Association Between Self-Reported Spinal Morning Stiffness and Radiographic Evidence of Lumbar Disk Degeneration in Participants of the Cohort Hip and Cohort Knee (CHECK) Study.

BACKGROUND: Low back pain (LBP) is very common and is a main cause of limited activity and work absence. Patients with LBP may also report spinal morning stiffness; this symptom could be useful for identifying subgroups with signs and symptoms related to spinal osteoarthritis. OBJECTIVE: This study investigated whether an association exists between reported spinal morning stiffness and radiographic evidence of lumbar disk degeneration (LDD) in people with LBP and a history of pain of the hip and/or knee. DESIGN: This cross-sectional study used 8-year follow-up data from the Cohort Hip and Cohort Knee study. METHODS: The association between spinal morning stiffness and radiographic LDD features was assessed with multivariable logistic regression models. RESULTS: The presence of osteophytes was significantly associated with spinal morning stiffness (odds ratio [OR] = 2.1 [95% confidence interval [CI] = 1.3-3.2]) as was the presence of grade 2 or 3 disk space narrowing (OR = 2.0 [95% CI = 1.1-3.5]). There was also a significant association between morning stiffness persisting for > 30 minutes and grade 2 osteophytes (OR = 2.6 [95% CI = 1.1-6.2]) and grade 1 disk space narrowing (OR = 2.0 [95% CI = 1.1-3.6]). Furthermore, there was a significant association between moderate spinal morning stiffness and the presence of osteophytes (OR = 2.0 [95% CI = 1.2-3.2]). Both the presence of osteophytes and disk space narrowing were significantly associated with severe spinal morning stiffness (for osteophytes: OR = 2.0 [95% CI = 1.2-3.7]; for narrowing at L1-S1: OR = 1.8 [95% CI = 1.1-3.1]). LIMITATIONS: Only lumbar lateral radiographs were available for each participant, implying that the LDD features could have been underestimated. The quality of the radiographs was not consistent. CONCLUSIONS: This study showed an association between self-reported spinal morning stiffness and symptomatic LDD. When morning stiffness lasted > 30 minutes, there was a significant association with the features of LDD. The association was stronger when the severity of spinal morning stiffness increased.

Natural History of Back Pain in Older Adults over Five Years.

INTRODUCTION: Back pain is a prevalent health problem. Research often focuses on adults. Evidence on the long-term course of back pain in older patients is limited. A prospective cohort study (BACE) was conducted in a primary care setting in the Netherlands. We aim to investigate the 5-year course and medical consumption of older adults (>55 years) presenting with back pain in general practice. METHODS: Patients aged >55 years, consulting their general practitioner with a new back pain episode, were included between 2009 to 2011. Follow-up questionnaires included, for example, pain severity, disability, quality of life, recovery, and medical consumption. RESULTS: A total of 675 patients (mean age ± SD, 66.4 ± 7.6 years) participated, showing a mean (± SD) back pain reduction from 5.2 (± 2.7) to 3.6 (± 2.8) (numeric rating scale, 0 to 10) at 3 months follow-up; disability decreased from 9.8 (± 5.8) to 7.8 (± 6.2) (Roland-Morris Disability Questionnaire, 0 to 24). After 6 months, this remained practically constant over time. Medical consumption was highest in the first months; medication was used by 72% at baseline and approximately one-third (25% to 39%) during follow-up. At 5-year follow-up (response rate 58%; n = 392), 43% had recovered; a majority reported persistent or recurrent back pain. CONCLUSION: Clinically relevant improvements in back pain intensity and disability were seen in the first 3 to 6 months of follow-up. A majority of patients does not become pain free within 3 months; this does not improve over 5 years. However, most patients stop consulting health care professionals during follow-up. Current medical strategies may not be sufficient in older back pain patients, where back pain becomes a recurrent or chronic condition in the majority of patients.

Predicting no return to sports after three months in patients with traumatic knee complaints in general practice by combining patient characteristics, trauma characteristics and knee complaints.

Background: It remains unclear to what extent patients with traumatic knee complaints aged 18-45 years seen in general practice experience difficulties with return to sports.Objectives: This study aims to determine the proportion of patients with a knee trauma that return to sports at six weeks and three months follow-up. Also examined were associations between no return to sports and baseline patient/trauma characteristics, knee complaints and MR (magnetic resonance) findings, as well as the additive value of MR findings.Methods: Included were patients with traumatic knee complaints participating in a randomized controlled trial assessing the cost-effectiveness of an MR scan in general practice. Patients were classified as 'no return to sports' or 'return to sports' (sports on pre-injury or adapted level). Potential baseline predictors for no return to sports were assessed using logistic regression analyses. The area under the curves (AUC) was compared.Results: At six weeks and three months follow-up, 147 (59%) and 175 (74%) patients, respectively, reported return to sports. Combining patient characteristics, trauma characteristics and knee complaints predicted no return to sports with an AUC of 0.86 (95%CI: 0.81-0.90) at six weeks and of 0.82 (95%CI: 0.76-0.88) at three months follow-up. After adding MR findings, the AUC was 0.79 (95%CI: 0.71-0.87) at six weeks and 0.79 (95%CI: 0.70-0.88) at three months follow-up.Conclusion: Three out of four patients with a knee trauma in general practice reported return to sports at three months follow-up. A combination of patient/trauma characteristics and knee complaints predicted no return to sports, whereas MR findings had no additive value. Trial registration: Dutch trial registration: registration number: NTR3689. registration date: 7 November 2012.

Daily Pain Measurements and Retrospective Pain Measurements in Hip Osteoarthritis Patients With Intermittent Pain.

OBJECTIVE: To examine the value of daily pain measurements in patients with hip osteoarthritis (OA), and whether the reliability of retrospective measurements was lower in patients with intermittent pain than in patients with more constant pain. METHODS: We used data from a randomized controlled trial that investigated the effectiveness of general practitioner care plus exercise therapy in 203 patients with hip OA. During the first 6 weeks, patients scored their pain each day. These daily measurements were available for 185 patients. At 6-week follow-up, patients filled in a questionnaire rating their pain during the previous week. We examined whether the daily measurements provided results for pain other than those provided by retrospective measurements, using a linear mixed-effects model. We also explored differences between subgroups, based on the frequency and severity of intermittent pain, during the pain course and reliability between retrospective measurements and daily measurements. RESULTS: Daily measurements showed no different effect of exercise therapy on pain compared with retrospective measurements. We found statistical differences (by analysis of variance) during the course of pain between the subgroups based on the intensity of intermittent pain. Reliability between retrospective and daily measurements was lower in the subgroup with severe intermittent pain (Cronbach's α = 0.642) than in other subgroups (Cronbach's α >0.843). CONCLUSION: In this specific trial, daily measurements did not yield more precise or additional information compared with retrospective measurements at the 6-week follow-up. However, reliability of retrospective measurements may be lower in patients with a higher intensity of intermittent pain.

General Practitioners Referring Adults to MR Imaging for Knee Pain: A Randomized Controlled Trial to Assess Cost-effectiveness.

Purpose To determine the cost-effectiveness of early referral by the general practitioner for magnetic resonance (MR) imaging compared with usual care alone in patients aged 18-45 years with traumatic knee symptoms. Materials and Methods Cost-utility analysis was performed parallel to a prospective multicenter randomized controlled trial in Dutch general practice. A total of 356 patients with traumatic knee symptoms were included from November 2012 to December 2015 (mean age, 33 years ± 8 [standard deviation]; 222 men [62%]). Patients were randomly assigned to usual care (n = 177; MR imaging was not performed, but patients were referred to an orthopedic surgeon when conservative treatment was unsatisfactory) or MR imaging (n = 179) within 2 weeks after injury. Main outcome measures were quality-adjusted life years (QALYs) and costs from a healthcare and societal perspective. Multiple imputation was used for missing data. The Student t test was used to assess differences in mean QALYs, costs, and net benefits. Results Mean QALYs were 0.888 in the MR imaging group and 0.899 in the usual care group (P = .255). Healthcare costs per patient were higher in the MR imaging group (€1109) than in the usual care group (€837) (P = .050), mainly due to higher costs for MR imaging, with no reduction in the number of referrals to an orthopedic surgeon in the MR imaging group. Conclusion MR imaging referral by the general practitioner was not cost-effective in patients with traumatic knee symptoms; in fact, MR imaging led to more healthcare costs, without an improvement in health outcomes.

No association between low bone quality and back pain in older adults: A cohort study.

BACKGROUND: It is unclear whether bone quality associates with severity and prognosis of back pain. OBJECTIVES: To investigate the association between bone quality and back pain severity at baseline, and whether low bone quality is a prognostic factor for persistent back pain in patients aged over 55 years at 1-year follow-up. METHODS: In this prospective cohort study persistent back pain was defined as a decrease in the back pain severity score of less than 30% at 1-year follow-up compared with baseline score or as a back pain severity score greater than 1 (0-10: 0 = no pain) Low bone quality was categorized as a T-score, calculated using a stiffness index by quantitative ultrasound of the heel, of 2.5 or below. Data were analyzed in multiple regression analyses. RESULTS: Of all 513 patients, 68 (13%) showed low bone quality at baseline. Back pain severity showed no differences between patients with normal and with low bone quality. At 1-year follow-up, low bone quality was not associated with persistent back pain (defined as < 30%: OR 1.0; 95% CI: 0.40-2.30, p-value = 0.93; and defined as score > 1: OR 0.4; 95% CI: 0.17-1.15), p-value = 0.09), adjusted for all covariates. CONCLUSIONS: In older adults with back pain presenting in general practice, low bone quality was not associated with severity of back pain at baseline nor with persistent back pain at 1-year follow-up.

Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: a 12-week blinded randomised controlled trial.

OBJECTIVES: Guidelines recommend intra-articular glucocorticoid injection in patients with painful hip osteoarthritis. However, intra-articular hip injection is an invasive procedure. The efficacy of systemic glucocorticoid treatment for pain reduction in hip osteoarthritis is unknown. This randomised, double-blind, trial assessed effectiveness in hip pain reduction of an intramuscular glucocorticoid injection compared with a placebo injection in patients with hip osteoarthritis. METHODS: Patients with painful hip osteoarthritis were randomised to either 40 mg triamcinolone acetate or placebo with an intramuscular injection into the gluteus muscle. The primary outcomes were severity of hip pain at rest, during walking (0-10) and WOMAC pain at 2-week postinjection. We used linear mixed models for repeated measurements at 2, 4, 6 and 12 weeks for the intention-to-treat data analysis. RESULTS: Of the 107 patients randomised, 106 could be analysed (52 in the glucocorticoid group, 54 in the placebo group). At 2-week follow-up, compared with placebo injection, the intramuscular glucocorticoid injection showed a significant and clinically relevant difference in hip pain reduction at rest (difference -1.3, 95% CI -2.3 to -0.3). This effect persisted for the entire 12-week follow-up. For hip pain during walking, the effect was present at 4-week, 6-week and 12-week follow-ups, and for WOMAC pain the effect was present at 6-week and 12-week follow-up. CONCLUSIONS: An intramuscular glucocorticoid injection showed effectiveness in patients with hip osteoarthritis on one of the three primary outcomes at 2-week postinjection. All primary outcomes showed effectiveness from 4 to 6 weeks, up to a 12-week follow-up. TRIAL REGISTRATION NUMBER: NTR2966.

Effectiveness and cost-effectiveness of duloxetine added to usual care for patients with chronic pain due to hip or knee osteoarthritis: protocol of a pragmatic open-label cluster randomised trial (the DUO trial).

INTRODUCTION: Osteoarthritis (OA) is a highly prevalent painful condition of the musculoskeletal system. The effectiveness of current analgesic options has proven to be limited and improved analgesic treatment is needed. Several randomised placebo-controlled trials have now demonstrated the efficacy of duloxetine, an antidepressant with a centrally acting effect, in the treatment of OA pain. The aim of the current study is to investigate if duloxetine is effective and cost-effective as a third-choice analgesic added to usual care for treating chronic pain compared with usual care alone in general practice. METHODS AND ANALYSIS: A pragmatic open, cluster randomised trial is conducted. Patients with pain due to hip or knee OA on most days of the past 3 months with insufficient benefit of non-steroidal anti-inflammatory drugs or contraindications or intolerable side effects are included. General practices are randomised to either (1) duloxetine and usual care or (2) usual care only. Primary outcome is pain at 3 months measured on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. Secondary outcomes at 3 months and 1 year are pain (WOMAC, at 1 year), function (WOMAC), adverse reactions, quality of life and modification of the response to treatment by the presence of centrally sensitised pain (modified PainDETECT). At 1 year, medical and productivity costs will be assessed. Analyses will be performed following the intention-to-treat principle taking the cluster design into account. ETHICS AND DISSEMINATION: The study is approved by the local Medical Ethics Committee (2015-293). Results will be published in a scientific peer-reviewed journal and will be communicated at conferences. TRIAL REGISTRATION NUMBER: Dutch Trial Registry(ntr4798); Pre-results.

The Association Between Self-reported Low Back Pain and Radiographic Lumbar Disc Degeneration of the Cohort Hip and Cohort Knee (CHECK) Study.

STUDY DESIGN: Cross-sectional study, nested in a prospective cohort (Cohort Hip and Knee, CHECK). OBJECTIVE: Low back pain (LBP) is very common and the main cause of activity limitations and work absence throughout the world. Although lumbar disc degeneration (LDD) is suggested as a cause of LBP, this association remains debatable. Therefore, this study assessed the association between the radiographic features of LDD and the presence of self-reported LBP, LBP persisting longer than 3 months, the perceived severity of LBP and presence of neuropathic pain. SUMMARY OF BACKGROUND DATA: Previous literature suggests an association between LBP and both the LDD definitions osteophytes and disc space narrowing. There are no studies that have explored the association between LDD and neuropathic pain. METHODS: Associations between the radiographic LDD using two definitions (i.e., osteophytes, disc space narrowing) versus the presence of LBP, LBP > 3 months, severe LBP and neuropathic pain, were analyzed with logistic regression models. RESULTS: A total of 699 participants completed the questionnaire and had a lumbar radiograph. Radiographs were scored by two independent observers. Osteophytes were present in 98% of the population and disc space narrowing in 67%. Osteophytes were not significantly associated with LBP (OR = 1.2, 95% CI 0.9-1.7). Disc space narrowing was significantly associated with the presence of LBP and neuropathic pain (OR = 1.7, 95% CI = 1.2-2.4 and OR 1.7, 95% CI 1.1-2.7, respectively). The presence of a LBP severity score of ≥4, and LBP persisting > 3 months were not significantly associated with the two definitions of LDD. CONCLUSION: This study shows the presence of an association between disc space narrowing, whereas no association was found between osteophytes and LBP. We are the first to report an association between disc space narrowing and neuropathic pain. LEVEL OF EVIDENCE: 3.

Back Complaints in the Elders in Brazil and the Netherlands: a cross-sectional comparison.

Background: although back pain is most prevalent in older adults, there is a paucity of studies investigating back pain in older people. Our objective was to characterize and compare Brazilian and Dutch older adults presenting to primary care with a new episode of back pain. We also aimed to investigate whether socio-demographic characteristics were associated with pain severity and disability. Methods: we sourced data on 602 Brazilian and 675 Dutch participants aged ≥55 years with a new episode of back pain from the Back Complaints in the Elders consortium. We analyzed country differences in participants' characteristics, and associations between socio-demographic/clinical characteristics and pain severity and pain-related disability. Results: the two populations differed in most characteristics. More Dutch participants were smokers, heavy drinkers, and reported back stiffness. More Brazilian participants were less educated, had higher prevalence of comorbidities; higher levels of pain intensity, disability and psychological distress. When controlling for the effect of country, being female and having altered quality of sleep were associated with higher pain intensity. Altered quality of sleep, having two or more comorbidities and physical inactivity were associated with higher disability. Higher educational levels were negatively associated with both pain and disability outcomes. Conclusions: back pain is disabling in the older population. Our country comparison has shown that country of residence is an important determinant of higher disability and pain in older people with back pain. Irrespective of country, women with poor sleep quality, comorbidities, low education and who are physically inactive report more severe symptoms.

Management of Symptomatic Cervical Disk Herniation: A Survey Among Dutch Neurosurgeons.

STUDY DESIGN: A questionnaire survey. OBJECTIVE: To assess the preferred surgical technique, the optimal timing of surgery, and the expectations of different surgical techniques of neurosurgeons in the Netherlands, regarding patients with cervical disc herniation (CDH). SUMMARY OF BACKGROUND DATA: To treat CDH, multiple surgical techniques are performed. Due to the lack of consensus, the daily routine management may vary. METHODS: All 134 neurosurgeons of the Dutch Association of Neurosurgery were sent a survey, evaluating the operative management as well as the attitude towards different surgical treatments for CDH. RESULTS: Ninety-six (74.4%) of the neurosurgeons treating CDH completed the survey. Anterior cervical discectomy with fusion (ACDF) was the standard procedure for the majority of neurosurgeons (76.3%). ACDF was expected to have the highest effectiveness on arm pain, yet also a higher risk for complications as compared with anterior cervical discectomy (ACD). Approximately, 47.9% of the surgeons regarded a minimal duration of 8 to 12 weeks of radicular arm pain before deciding to perform surgery. Regarding the risk of recurrent CDH, DCF was expected to give the highest risk, whereas ACDF the lowest. CONCLUSION: Despite the lack of solid evidence in favor for ACDF this survey showed that ACDF is the preferred technique to treat cervical radiculopathy. A minimum duration of 8 to 12 weeks of radicular arm pain was considered the optimal timing to perform surgery for CDH by the majority of the neurosurgeons. Whether to fuse or not remains a controversial subject in degenerative spinal surgery. This study emphasizes the need of high-quality evidence on the optimal surgical management of CDH. LEVEL OF EVIDENCE: N/A.

Knee osteoarthritis in traumatic knee symptoms in general practice: 6-year cohort study.

AIM: To identify degenerative knee abnormalities using MRI and radiography 6 years after knee trauma, their relation with persistent knee symptoms and baseline prognostic factors. METHODS: Adults (18-65 years) with incident traumatic knee symptoms visiting their general practitioner were followed up for 6 years and underwent baseline MRI and 6-year follow-up MRI and radiography. Logistic regression was used to analyse associations between various degenerative abnormalities on 6-year MRI and radiography, persistent knee symptoms and baseline prognostic factors for knee osteoarthritis (OA) on 6-year MRI. RESULTS: On 6-year radiography, 60% of patients showed no OA, 28% showed OA with Kellgren&Lawrence (K&L) grade 1 and 13% showed with K&L grade 2. On 6-year MRI, 55% of patients showed cartilage defect(s), 45% showed osteophyte(s), 36% showed subchondral cyst(s), 40% showed bone marrow oedema, 21% showed meniscal subluxation, 83% showed meniscal degeneration,11% showed effusion and 11% showed a Baker's cyst. Of these, most were significantly related with 6-year radiographic K&L grade, while only lateral cartilage defect(s), medial osteophyte(s) and medial meniscal subluxation were significantly related with persistent knee symptoms. 32% of patients showed new onset or progressive knee OA on 6-year MRI, for which age, history of non-traumatic knee symptoms and bone marrow oedema at baseline were independent prognostic factors. CONCLUSIONS: Degenerative knee abnormalities on MRI are related to the K&L score; however, not all abnormalities are reflected in clinical outcome. Age, history of non-traumatic knee symptoms and bone marrow oedema predict knee OA 6 years after knee trauma, present in 32% of the patients.

Defining trajectories in older adults with back pain presenting in general practice.

BACKGROUND: although back pain is a frequently recurring disorder, the course of back pain remains uncertain. Therefore, this study aimed to identify different trajectories in older adults with back pain who presented in general practice and to determine which baseline characteristics are associated with these trajectories. METHODS: the BACE study is a prospective cohort study including 675 patients (aged >55 years) with back pain who consulted a general practitioner; patients were followed for 3 years. Latent class growth analysis was used to identify different trajectories in back pain severity measured at eight different time points. A multinomial regression analysis was used to assess variables associated with membership of an identified trajectory. RESULTS: using the different indices of fit and the usefulness of the different trajectories in clinical practice, a 3-class cubic model was determined to be the best model. The three trajectories were defined as 'low pain trajectory', 'high pain trajectory' and 'intermediate pain trajectory'. Baseline variables associated with a higher chance of being in the intermediate or high trajectory were: female gender, higher body mass index, chronic back pain, more disability, lower scores on the SF-36 physical summary scale, and negative expectations of recovery. CONCLUSIONS: three different back pain trajectories were identified in older adults presenting with back pain in general practice. Various baseline characteristics were associated with a higher chance of being in the high or intermediate back pain trajectory. These characteristics might help identify patients at risk for a less favourable outcome.

The added prognostic value of MRI findings for recovery in patients with low back pain in primary care: a 1-year follow-up cohort study.

PURPOSE: Information on the prognostic value of MRI findings in low back pain patients in primary care is lacking. The objective of this study is to investigate the added prognostic value of baseline MRI findings over known prognostic factors for recovery at 12-month follow-up in patients with low back pain referred to MRI by their general practitioner. METHODS: Patients referred by their general practitioner for MRI of the lumbar spine were recruited at the MRI Center. The questionnaires at baseline and at 3 and 12-months follow-up included potential clinical predictors from history taking and the outcome recovery. The MRI radiology reports were scored. Analysis was performed in 3 steps: derivation of a predictive model including characteristics of the patients and back pain only (history taking), including reported MRI findings only, and the addition of reported MRI findings to the characteristics of the patients and back pain. RESULTS: At 12-months follow-up 53% of the patients reported recovery (n = 683). Lower age, better attitude/beliefs regarding back pain, acute back pain, presence of neurological symptoms of the leg(s), and presence of non-continuous back pain were significantly associated with recovery at 12-months follow-up: area under the curve (AUC) 0.77. Addition of the MRI findings resulted in an AUC of 0.78. CONCLUSIONS: At 12-months follow-up, only 53% of these patients with low back pain referred for MRI in general practice reported recovery. Five clinic baseline characteristics were associated with recovery at 12-months follow-up; adding the MRI findings did not result in a stronger prediction of recovery.

Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice.

BACKGROUND: The use of magnetic resonance imaging (MRI) as initial imaging for back pain has increased in general practice. However, few data are available on the characteristics of these referred patients. The objective of this study was to describe the baseline characteristics and MRI findings of patients presenting for a lumbar MRI examination as referred by their GP. METHODS: Patients presenting for a lumbar MRI examination as referred by their GP were recruited at the MRI Center. The MRI radiology reports were scored for the presence of disc bulging, disc herniation, nerve root compression, spinal stenosis, spondylolisthesis and serious pathologies. Information on patients' characteristics, characteristics of the complaints and red flags were derived from questionnaires. Cross-sectional differences between patients with and without specific MRI findings were analyzed. RESULTS: A total of 683 low back pain (LBP) patients were included; mean age was 49.9 (range 19-80) years and 53% was male. Mean back pain severity score was 6.6 (SD 2.0) and 67% of the patients reported having chronic LBP. In total, 374 patients (55%) reported sciatica complaints for at least 6 weeks. Of all MRI reports, 69% mentioned signs of nerve root compression. Serious pathologies were reported in 3% of the patients. In total, 94% of patients had abnormal MRI findings. CONCLUSIONS: Almost all patients presenting for a lumbar MRI examination as referred by their GP had abnormal MRI findings. In total, 55% of the patients reported persistent sciatica in which imaging is recommended according to international guidelines.

Six-year course and prognosis of traumatic knee symptoms in general practice: Cohort study.

BACKGROUND: Traumatic knee symptoms are frequently seen, however, evidence about the course and prognostic factors are scarce. OBJECTIVES: To describe the one and six-year course of traumatic knee symptoms presenting in general practice, and to identify prognostic factors for persistent knee symptoms. METHODS: Adolescents (≥12 years) and adults with traumatic knee symptoms (n = 328) from general practice were followed for six years with self-report questionnaires and physical examination. RESULTS: Persistent knee symptoms were reported by 27% of the patients at one year and by 33% at six years. There was a strong relationship (OR: 11.0, 95% CI: 5.0-24.2) between having persistent knee symptoms at one year and at six-year follow-up. Prognostic factors associated with persistent knee symptoms at one year were age, poor general health, history of non-traumatic knee symptoms, absence floating patella and laxity on the anterior drawer test (AUC: 0.72). At six-year follow-up, age, body mass index > 27, non-skeletal co-morbidity, self-reported crepitus of the knee, history of non-traumatic knee symptoms, and laxity on the anterior drawer test were associated with persistent knee symptoms (AUC: 0.82). CONCLUSION: Traumatic knee symptoms in general practice seem to become a chronic disorder in one out of three patients. Several prognostic factors assessed at baseline were associated with persistent knee symptoms at one and six-year follow-up.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice.

BACKGROUND: In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present. OBJECTIVE: The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain. METHODS: The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry. RESULTS: Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values. LIMITATIONS: Low prevalence of vertebral fractures could have led to findings by chance. CONCLUSIONS: In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

Prognosis and course of work-participation in patients with chronic non-specific low back pain: a 12-month follow-up cohort study.

OBJECTIVE: To investigate the clinical course of, and prognostic factors for, work-participation in patients with chronic non-specific low back pain. METHODS: A total of 1,608 patients with chronic non-specific low back pain received a multidisciplinary therapy and were evaluated at baseline and 2-, 5- and 12-month follow-ups. Recovery was defined as absolute recovery if the patient worked 90% of his contract hours at follow-up. Potential factors were identified using multivariable logistic regression analysis. RESULTS: Patients reported a mean increase in work-participation from 38% at baseline to 82% after 12 months. Prognostic factors for ≥ 90% work-participation at 5 months were being married (odds ratio (OR) 1.72 (95% confidence interval (95% CI) 1.12-2.65)), male (OR 1.99 (95% CI 1.24-3.20)), a higher score on disability (OR 1.00 (95% CI 0.997-1.02)) and physical component scale (Short-Form 36 (SF-36)) (OR 1.05 (95% CI 1.02-1.07)), previous rehabilitation (OR 1.85 (95% CI 1.14-2.98)), not receiving sickness benefits (OR 0.52 (95% CI 0.24-1.10)) and more work-participation (OR 4.86 (95% CI 2.35-10.04)). More work-participation (OR 5.22 (95% CI 3.47-7.85)) and male sex (OR 1.79 (95% CI 1.25-2.55)) were also prognostic factors at 12-month follow-up. CONCLUSION: At 12 months 52% of patients reported ≥ 90% work-participation. The strongest prognostic factor was more work-participation at baseline for the recovery of chronic non-specific low back pain.

Adverse drug reactions in a primary care population prescribed non-steroidal anti-inflammatory drugs.

OBJECTIVE: To determine how often patients with musculoskeletal (MSK) complaints prescribed a non-steroidal anti-inflammatory drug (NSAID) subsequently consult their general practitioner (GP) with a non-serious adverse drug reaction (ADR). DESIGN: Cohort study. SETTING: A healthcare database containing the electronic GP medical records of over 1.5 million patients throughout the Netherlands. PATIENTS: A total of 16 626 adult patients with MSK complaints prescribed an NSAID. MAIN OUTCOME MEASURES: The patients' medical records were manually assessed for the duration of NSAID use for a maximum of two months, and consultations for complaints predefined as potential ADRs were identified. Subsequently, the likelihood of an association with the NSAID use was assessed and these potential ADRs were categorized as likely, possible, or unlikely ADRs. RESULTS: In total, 961 patients (6%) consulted their GP with 1227 non-serious potential ADRs. In 174 patients (1%) at least one of these was categorized as a likely ADR, and in a further 408 patients (2.5%) at least one was categorized as a possible ADR. Dyspepsia was the most frequent likely ADR, followed by diarrhoea and dyspnoea (respectively 34%, 8%, and 8% of all likely ADRs). CONCLUSION: Of the patients with MSK complaints prescribed an NSAID, almost one in 30 patients re-consulted their GP with a complaint likely or possibly associated with the use of this drug. The burden of such consultations for non-serious ADRs should be taken into account by GPs when deciding whether treatment with an NSAID is appropriate.