Moderators of treatment effect of non-steroidal anti-inflammatory drugs for patients with (sub) acute low back pain: Protocol for a systematic review with individual participant data meta-analysis.

A Cochrane review found that non-steroidal anti-inflammatory drugs (NSAIDs) are slightly more effective than placebo on acute and subacute low back pain (LBP) outcomes (pain intensity, disability, and global improvement). Our objectives are: (1) to assess the overall treatment effect of NSAIDs in adults with acute and subacute LBP; (2) to identify the moderation of baseline patients' characteristics on treatment effect. We will conduct a systematic search of RCTs on effectiveness of NSAIDs compared with placebo in adults with non-chronic LBP in Medline ALL, Embase, Cochrane Central Register of Controlled Trials*. We will screen the records after January 2020, and include eligible RCTs before January 2020 screened by the Cochrane review mentioned above. Our primary outcomes are pain intensity, disability, and health-related quality of life, secondary outcomes are adverse events. Our IPD dataset will consist of the information on each eligible trial characteristics and included variables according to a predefined coding scheme. We will assess risk-of-bias of included RCTs with the Cochrane Risk Of Bias (RoB)-2 assessment tool. We will perform power calculations with closed-form solutions and prioritize a one-stage approach for IPD-MA. For reporting the results, we will adhere to the PRISMA-IPD statement.

Exploring usual care for patients with low back pain in primary care: a cross-sectional study of general practitioners, physiotherapists and chiropractors.

OBJECTIVES: To explore the elements and composition of care provided by general practitioners (GPs), physiotherapists (PTs) and chiropractors (DCs) to patients with low back pain (LBP). DESIGN: Observational study. SETTING: Primary care setting, Denmark. PARTICIPANTS: Primary care clinicians (GPs, PTs and DCs) in the Region of Southern Denmark were invited to register consecutive adult patient visits with LBP as the primary complaint. PRIMARY OUTCOME MEASURES: Clinicians reported care elements provided to patients with LBP. Elements varied due to professional differences (eg, prescriptive rights). Data were descriptively analysed, on group and individual levels, for frequency and combination of care elements, and practice patterns were explored with latent class analysis. RESULTS: The clinicians (33 GPs, 67 PTs and 43 DCs with a median experience of 15 years and 59% were females) registered 3500 patient visits. On average, the visits involved patients aged 51 years, and 51% were with females. The frequencies of common care elements across professions were information (42%-56% of visits between professions) and advice (56%-81%), while other common elements for GPs were pain medication (40%) and referrals to PTs (36%), for PTs, use of exercises (81%) and for DCs, use of manual therapy (96%). Substantial variation was observed within professions and distinct practice patterns, with different focuses of attention to information and advice versus exercise and manual therapy, were identified for PTs and DCs. CONCLUSIONS: These data indicate substantial variation in the care elements provided by GPs, PTs and DCs to LBP patients. The compositions of care and practice patterns identified challenge the understanding of usual care as a uniform concept and professions as homogeneous groups. Strategic use of particular care elements in different parts of treatment courses is indicated. Longitudinal data and qualitative enquiry are needed to assess if or how care is tailored to individual patients.

Demographic and clinical characteristics of patients with low back pain in primary and secondary care settings in Southern Denmark.

OBJECTIVE: To describe and compare the demographic and clinical characteristics of patients with acute or chronic low back pain across all health care settings treating this condition.Design and setting: Concurrent prospective survey registration of all consecutive consultations regarding low back pain at general practitioners, chiropractors, physiotherapists, and the secondary care spine centre in Southern Denmark. SUBJECTS: Patients ≥16 years of age with low back pain. MAIN OUTCOME MEASURE: Demographic characteristics, symptoms, and clinical findings were registered and descriptively analysed. Pearson's chi-square tested differences between the populations in the four settings. Multiple logistic regression assessed the odds of consulting specific settings, and t-test assessed differences between patients attending for a first and later consultation. RESULTS: Thirty-six general practitioners, 44 chiropractors, 74 physiotherapists, and 35 secondary care Spine Centre personnel provided information on 5645 consultations, including 1462 first-visit consultations. The patients differed significantly across the settings. Patients at the Spine Centre had the most severe symptoms and signs and were most often on sick leave. Compared to the other populations, the chiropractor population was younger, whereas the physiotherapist population was older, more often females, and had prolonged symptoms. In general practice, first-time consultations were with milder cases while patients who attended for a second or later consultation had the worst symptoms, findings, and risk of sick leave compared to the other primary care settings. CONCLUSION: The demographic and clinical characteristics of patients with low back pain differ considerably across the health care settings treating them.KEY POINTSThe study describes the symptoms and clinical findings of patients with low back pain consulting the Danish health care system in all its settings.Patients with chiropractors were youngest, while those with physiotherapists were the oldest and most frequently female.First consultations in general practice were generally with the least symptomatic patients while those returning for a subsequent consultation had more severe disease including more sick leave compared to patients in the other primary care settings.Our findings call for caution when generalizing between health care settings for patients with low back pain.

Database coverage and their use in systematic reviews regarding spinal manipulative therapy: an exploratory study.

BACKGROUND: Systematic reviews (SRs) of randomized controlled trials (RCTs) are considered one of the most reliable study types. Through a systematic and thorough literature search, researchers aim to collect all research relevant to their purpose. The selection of databases can be challenging and depend on the topic of interest. The Cochrane Handbook suggests searching at least the following three databases: Cochrane Library, MEDLINE, and EMBASE. However, this is not always sufficient for reviews on the musculoskeletal field in general. This study aimed to examine the frequency and choice of databases used by researchers in SRs of spinal manipulative therapy (SMT). Secondly, to analyze the RCTs included in the SRs to determine the optimal combination of databases needed to conduct efficient literature searches for SRs of SMT. METHODS: SRs investigating the effect of SMT on any patient-reported outcome measure were identified through searches in PubMed and Epistemonikos (all entries till date of search February 25, 2022). For each SR, databases searched and included RCTs were collected. RCTs were searched individually in nine databases (Cochrane Library, MEDLINE/PubMed, EMBASE, Google Scholar, CINAHL, Web of Science, Index to Chiropractic Literature, PEDro, and AMED). Coverage rates were calculated using the number of retrieved RCTs by the database or combinations of databases divided by the total number of RCTs. RESULTS: Eighty-five SRs published met the inclusion criteria, and 442 unique RCTs were retrieved. The most frequently searched database was MEDLINE/PubMed. Cochrane Library had the highest overall coverage rate and contained the third most unique RCTs. While a 100% retrieval was not possible, as 18 RCTs could not be retrieved in any of the nine databases, the combination of Cochrane Library, Google Scholar, and PEDro retrieved all possible RCTs with a combined coverage rate of 95.9%. CONCLUSIONS: For SRs on SMT, we recommend using the combination suggested by the Cochrane Handbook of Cochrane Library, MEDLINE/PubMed, Embase, and in addition, PEDro and Index to Chiropractic Literature. Google Scholar might be used additionally as a tool for searching gray literature and quality assurance.

Providing information at the initial consultation to patients with low back pain across general practice, chiropractic and physiotherapy - a cross-sectorial study of Danish primary care.

OBJECTIVE: Clinical guidelines for managing low back pain (LBP) emphasise patient information, patient education and physical activity as key components. Little is known about who actually receives information. This study investigates to what extent information at the first consultation with general practitioner (GP), chiropractor (DC) and physiotherapist (PT) in Danish primary care is provided to patients with LBP. DESIGN AND SETTING: This cross-sectorial study was conducted as a prospective survey registration of LBP consultations at the three primary health care professions in Denmark. INTERVENTION: Clinicians ticked off a paper survey chart during or after consultations with patients who visited the clinic for LBP (Approval number: ID # 11.220). SUBJECTS: 33 GPs, 43 DCs and 61 PTs registered first-time consultations. MAIN OUTCOME MEASURES: The primary outcome was provision of information, overall and across care settings. RESULTS: The overall proportion of patients provided with information was 72%, but this varied among professions (GP, 44%; DC, 76%; and PT, 74%). Provision of information increased to 78% if patients had increased emotional distress or back-related leg pain below the knee. The strongest association with provision of information was having two or three signs of elevated distress (OR 2.58 and 5.05, respectively, p= 0.00) or physical disability (OR 2.55, p= 0.00). CONCLUSION: In more than a quarter of first-time consultations, patient information was not provided. Large variation in providing information was found across the settings. The proportion provided with information increased for sub-populations having elevated distress or back-related leg pain below the knee.Key Points Clinical guidelines recommend patient information, patient education and physical activity for managing low back pain (LBP) • Information is not provided in more than a quarter of first-time consultations in Danish primary care settings that manage these patients. • Information increased for the sub-populations having elevated distress and back-related leg pain below the knee. • The conducted primary care surveys monitored clinical activity and illustrated variations in provision of information.