Back Pain: Kochen MM

Becker A, Chenot JF, Niebling W, Kochen MM, Anonymous00255. · Abteilung Allgemeinmedizin, Universität Göttingen. · Z Orthop Ihre Grenzgeb. · Pubmed #15614654 No free full text.

Abstract: Chronic back pain is one of our society's most important health problems, causing long periods of sick leave and early retirements. Recently the German Society of General Practice and Family Medicine (DEGAM) published an evidence-based guideline for low back pain. It has been developed according to the 10-step concept of guideline development of the DEGAM, aiming for early detection of complicated clinical conditions, avoidance of unnecessary diagnostic tests and prevention of chronicity. Complicated, uncomplicated and radicular pain are defined by patient history and a short clinical examination. Imaging and further diagnostic tests are reserved for patients at risk. Basic therapy consists of structured advice. The aim of the guideline is to get patients back to their usual activity supported by effective pain relief. Psychosocial factors which are important for the prognosis should be evaluated already during the first consultation. Manual therapy might help in acute pain. Patients with persistent pain symptoms and long periods of sick leave should be transferred to multiprofessional management including pain treatment, behavioural therapy and physiotherapy. A randomised controlled trial has been set up to study the efficacy of guideline implementation.

Chenot JF, Pieper A, Kochen MM, Himmel W. · Abteilung Allgemeinmedizin, Universitätsmedizin Göttingen, Humboldtallee 38, 37073, Göttingen, Deutschland. · Schmerz. · Pubmed #19247696 No free full text.

Abstract: INTRODUCTION: Low back pain is a frequent reason for consultation in general practice. Many patients are treated in cooperation with an orthopaedic surgeon which requires an effective exchange of information. The aim of this study was to investigate the level of communication between general practitioners (GPs) and orthopaedic surgeons. MATERIAL AND METHODS: In this retrospective observational study referrals from GPs and corresponding response letters from orthopaedic surgeons were analyzed. GPs were asked to provide reasons for referral and to rate the quality of the response letters. RESULTS: A total of 12 out of 82 GPs from the teaching network of the Medical School of Göttingen participated in the study. Of 911 referrals to ambulatory orthopaedic surgeons within 3 months, 34% (n=312) were referred for low back pain. GPs provided little information beyond a diagnosis on the referral contrary to their self-perception. Most referrals (61%) were initiated by patients and most of them were considered at risk for chronification (72%) by the referring GP. Despite a formal obligation to report back, GPs received a response letter for only one-third (114/312) of the patients. GPs rated most of them as satisfactory, however, 59% were unsatisfied with the treatment recommendations. Only 10% of the letters contained psychosocial details. The information provided in the orthopaedic response letters was heterogeneous and only partly fulfilled the criteria set by the Interdisciplinary Society for Orthopaedic Pain Management. CONCLUSION: Incomplete and scant information on referral forms from GPs and a high non-response rate from orthopaedic surgeons suggest that current health care system and referral forms do not promote effective communication about the patient. This might explain the satisfaction of GPs with the orthopaedic response letters despite the lack of information. The GPs dissatisfaction with the treatment recommendations reflects the limited treatment options for chronic low back pain in ambulatory care.

Kochen MM, Blozik E, Scherer M, Chenot JF. · Department of General Practice, University of Goettingen, D-37073 Göttingen, Germany. · Lancet. · Pubmed #19200903 No free full text.

This publication has no abstract.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Hildebrandt J, Basler HD, Baum E, Kochen MM, Pfingsten M. · Department of General Practice parallelDepartment of Anesthesiology, Pain Clinic, University Goettingen, Germany. · Clin J Pain. · Pubmed #18716496 No free full text.

Abstract: OBJECTIVE: Epidemiologic surveys frequently show that women more often and are more affected by low back pain (LBP). The aim of this secondary analysis of a randomized controlled study was to explore whether presentation and course of LBP of women is different from men, and if sex affects the use of healthcare services for LBP. METHODS: Data from 1342 [778 (58%) women] patients presenting with LBP in 116 general practices were collected. Patients completed standardized questionnaires before and after consultation and were contacted by phone 4 weeks, 6 months, and 12 months later for standardized interviews by study nurses. Functional capacity was assessed with Hannover Functional Ability Questionnaire (HFAQ). Logistic regression models-adjusting for sociodemographic and disease-related data-were conducted to investigate the effect of sex for the use of healthcare services. RESULTS: Women had on average a lower functional capacity at baseline and after 12 months. They were more likely to have recurrent or chronic LBP and to have a positive depression score. Being female was associated with a low functional capacity after 12 months (odds ratio: 1.7, 95% confidence interval: 1.2-2.3), but baseline functional capacity, chronicity, and depression were stronger predictors. In univariate analysis, women had a tendency of higher use of healthcare services. Those differences disappeared after adjustment. DISCUSSION: Our findings confirm that women are more severely affected by LBP and have a worse prognosis. Utilization of healthcare services cannot be fully explained by female sex, but rather by a higher impairment by back pain and pain in other parts of the body characteristic of the female population.

Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider K, Baum E, Donner-Banzhoff N, Pfingsten M, Hildebrandt J, Basler HD, Chenot JF. · Department of General Practice, Preventive and Rehabilitation Medicine, University of Marburg, Marburg, Germany. · Spine (Phila Pa 1976). · Pubmed #18317189 No free full text.

Abstract: STUDY DESIGN: Cluster randomized controlled trial. OBJECTIVE: To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention. SUMMARY OF BACKGROUND DATA: International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen. METHODS: We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders. RESULTS: After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. CONCLUSION: Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Chenot JF, Scherer M, Becker A, Donner-Banzhoff N, Baum E, Leonhardt C, Keller S, Pfingsten M, Hildebrandt J, Basler HD, Kochen MM. · Dpt, of General Practice, University of Göttingen, Humboldtallee 38, 37073 Goettingen, Germany. · Implement Sci. · Pubmed #18257923 links to  free full text

Abstract: ABSTRACT: BACKGROUND: Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation. METHODS: Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion. RESULTS: Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP. CONCLUSION: Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system. TRIAL REGISTRATION: BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 25.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Baum E, Pfingsten M, Hildebrandt J, Basler HD, Kochen MM. · Dpt. of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany. · BMC Complement Altern Med. · Pubmed #18088435 links to  free full text

Abstract: BACKGROUND: Although back pain is considered one of the most frequent reasons why patients seek complementary and alternative medical (CAM) therapies little is known on the extent patients are actually using CAM for back pain. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study embedded in a RCT. General practitioners (GPs) recruited consecutively adult patients presenting with LBP. Data on physical function, on subjective mood, and on utilization of health services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months RESULTS: A total of 691 (51%) respectively 928 (69%) out of 1,342 patients received one form of CAM depending on the definition. Local heat, massage, and spinal manipulation were the forms of CAM most commonly offered. Using CAM was associated with specialist care, chronic LBP and treatment in a rehabilitation facility. Receiving spinal manipulation, acupuncture or TENS was associated with consulting a GP providing these services. Apart from chronicity disease related factors like functional capacity or pain only showed weak or no association with receiving CAM. CONCLUSION: The frequent use of CAM for LBP demonstrates that CAM is popular in patients and doctors alike. The observed association with a treatment in a rehabilitation facility or with specialist consultations rather reflects professional preferences of the physicians than a clear medical indication. The observed dependence on providers and provider related services, as well as a significant proportion receiving CAM that did not meet the so far established selection criteria suggests some arbitrary use of CAM.

Leonhardt C, Keller S, Chenot JF, Luckmann J, Basler HD, Wegscheider K, Baum E, Donner-Banzhoff N, Pfingsten M, Hildebrandt J, Kochen MM, Becker A. · Institute for Medical Psychology, University of Marburg, Germany. · Patient Educ Couns. · Pubmed #18023130 No free full text.

Abstract: OBJECTIVE: To investigate the effectiveness of a TTM-based motivational counselling approach by trained practice nurses to promote physical activity of low back pain patients in a German primary care setting. METHODS: Data were collected in a cluster-randomized controlled trial with three study arms via questionnaires and patient interviews at baseline and after 6 and 12 months. We analysed total physical activity and self-efficacy by using random effect models to allow for clustering. RESULTS: A total of 1378 low back pain patients, many with acute symptoms, were included in the study. Nearly 40% of all patients reported sufficient physical activity at baseline. While there were significant improvements in patients' physical activity behaviour in all study arms, there was no evidence for an intervention effect. CONCLUSION: The outcome may be explained by insufficient performance of the practice nurses, implementation barriers caused by the German health care system and the heterogenous sample. PRACTICE IMPLICATIONS: Given the objective to incorporate practice nurses into patient education, there is a need for a better basic training of the nurses and for a change towards an organizational structure that facilitates patient-nurse communication. Counselling for low back pain patients has to consider more specificated aims for different subgroups.

Chenot JF, Leonhardt C, Keller S, Scherer M, Donner-Banzhoff N, Pfingsten M, Basler HD, Baum E, Kochen MM, Becker A. · Department of General Practice, University of Göttingen, Humboldtallee 38, 37073 Goettingen, Germany. · Eur J Pain. · Pubmed #17681811 No free full text.

Abstract: Guidelines portray low back pain (LBP) as a benign self-limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow-up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease-related and socio-demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Baum E, Pfingsten M, Hildebrandt J, Kochen MM, Basler HD. · Dpt, of General Practice, University of Göttingen, Humboldtallee 38, 37073 Goettingen, Germany. · BMC Health Serv Res. · Pubmed #17112374 links to  free full text

Abstract: BACKGROUND: Acupuncture is a frequently used but controversial adjunct to the treatment of chronic low back pain (LBP). Acupuncture is now considered to be effective for chronic LBP and health care systems are pressured to make a decision whether or not acupuncture should be covered. It has been suggested that providing such services might reduce the use of other health care services. Therefore, we explored factors associated with acupuncture treatment for LBP and the relation of acupuncture with other health care services. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study. General practitioners (GPs) recruited consecutive adult patients with LBP. Data on physical function, subjective mood and utilization of health care services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months. RESULTS: A total of 179 (13 %) out of 1,345 patients received acupuncture treatment. The majority of those (59 %) had chronic LBP. Women and elderly patients were more likely to be given acupuncture. Additional determinants of acupuncture therapy were low functional capacity and chronicity of pain. Chronic (vs. acute) back pain OR 1.6 (CL 1.4-2.9) was the only significant disease-related factor associated with the treatment. The strongest predictors for receiving acupuncture were consultation with a GP who offers acupuncture OR 3.5 (CL 2.9-4.1) and consultation with a specialist OR 2.1 (CL 1.9-2.3). After adjustment for patient characteristics, acupuncture remained associated with higher consultation rates and an increased use of other health care services like physiotherapy. CONCLUSION: Receiving acupuncture for LBP depends mostly on the availability of the treatment. It is associated with increased use of other health services even after adjustment for patient characteristics. In our study, we found that receiving acupuncture does not offset the use of other health care resources. A significant proportion of patients who received did not meet the so far only known selection criterion (chonicity). Acupuncture therapy might be a reflection of helplessness in both patients and health care providers.