilitation center; (ii) less intensive outpatient program conducted by a trained private physiotherapist; (iii) mixed strategy combining the same outpatient program associated with a weekly multidisciplinary intervention. The effects of treatment conditions were compared using an "intention to treat" approach: Number of days' sick leave during the 12-months following treatment, and quality of life and social ability assessed by auto-questionnaires. RESULTS: A total of 159 patients (58.9% men, 41.5 ± 10.3 years old, median duration of sick leave = 221.0 days (127.5-319.0)) were included. Sick leave duration significantly decreased during the 12-months following treatment in the three groups. There was no significant difference for the evolution of participants' quality of life, social ability, and personal beliefs between the three groups. CONCLUSION: This study confirms that disparate treatments might show similar effectiveness because they could all work through concomitant changes in beliefs, attitudes, and coping mechanisms. The original mixed strategy can treat a larger number of chronic low back pain patients, at a lower cost and provide local community-based care. CLINICAL TRIAL REGISTRATION: NCT02030171.

[Musculoskeletal disorders: Role of medical advisers and inter-professional relations]. / Troubles musculo-squelettiques?: rôles des médecins-conseils et relations interprofessionnelles.

INTRODUCTION: Musculoskeletal disorders (MSD) were responsible for 9.7 million days of sick leave in 2010 in France. They are also a leading cause of occupational exclusion. The objective was to study the role of medical advisers (Mas) in the care of patients with MSD and their interactions with general practitioners (GPs) and occupational health physicians (OPs). METHODS: We performed a qualitative study with semi-structured interviews with medical advisers from the Brittany region. Semistructured interviews were double-coded and were submitted to thematic analysis. RESULTS: Nine interviews were conducted with MAs from the general regime, agricultural regime, and independent workers regime. MAs described an increase in MSD, especially with complex forms. They explained that their activity was not limited to control, but that they also had an important role in limiting occupational exclusion. It is important to anticipate difficulties related to return to work in this setting. They reported contrasted but necessary relations with GPs who are at the centre of care. Return to work may require negotiation with OPs. CONCLUSION: Relations between MAs and GPs are partly based on control of prescriptions, which can create a climate of suspicion. Emphasizing the fight against occupational exclusion can provide new light on the role of MAs. Improving relations between MAs and GPs can be achieved by a better understanding of their respective roles.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care.

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.