Usual care for low back pain and barriers to best practice: A cross-sectional study in Danish general practice.

OBJECTIVES: To describe the current content of low back pain (LBP) care in Danish general practice, the patients' self-management activities, and the clinicians' experienced barriers to providing best practice care. METHODS: This cross-sectional observational study included adults with LBP seeking care in Danish general practice from August 2022 to June 2023. Patient-reported information included demographics, pain intensity, medical history, treatments, and self-management strategies. Clinicians provided data specific to each consultation, detailing the content of these consultations, and barriers to best practice in the specific cases. RESULTS: The study involved 71 clinicians from 42 general practice clinics, with patient-reported data from 294 patients, and clinician-reported data from 283 (95%) consultations. The mean age for the included patients was 53 years, 56% were female, and 31% had been on sick leave for LBP during the previous 3 months. Moreover, 44% had seen two or more healthcare professionals in the previous month, 55% had previously undergone diagnostic imaging for LBP, 81% reported using any type of analgesics, and 14% reported using opioids. The majority (91%) reported engaging in self-management activities to alleviate pain. Consultations typically included a physical examination (84%), information about the cause of the pain (74%), and management advice (68%), as reported by clinicians or patients. In general, clinicians reported consultation elements more frequently than patients. Clinicians reported providing best practice care in 84% of cases, with time constraints (23%) and patient expectations (10%) being the most common barriers. CONCLUSIONS: This study provides detailed insights into the management of LBP in Danish general practice. It reveals a complex landscape of patient engagement, varying management strategies, and differing perceptions of care content between patients and clinicians. Patients were often engaged in self-management activities and clinicians reported few barriers to providing best practice care.

Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study.

BACKGROUND: Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care. METHODS: A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme. RESULTS: The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks. CONCLUSIONS: A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase. TRIAL REGISTRATION: Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

The effect of clinical guidelines on the utilisation of radiographs in chiropractic clinics in Denmark - an interrupted time series analysis.

BACKGROUND: In Denmark, chiropractors have a statutory right to use radiography and the government-funded national Health Insurance provides partial reimbursement. Danish National Clinical Guidelines recommends against routine use of imaging for uncomplicated spinal pain; however, it is not clear if clinical imaging guidelines recommendations have had an effect on the utilisation of spinal radiography. This study aimed to describe the utilisation rate of radiographs in Danish chiropractic clinics in the period from 2010 to 2020 and to assess the impact of clinical guidelines and policy changes on the utilisation of radiographs in Danish chiropractic clinics. METHODS: Anonymised data from January 1st, 2010, to December 31st, 2020, were extracted from the Danish Regions register on health contacts in primary care. Data consisted of the total number of patients consulting one of 254 chiropractic clinics and the total number of patients having or being referred for radiography. Data were used to investigate the radiography utilisation per month from 2010 to 2020. An 'interrupted time series' analysis was conducted to determine if two interventions, the dissemination of 1) Danish clinical imaging guidelines recommendations and policy changes related to referral for advanced imaging for chiropractors in 2013 and 2) four Danish clinical guidelines recommendations in 2016, were associated with an immediate change in the level and/or slope of radiography utilisation. RESULTS: In total, 336,128 unique patients consulted a chiropractor in 2010 of which 55,449 (15.4%) had radiography. In 2020, the number of patients consulting a chiropractor had increased to 366,732 of which 29,244 (8.0%) had radiography. The pre-intervention utilisation decreased by two radiographs per 10,000 patients per month. Little absolute change, but still statistically significant for Intervention 1, in the utilisation was found after the dissemination of the clinical guidelines and policy changes in 2013 or 2016. CONCLUSIONS: The proportion of Danish chiropractic patients undergoing radiography was halved in the period from 2010 to 2020. However, the dissemination of clinical imaging guidelines recommendations and policy changes related to referrals for advanced imaging showed little meaningful change in the monthly utilisation of radiographs in the same period.

The clinical relevance of magnetic resonance imaging of the lower back.

Magnetic resonance imaging (MRI) is commonly used in the management of low back pain (LBP). This review provides an overview of the clinical relevance of degenerative MRI findings in the lumbar spine. The association between degenerative MRI findings and LBP is relatively consistent at population level, but very little research exists on the prognostic value of MRI findings and based on the current evidence, MRI cannot be used to guide treatment. Lumbar spine MRI is only recommended for patients with progressive neurological deficits, suspicion of specific pathology or in absence of progress of conservative treatment.

Prognostic value of the clinical and imaging arm of the ASAS criteria for progression of structural sacroiliac joint lesions.

OBJECTIVE: To investigate the prognostic value of the two arms of the Assessment of SpondyloArthritis international Society (ASAS) criteria regarding the progression of structural lesions in the sacroiliac joints (SIJ). METHODS: Information on baseline fulfilment of the ASAS criteria and baseline and follow-up magnetic resonance imaging of the SIJ in 603 patients aged 18-40 years, referred with low back pain to an outpatient spine were collected. MRI-positivity was defined as bone marrow oedema (BMO) in ≥2 consecutive slices or ≥2 lesions in 1 slice, as described in ASAS definition of sacroiliitis. RESULTS: Of 71 participants fulfilling the ASAS criteria at baseline, 66(93%) fulfilled the 'imaging arm' and 14(20%) the 'clinical arm'. The 'clinical arm' predicted progression of erosions with an odds ratio of 55 (compared with not fulfilling the ASAS criteria), while the 'imaging arm' predicted progression of erosions with an odds ratio of 8. Moreover, in 24% of patients in the 'imaging arm', all having BMO at the SIJ at baseline, the BMO disappeared without neither erosions nor ankylosis emerging. CONCLUSION: We found that the 'clinical arm' was a strong predictor for progression of sacroiliac joint erosion, while the 'imaging arm' had a more modest prognostic value for structural progression.

Barriers to the use of clinical practice guidelines: a qualitative study of Danish physiotherapists and chiropractors.

PURPOSE: Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice. MATERIALS AND METHODS: A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/- observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted. RESULTS: Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors. CONCLUSIONS: For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.

It is important that physiotherapists and chiropractors reflect on what constitutes their core task and professional identity if the implementation of the biopsychosocial model is to be successful.To overcome the barrier of scepticism towards guidelines, the applicability of the guidelines could be improved by elaborating on how the recommendations could be individualised.It is important to incorporate the biopsychosocial model into the programs of educational institutions and provide training to improve those skills in physiotherapists and chiropractors.

Reliability of reporting differences in degenerative MRI findings of the lumbar spine from the supine to the upright position.

OBJECTIVE: To determine the inter-rater reliability of identifying differences and types of differences in lumbar degenerative findings comparing supine and upright MRI. MATERIALS AND METHODS: Fifty-nine participants, low back pain patients (LBP) with or without leg pain and no-LBP individuals were consecutively enrolled to receive supine and upright MRI of the lumbar spine. Three raters independently evaluated the MRIs for degenerative spinal pathologies and compared for differences. Presence/absence of degenerative findings were recorded for all supine and upright images, and then differences from the supine to the upright positions were classified into no-change, appeared, disappeared, worsened, or improved at each individual disc level. Reliability and agreement were calculated using Gwet's agreement coefficients (AC1 or AC2) and absolute agreement. RESULTS: Inter-rater reliability of evaluating differences in eight degenerative lumbar findings comparing the supine and upright MRI position, ranged from 0.929 to 0.996 according to Gwet's agreement coefficients (AC2). The total number of positive MRI findings in the supine position ranged from 270 to 453, with an average of 366 per rater. Observed differences from supine to upright MRI ranged from 18 to 80, with an average of 56 per rater. CONCLUSION: Inter-rater reliability was found overall acceptable for classification of differences in eight types of degenerative pathology observed with supine and upright MRI of the lumbar spine. Results were primarily driven by high numbers and high reliability of rating negative findings, whereas agreement regarding positive findings and positive positional differences was lower.

Patients with low back pain presenting for chiropractic care who want diagnostic imaging are more likely to receive referral for imaging: a cross-sectional study.

BACKGROUND: It is unclear if the use of imaging for low back pain (LBP) is impacted by patient beliefs. This study aimed to: (1) describe beliefs about the importance of imaging and whether patients wanted imaging when presenting for chiropractic care for LBP; (2) describe associations between baseline patient characteristics and imaging beliefs and whether patients wanted imaging; and (3) determine whether patients who believed imaging to be important in the management of LBP, or who wanted to receive imaging, were more likely to receive an imaging referral. METHODS: Cross-sectional observational data was collected between November 2016 to December 2019 from 10 primary care chiropractic clinics in Denmark. Consecutive patients aged 18 or older and presenting with a new episode of LBP were included (N = 2818). Beliefs about the importance of imaging (two questions) and whether imaging was wanted (one question) were collected at the initial visit, together with baseline participant characteristics and whether an imaging referral was provided. Associations between imaging beliefs/desire to receive imaging and participant characteristics were explored using multivariable logistic regression analysis. The relationships between imaging beliefs and desire to receive imaging with subsequent imaging referral were assessed using multivariable logistic regression analysis adjusted for pre-selected confounder variables. RESULTS: Approximately one third of participants believed imaging to be important for the management of LBP (29.5% (95%CI 27.8, 31.3) or 41.5% (95%CI 39.6, 43.3) depending on the two imaging beliefs questions). Approximately one quarter (26.1%, 95%CI 24.5, 27.7) of participants wanted to receive an imaging referral. Participants were more likely to believe in the importance of imaging or want an imaging referral if they had a longer duration of LBP, history of previous imaging for LBP, or a lower completed education level. Participants who wanted imaging at the initial consult were more likely to receive an imaging referral (Odds ratio; 95%CI 1.6; 1.2, 2.1). CONCLUSIONS: Approximately one third of patients presenting for chiropractic care in Denmark believed imaging to be important in the management of LBP. One quarter wanted imaging at the initial consult. Patients' desire for imaging appeared to impact the use of diagnostic imaging.

Appropriateness of referrals from primary care for lumbar MRI.

BACKGROUND: International guidelines do not recommend routine imaging, including magnetic resonance imaging (MRI), and seek to guide clinicians only to refer for imaging based on specific indications. Despite this, several studies show an increase in the use of MRI among patients with low back pain (LBP) and an imbalance between appropriate versus inappropriate use of MRI for LBP. This study aimed to investigate to what extent referrals from general practice for lumbar MRI complied with clinical guideline recommendations in a Danish setting, contributing to the understanding and approaches to lumbar MRI for all clinicians managing LBP in the primary sector. MATERIALS AND METHODS: From 2014 to 2018, all referrals for lumbar MRI were included from general practitioners in the Central Denmark Region for diagnostic imaging at a public regional hospital. A modified version of the American College of Radiology Imaging Appropriateness Criteria for LBP was used to classify referrals as appropriate or inappropriate, based on the unstructured text in the GPs' referrals. Appropriate referrals included fractures, cancer, symptoms persisting for more than 6 weeks of non-surgical treatment, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals were sub-classified as lacking information about previous non-surgical treatment and duration. RESULTS: Of the 3772 retrieved referrals for MRI of the lumbar spine, 55% were selected and a total of 2051 referrals were categorised. Approximately one quarter (24.5%) were categorised as appropriate, and 75.5% were deemed inappropriate. 51% of the inappropriate referrals lacked information about previous non-surgical treatment, and 49% had no information about the duration of non-surgical treatment. Apart from minor yearly fluctuations, there was no change in the distribution of appropriate and inappropriate MRI referrals from 2014 to 2018. CONCLUSION: The majority of lumbar MRI referrals (75.5%) from general practitioners for lumbar MRI did not fulfil the ACR Imaging Appropriateness Criteria for LBP based on the unstructured text of their referrals. There is a need for referrers to include all guideline-relevant information in referrals for imaging. More research is needed to determine whether this is due to patients not fulfilling guideline recommendations or simply the content of the referrals.

Advanced magnetic resonance imaging of chronic whiplash patients: a clinical practice-based feasibility study.

BACKGROUND: Whiplash injury is common following road traffic crashes affecting millions worldwide, with up to 50% of the injured developing chronic symptoms and 15% having a reduced working capability due to ongoing disability. Many of these patients receive treatment in primary care settings based upon clinical and diagnostic imaging findings. Despite the identification of different types of injuries in the whiplash patients, clinically significant relationships between injuries and chronic symptoms remains to be fully established. This study investigated the feasibility of magnetic resonance imaging (MRI) techniques including quantitative diffusion weighted imaging and measurements of cerebrospinal fluid (CSF) flow as novel non-invasive biomarkers in a population of healthy volunteers and chronic whiplash patients recruited from a chiropractic clinic for the purpose of improving our understanding of whiplash injury. METHODS: Twenty chronic whiplash patients and 18 healthy age- and gender matched control subjects were included [mean age ± SD (sex ratio; females/males), case group: 37.8 years ± 9.1 (1.22), control group: 35.1 years ± 9.2 (1.25)]. Data was collected from May 2019 to July 2020. Data from questionnaires pertaining to the car crash, acute and current symptoms were retrieved and findings from clinical examination and MRI including morphologic, diffusion weighted and phase-contrast images were recorded. The apparent diffusion coefficient and fractional anisotropy were calculated, and measurement and analysis of CSF flow was conducted. Statistical analyses included Fisher's exact test, Mann Whitney U test and analysis of variance between groups. RESULTS: The studied population was described in detail using readily available clinical tools. No statistically significant differences were found between the groups on MRI. CONCLUSIONS: This study did not show that MRI-based measures of morphology, spinal cord and nerve root diffusion or cerebrospinal fluid flow are sensitive biomarkers to distinguish between chronic whiplash patients and healthy controls. The detailed description of the chronic whiplash patients using readily available clinical tools may be of great relevance to the clinician. In the context of feasibility, clinical practice-based advanced imaging studies with a technical setup similar to the presented can be expected to have a high likelihood of successful completion.

What are the effects of diagnostic imaging on clinical outcomes in patients with low back pain presenting for chiropractic care: a matched observational study.

BACKGROUND: Evidence suggests that diagnostic imaging for low back pain does not improve care in the absence of suspicion of serious pathology. However, the effect of imaging use on clinical outcomes has not been investigated in patients presenting to chiropractors. The aim of this study was to determine if diagnostic imaging affects clinical outcomes in patients with low back pain presenting for chiropractic care. METHODS: A matched observational study using prospective longitudinal observational data with one year follow up was performed in primary care chiropractic clinics in Denmark. Data was collected from November 2016 to December 2019. Participants included low back pain patients presenting for chiropractic care, who were either referred or not referred for diagnostic imaging during their initial visit. Patients were excluded if they were less than 18 years old, had a diagnosis of underlying pathology, or had previous imaging relevant to their current clinical presentation. Coarsened exact matching was used to match participants referred for diagnostic imaging with participants not referred for diagnostic imaging on baseline variables including participant demographics, pain characteristics, and clinical history. Mixed linear and logistic regression models were used to assess the effect of imaging on back pain intensity and disability at two-weeks, three-months, and one-year, and on global perceived effect and satisfaction with care at two-weeks. RESULTS: 2162 patients were included, with 24.1% referred for imaging. Near perfect balance between matched groups was achieved for baseline variables except age and leg pain. Participants referred for imaging had slightly higher back pain intensity at two-weeks (0.4, 95%CI: 0.1, 0.8) and one-year (0.4, 95%CI: 0.0, 0.7), and disability at two-weeks (5.7, 95%CI: 1.4, 10.0), but the changes are unlikely to be clinically meaningful. No difference between groups was found for the other outcome measures. Similar results were found when sensitivity analysis, adjusted for age and leg pain intensity, was performed. CONCLUSIONS: Diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. These results support that current guideline recommendations against routine imaging apply equally to chiropractic practice.

Effects of weekly pain monitoring on back pain outcomes: a non-randomised controlled study.

BACKGROUND: Disease monitoring is an important element of self-management of several chronic diseases. Pain monitoring has become very easily available, but the role in musculoskeletal pain conditions is not clear. Awareness of pain might be helpful for people to understand pain, but focusing on pain may on the contrary negatively affect pain experience and behaviours. The objective of this study was to investigate the potential impact of pain monitoring on low back pain (LBP), specifically to determine if pain intensity, activity limitation and pain control, differed between patients with weekly pain monitoring over 12 months and patients with follow-ups at 2 weeks, 3 months and 12 months. METHODS: This was a non-randomised controlled study embedded in a cohort study with data collection November 1st 2016 to December 21st 2018. Adults seeking care for LBP were enrolled at the first visit to a chiropractor and followed with surveys after 2 weeks, 3 months and 12 months. Those enrolled first, n = 1,623, furthermore received weekly SMS-questions about pain frequency and pain intensity, whereas those enrolled next was the control group, n = 1,269 followed only by surveys. Outcomes at 12-months were compared, adjusting for group differences on baseline parameters. RESULTS: LBP intensity (0-10) was slightly lower at 12-months follow-up in the SMS group than the control group (adjusted beta - 0.40 (95% CI: - 0.62; - 0.19)). No relevant between-group differences were observed for activity limitation (0-100) (1.51 (95% CI: - 0.83; 3.85)) or ability to control pain (0-10) (- 0.08 (95% CI - 0.31; 0.15)). CONCLUSIONS: Frequent pain monitoring did not demonstrate any negative effects of weekly pain monitoring, and it was perhaps even helpful. The role of self-monitoring as part of self-managing LBP should be explored further including optimal frequencies, formats, and methods for feedback. TRIAL REGISTRATION: The study was not registered as a clinical trial.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study.

BACKGROUND: Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals' appropriateness. METHODS: Four inexperienced students (chiropractic master's students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or "other reasons" for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison. RESULTS: Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55-0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58-0.91) and 0.82 (95% CI: 0.72-0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters' results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84-92%, respectively, for the pairwise comparisons. CONCLUSION: The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

The Danish Chiropractic Low Back Pain Cohort (ChiCo): Description and Summary of an Available Data Source for Research Collaborations.

BACKGROUND: Back pain is among the most frequent reasons for care seeking globally. Observational clinical cohorts are useful for understanding why people seek care, the content of that care, and factors related to prognosis. This paper describes the Danish Chiropractic low back pain Cohort (ChiCo) and summarizes the primary characteristics of the population to inform the scientific community of the availability of these data as a resource for collaborative research projects. METHODS: Adults seeking chiropractic care for a new episode of non-specific back pain were enrolled at the initial visit and followed up after 2, 13, and 52 weeks, with a subpopulation having weekly follow-ups for 1 year. Patient-reported and clinical-reported data were collected in an electronic database using the REDCap software (REDCap Consortium, projectredcap.org). Variables were chosen to measure pre-defined research domains and questions and to capture information across health constructs deemed relevant for additional research. Non-responders at 13 and 52 weeks were contacted by phone to maximize follow-up data and explore differences on core outcomes between responders and non-responders. RESULTS: A total of 2848 patients (mean age 45 years, 59% men) were included from 10 clinics with 71%, 68% and 64% responding to follow-ups at 2, 13 and 52 weeks, respectively. Most participants (82%) were employed, nearly half reported current LBP for 1-7 days, and 83% had experienced LBP episodes previously. We did not identify indications of serious attrition bias. CONCLUSION: We have described the aims and procedures for establishing the ChiCo cohort, characteristics of the cohort, and available information about attrition bias. These data have the potential to be linked, at an individual participant level, to the extensive Danish population-based registries that measure diverse health and social characteristics.

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population.

BACKGROUND: Lumbar disc degeneration seen on magnetic resonance imaging (MRI) is defined as loss of signal intensity and/or disc height, alone or in combination with other MRI findings. The MRI findings and thresholds used to define disc degeneration vary in the literature, and their associations with low back pain (LBP) remain uncertain. OBJECTIVE: To explore how various thresholds of lumbar disc degeneration alter the association between disc degeneration and self-reported LBP. METHODS: An exploratory, cross-sectional cohort study of a general population. Participants in the cohort 'Backs-on-Funen' had MRI scans and completed questionnaires about LBP at ages 41, 45 and 49 years. The MRI variables, signal intensity (Grades 0-3) and disc height (Grades 0-3), were dichotomised at different thresholds. Logistic regression analyses were used to determine associations. Arbitrarily, a difference in odds ratio (OR) of > 0.5 between thresholds was considered clinically relevant. Receiver Operating Characteristic curves were used to investigate differences between diagnostic values at each threshold. RESULTS: At age 41, the difference in ORs between signal loss and LBP exceeded 0.5 between the thresholds of ≥2 (OR = 2.02) and = 3 (OR = 2.57). Difference in area under the curves (AUC) was statistically significant (p = 0.02). At ages 45 and 49, the difference in ORs exceeded 0.5 between the thresholds of ≥2 and = 3, but the differences between AUC were not statistically significant. At age 41, the difference in ORs between disc height loss and LBP at the thresholds of ≥1 (OR = 1.44) and ≥ 2 (OR = 2.53) exceeded 0.5. Differences in AUC were statistically significant (p = 0.004). At age 49, differences in ORs exceeded 0.5 (OR = 2.49 at the ≥1 threshold, 1.84 at ≥2 and 0.89 at =3). Differences between AUC were not statistically significant. CONCLUSION: The results suggest that the thresholds used to define the presence of lumbar disc degeneration influence how strongly it is associated with LBP. Thresholds at more severe grades of disc signal and disc height loss were more strongly associated with LBP at age 41, but thresholds at moderate grades of disc degeneration were most strongly associated with LBP at ages 45 and 49.

Degenerative findings in lumbar spine MRI: an inter-rater reliability study involving three raters.

BACKGROUND: For diagnostic procedures to be clinically useful, they must be reliable. The interpretation of lumbar spine MRI scans is subject to variability and there is a lack of studies where reliability of multiple degenerative pathologies are rated simultaneously. The objective of our study was to determine the inter-rater reliability of three independent raters evaluating degenerative pathologies seen with lumbar spine MRI. METHODS: Fifty-nine people, 35 patients with low back pain (LBP) or LBP and leg pain and 24 people without LBP or leg pain, received an MRI of the lumbar spine. Three raters (one radiologist and two chiropractors) evaluated the MRIs for the presence and severity of eight degenerative spinal pathologies using a standardized format: Spondylolisthesis, scoliosis, annular fissure, disc degeneration, disc contour, nerve root compromise, spinal stenosis and facet joint degeneration. Findings were identified and classified at disc level according to type and severity. Raters were instructed to evaluate all study sample persons once to assess inter-rater reliability (fully crossed design). Reliability was calculated using Gwet's Agreement Coefficients (AC1 and AC2) and Cohen's Kappa (κ) and Conger's extension of Cohen's. Gwet's probabilistic benchmarking method to the Landis and Koch scale was used. MRI-findings achieving substantial reliability was considered acceptable. RESULTS: Inter-rater reliability for all raters combined, ranged from (Gwet's AC1 or AC2): 0.64-0.99 and according to probabilistic benchmarking to the Landis and Koch scale equivalent to moderate to almost perfect reliability. Overall reliability level for individual pathologies was almost perfect reliability for spondylolisthesis, spinal stenosis, scoliosis and annular fissure, substantial for nerve root compromise and disc degeneration, and moderate for facet joint degeneration and disc contour. CONCLUSION: Inter-rater reliability for 3 raters, evaluating 177 disc levels, was found to be overall acceptable for 6 out of 8 degenerative MRI-findings in the lumbar spine. Ratings of facet joint degeneration and disc contour achieved moderate reliability and was considered unacceptable.

Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis.

PURPOSE: To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. METHODS: Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. RESULTS: In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care. CONCLUSIONS: The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.

Catastrophization, fear of movement, anxiety, and depression are associated with persistent, severe low back pain and disability.

BACKGROUND CONTEXT: Psychological characteristics are important in the development and progression of low back pain (LBP); however, their role in persistent, severe LBP is unclear. PURPOSE: To investigate the relationship between catastrophization, depression, fear of movement, and anxiety and persistent, severe LBP, and disability. STUDY DESIGN/ SETTING: One-year prospective cohort study. PATIENT SAMPLE: Participants were selected from the SpineData registry (Denmark), which enrolls individuals with LBP of 2 to 12 months duration without radiculopathy and without satisfactory response to primary intervention. OUTCOME MEASURES: Psychological characteristics, including catastrophization, depression, fear of movement, and anxiety, were examined at baseline using a validated screening questionnaire. Current, typical, and worst pain in the past 2 weeks were assessed by 11-point numeric rating scales and an average pain score was calculated. Disability was measured using the 23-item Roland-Morris Disability Questionnaire. METHODS: Participants completed baseline questionnaires on initial presentation to the Spine Center (Middelfart, Denmark), and follow-up questionnaires were sent and returned electronically. Statistical analysis involved multivariable Poisson regression to investigate the association between psychological factors and the number of episodes of severe pain or disability. This study received no direct funding. RESULTS: Of the 952 participants at baseline, 633 (63.4%) provided data 1 year later. Approximately half of the participants reported severe LBP (n=299, 47.2%, 95% confidence interval [CI] 43.3%-51.2%) or disability (n=315, 57.6%, 95% CI 53.3%-61.8%) at a minimum of one time point, and 14.9% (n=94, 95% CI 12.2%-17.9%) and 24.3% (n=133, 95% CI 20.8%-28.1%) experienced severe LBP or disability at two time points, respectively. Multivariable Poisson regression showed a relationship between catastrophization, depression, fear of movement, and anxiety and a greater number of time points with severe LBP and disability, after adjusting for age, gender, body mass index, and duration of symptoms. However, when all psychological factors were added to the regression model, only catastrophization and depression remained significantly associated. CONCLUSIONS: This study showed that persistent, severe LBP, and disability is common in a secondary care population with LBP and is associated with a variety of psychological risk factors, in particular catastrophization and depression, highlighting the importance of considering these factors in the design and evaluation of outcomes studies for LBP.

Back beliefs in patients with low back pain: a primary care cohort study.

BACKGROUND: The Back Belief Questionnaire (BBQ) measures beliefs about negative consequences of back pain. The aim of this study was to describe the back beliefs of a large clinical population with low back pain (LBP), to investigate the associations between back beliefs and patient characteristics when care-seeking, and between on-going pain and back beliefs at follow up. METHODS: Patients aged over 18, consulting with LBP with or without radicular pain of all symptom durations, were recruited from chiropractic clinics. The BBQ was completed on the first visit and at 3- and 12-month follow-ups. Sociodemographic- and symptom-related questions were answered at baseline. A BBQ sum score was calculated at all three time points, and linear regression was used to analyse the cross-sectional association between baseline patient characteristics and BBQ scores. Wilcoxon signed-rank test was used to test differences in BBQ scores for patients with and without on-going LBP at 3- and 12-months follow up. RESULTS: The baseline population consisted of 2295 participants. The median BBQ sum scores at baseline, 3 and 12 months had interquartile ranges of 33 [29-36], 33 [29-37], and 31 [27-35] respectively. Patient characteristics and symptoms were associated with baseline BBQ scores (p < 0.05), but most association were weak. The strongest association was with severe disability (4.0 points (95% CI 3.3-4.6) lower BBQ than no disability). Negative beliefs were related to more severe LBP at baseline and with on-going pain at follow up. CONCLUSION: At a population level, back beliefs were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common. Studies exploring individual patterns of back beliefs and associations with clinical outcomes over time are recommended.