Pain
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Randomized Controlled Trial Multicenter Study Clinical Trial
How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists.
Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n=2000) and PTs (n=2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT. ⋯ Many HCPs held the belief that LBP necessitates some avoidance of activities and work. The attitudes and beliefs of these HCPs were associated with their self-reported clinical behaviour regarding advice about work. Future studies need to investigate whether approaches aimed at modifying these HCP factors can lead to improved patient outcomes.
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To assess whether pseudoradicular low-back pain may be associated with subclinical sensory deficits in the distal extremity, we applied the quantitative sensory testing protocol of the German Research Network on Neuropathic Pain (DFNS) in 15 patients with pseudoradicular pain distribution. Sixteen age- and gender-matched healthy control subjects as well as 12 patients with radicular pain syndromes (L4-S1) were studied with the same protocol. Radicular pain was diagnosed using clinical criteria (pain radiation beyond the knee, motor-, sensory-, or reflex deficits, positive Laségue's test). ⋯ In contrast to some central pain syndromes this sensory loss involved predominantly large fiber functions. The subclinical sensory loss in pseudoradicular cases suggests that these patients may also have a neuropathic component of their chronic pain. The spatial incongruence of pain and sensory loss in pseudoradicular pain, however, may also indicate that the two are not causally related.
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The present study examined the relation between stage of chronicity and treatment response in patients with work-related musculoskeletal conditions and concurrent depressive symptoms. Also of interest was the role of reductions in pain severity, catastrophic thinking and fear of movement/re-injury as mediators of the relation between chronicity and treatment response. A sample of 80 individuals (38 women, 42 men) with a disabling musculoskeletal pain condition and concurrent depressive symptoms participated in the research. ⋯ The results highlight the importance of early detection and treatment of depressive symptoms, given that treatment response decreases over time. The results also suggest that reductions in depressive symptoms might be a precondition to the effective reduction of pain symptoms in this population. Discussion addresses the factors that might contribute to treatment resistance as the period of disability extends over time.
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A novel prognostic approach to defining chronic pain was developed in a US primary care low back pain population, using a combination of information about pain history, current status and likely prognosis. We tested whether this method was generalizable to a UK population. A prospective cohort of 426 patients who consulted with back pain at one of five UK general practices, and who returned follow-up information 1-year later were included. ⋯ The cut-points for probable and possible chronic pain developed in the US population (80% and 50% probability of future clinically significant back pain, respectively) were appropriate for the UK population, but the cut-point for classifying people at low risk (20% probability) was not replicated in the UK sample. The newly derived cut-points in the UK sample were similar; they remained the same for probable chronic pain, were slightly increased for possible chronic pain, and slightly reduced for those at intermediate or low risk. This method for defining chronic pain prospectively, using risk thresholds for future clinically significant pain, appears to be generalizable to a UK back pain population, particularly for identifying probable chronic pain, and may be generalizable to other primary care low back pain populations.
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Psychological and social factors have been shown, separately, to predict outcome in individuals with chronic low back pain. Few previous studies, however, have integrated both psychological and social factors, using prospective study of clinic populations of low back pain patients, to identify which are the most important targets for treatment. One hundred and eight patients with chronic low back pain, newly referred to an orthopaedic outpatient clinic, completed assessments of demographic characteristics, details of back pain, measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS), fearful beliefs about pain (Fear Avoidance Beliefs Questionnaire), social stresses (Life Events and Difficulties Schedule) and physical aspects of health-related quality of life [SF-36 Physical Component summary Score scale (PCS)]. ⋯ Number of healthcare contacts over the 6 months ranged from 1 to 29, and was independently predicted by perceived cause of pain [Incident Rate Ratio (IRR)=1.46, p=0.03], Fear Avoidance Beliefs about work (IRR=1.02, p=0.009) and back pain related social difficulties (IRR=1.16, p=0.03). To conclude, anxiety, depression, fear avoidance beliefs relating to work and back pain related stresses predict impairment in subsequent physical health-related quality of life and number of healthcare contacts. Interventions targeting these psychosocial variables in clinic patients may lead to improved quality of life and healthcare costs.