The objectives of this systematic review were to determine whether sociologic and demographic factors modify the effect of fusion versus nonoperative management in patients with chronic low back pain.
Chronic low back pain is among the most common symptoms leading patients to seek medical care and presents significant challenges in treatment decision making. This is due to the wide array of pathologic conditions causing back pain, the multitude of patient variables (i.e., litigation, psychologic issues, social issues) that are thought to influence the perception of back pain, and the wide variation in treatment response. Sociodemographic factors are thought to play a role in pain perception and treatment response, though this has been poorly assessed in the literature.
Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of sociodemographic factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain.
The only sociologic factors evaluated in randomized controlled trials adequate to assess heterogeneity of treatment effect are pending litigation, worker's compensation, sick leave, and heavy labor job type. Litigation patients, although thought to do poorly with treatment of chronic low back pain in general, responded more favorably to fusion than nonoperative care. Likewise, patients with lighter jobs and those patients who were not on sick leave did better with fusion than nonoperative care. No demographic factors were observed to respond more favorably to one treatment over the other.
Sociodemographic factors are not well studied in the literature, but are assumed to affect treatment outcomes. After rigorous review, few studies held up to the standards required for defining the comparative treatment effect of these factors. Pending litigation may negatively impact outcomes of patients with chronic low back pain; however, those who underwent fusion had better outcomes than those with nonoperative management in two European studies. There is no evidence to suggest that sociodemographic factors alone should preclude surgery. Well-constructed prospective randomized studies with predefined subgroup analyses are required to further understand the impact of sociodemographic factors in the treatment of chronic low back pain.
Sociodemographic factors should be considered when making treatment decisions for patients with chronic low back pain, but alone do not preclude fusion for chronic low back pain. Strength of recommendation: Weak.
[Show abstract][Hide abstract] ABSTRACT: In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 03/2012; 54(4):504-12. DOI:10.1097/JOM.0b013e31824fe0aa · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?
Journal of manipulative and physiological therapeutics 09/2012; 35(7):493-513. DOI:10.1016/j.jmpt.2012.09.001 · 1.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study investigated the effect of low-level laser therapy (LLLT) on the masticatory performance (MP), pressure pain threshold (PPT), and pain intensity in patients with myofascial pain. Twenty-one subjects, with myofascial pain according to Research Diagnostic Criteria/temporomandibular dysfunction, were divided into laser group (n = 12) and placebo group (n = 9) to receive laser therapy (active or placebo) two times per week for 4 weeks. The measured variables were: (1) MP by analysis of the geometric mean diameter (GMD) of the chewed particles using Optocal test material, (2) PPT by a pressure algometer, and (3) pain intensity by the visual analog scale (VAS). Measurements of MP and PPT were obtained at three time points: baseline, at the end of treatment with low-level laser and 30 days after (follow-up). VAS was measured at the same times as above and weekly throughout the laser therapy. The Friedman test was used at a significance level of 5 % for data analysis. The study was approved by the Ethics Committee of the Federal University of Sergipe (CAAE: 0025.0.107.000-10). A reduction in the GMD of crushed particles (p < 0.01) and an increase in PPT (p < 0.05) were seen only in the laser group when comparing the baseline and end-of-treatment values. Both groups showed a decrease in pain intensity at the end of treatment. LLLT promoted an improvement in MP and PPT of the masticatory muscles.
Lasers in Medical Science 11/2012; 29(1). DOI:10.1007/s10103-012-1228-7 · 2.49 Impact Factor
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