A Long Way to Go Practice Patterns and Evidence in Chronic Low Back Pain Care

Cecil G. Sheps Center for Health Services Research, University of North Carolina, 725 Airport Road, Chapel Hill, NC 27599-7590, USA.
Spine (Impact Factor: 2.3). 05/2009; 34(7):718-24. DOI: 10.1097/BRS.0b013e31819792b0
Source: PubMed


A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006.
The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition.
Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer.
Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews.
Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state.
Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

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Available from: Liana Castel, Sep 05, 2014
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    • "However, recent studies of care coordination between medical doctors (MD) or doctors of osteopathy (DO) and doctors of chiropractic suggest low patterns of referral or co-management between these provider groups for patients with musculoskeletal conditions [17,29-31]. Among 7,447 Medicare recipients, the percent of episodes of chiropractic-sensitive conditions in which an older adult concurrently visited a DC and another healthcare professional, such as a primary care provider, diagnostic radiologist, orthopedist, anesthesiologist or physical therapist, ranges from 4.9% to 10.9% [32]. "
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    ABSTRACT: Background Low back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults. Methods/design This pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes. Discussion This pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain. Trial registration This trial registered in on 04 March 2011 with the ID number of NCT01312233.
    Full-text · Article · Jan 2013 · Trials
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    • "One of these methods is transcutaneous electrical nerve stimulation (TENS), a noninvasive treatment that can be self-administered by patients and is generally associated with few safety concerns, adverse effects being principally limited to transient skin irritation. TENS is currently widely used as an add-on therapy for chronic LBP patients (Buchmuller-Cordier et al., 2008; Carey et al., 2009). Despite wide use of this treatment, its efficacy in relieving chronic LBP has not been established: in the last review of the Cochrane Database (Khadilkar et al., 2008), only four studies meeting the criteria for high methodological quality were included in the qualitative analysis (Deyo et al., 1990; Cheing and Hui-Chan, 1999; Topuz et al., 2004; Jarzem et al., 2005). "
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    ABSTRACT: To evaluate the efficacy of transcutaneous electrical neurostimulation (TENS) in patients with chronic low back pain (LBP). Design: Prospective, randomized, multicentre, single-blind study. Setting: Twenty-one French pain centres. Participants: Two hundred thirty-six consecutive adult patients consulting for chronic LBP, with or without radicular pain (mean age ± standard deviation: 53 ± 13 years; range: 28-86 years). Intervention: Patients were randomly assigned to receive either active (n = 117) or sham (n = 119) TENS in four 1-h daily treatment sessions for 3 months. Main outcome measures: The primary outcome measured was improvement of functional status at 6 weeks (Roland-Morris Disability Questionnaire). Secondary outcome measures were improvement of functional status at 3 months, pain relief (weekly visual analogue scale assessments), positive functional repercussions of pain levels on quality of life, a diminution of the use of analgesic and anti-inflammatory medication, satisfaction with the overall treatment strategy and compliance. Functional status did not differ between the groups, whether at 6 weeks or 3 months (p = 0.351 at 6 weeks). A significant improvement between the first and last visual analogue scale assessments was observed in patients with either lumbar pain alone or lumbar and radicular pain treated with active TENS. Other outcome measures did not differ significantly between the two groups. There was no functional benefit of TENS in the treatment of patients with chronic LBP.
    Full-text · Article · May 2012 · European journal of pain (London, England)
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    • "Physical activity and exercise are often recommended by DCs to their older adult patients. A recent population survey demonstrated that exercise recommendation was underutilized by providers of multiple disciplines [56]. Position statements for osteoarthritis recommend exercise as a key component of disease management [57]. "
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    ABSTRACT: There are a rising number of older adults; in the US alone nearly 20% of the population will be 65 or older by 2030. Chiropractic is one of the most frequently utilized types of complementary and alternative care by older adults, used by an estimated 5% of older adults in the U.S. annually. Chiropractic care involves many different types of interventions, including preventive strategies. This commentary by experts in the field of geriatrics, discusses the evidence for the use of spinal manipulative therapy, acupuncture, nutritional counseling and fall prevention strategies as delivered by doctors of chiropractic. Given the utilization of chiropractic services by the older adult, it is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.
    Full-text · Article · Feb 2012 · Chiropractic and Manual Therapies
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