Back Pain: Underwood M

Pincus T, Santos R, Breen A, Burton AK, Underwood M, Anonymous00084. · Royal Holloway, University of London, London, UK. · Arthritis Rheum. · Pubmed #18163411 links to  free full text

This publication has no abstract.

Brealey S, Burton K, Coulton S, Farrin A, Garratt A, Harvey E, Letley L, Martin J, Klaber MJ, Russell I, Torgerson D, Underwood M, Vickers M, Whyte K, Williams M, Anonymous00369. · Institute of Community Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, Mile End, London, UK. · BMC Health Serv Res. · Pubmed #12892566 links to  free full text

Abstract: BACKGROUND: Low back pain has major health and social implications. Although there have been many randomised controlled trials of manipulation and exercise for the management of low back pain, the role of these two treatments in its routine management remains unclear. A previous trial comparing private chiropractic treatment with National Health Service (NHS) outpatient treatment, which found a benefit from chiropractic treatment, has been criticised because it did not take treatment location into account. There are data to suggest that general exercise programmes may have beneficial effects on low back pain. The UK Medical Research Council (MRC) has funded this major trial of physical treatments for back pain, based in primary care. It aims to establish if, when added to best care in general practice, a defined package of spinal manipulation and a defined programme of exercise classes (Back to Fitness) improve participant-assessed outcomes. Additionally the trial compares outcomes between participants receiving the spinal manipulation in NHS premises and in private premises. DESIGN: Randomised controlled trial using a 3 x 2 factorial design. METHODS: We sought to randomise 1350 participants with simple low back pain of at least one month's duration. These came from 14 locations across the UK, each with a cluster of 10-15 general practices that were members of the MRC General Practice Research Framework (GPRF). All practices were trained in the active management of low back pain. Participants were randomised to this form of general practice care only, or this general practice care plus manipulation, or this general practice care plus exercise, or this general practice care plus manipulation followed by exercise. Those randomised to manipulation were further randomised to receive treatment in either NHS or private premises. Follow up was by postal questionnaire one, three and 12 months after randomisation. The primary analysis will consider the main treatment effects before interactions between the two treatment packages. Economic analysis will estimate the cost per unit of health utility gained by adding either or both of the treatment packages to general practice care.

Underwood M, O'Meara S, Harvey E. · Department of General Practice and Primary Care, Queen Mary University of London, Mile End, London E1 4NS, UK. · Fam Pract. · Pubmed #12356704 links to  free full text

Abstract: BACKGROUND: Implementing clinical guidelines is more likely to be successful when the whole practice team is committed to the process. Practices from the MRC General Practice Research Framework in two distinct geographical centres in the UK (West Yorkshire and Greater Manchester) participated in the feasibility study for the UK Back pain Exercise And Manipulation (UK BEAM) trial. Practice teams were randomized to continue with their usual care for back pain patients, or to be trained in managing back pain in line with national guidelines. Those randomized to the intervention arm of the trial were invited to attend training, delivered by either a generic trainer or a back pain expert. OBJECTIVES: Our aims were to assess the general acceptability of the training package to staff, to assess the acceptability of the multidisciplinary approach and to determine if a generic primary care educator could deliver the training as effectively as a clinical back pain expert. METHODS: All staff (clinical and non-clinical) from intervention practices were invited to attend multidisciplinary training sessions on the active management of back pain. Practice staff in West Yorkshire were trained by a generic primary care educator and practice staff in Greater Manchester were trained by a clinical back pain expert. The content of sessions was standardized for both trainers and included didactic and interactive components and small group, case study discussions. Detailed notes were taken of observations made of participants during sessions, and evaluation forms were completed by all those who attended. RESULTS: The majority of participants found the training useful and said that the session had lived up to their expectations. Most found that the session was well planned and that they had sufficient opportunity to participate in learning. The training package was well received by clinical staff, but was less acceptable to non-clinical staff. GPs dominated the small group work discussions. No differences were found between the preferences of participants for the two different trainers. CONCLUSION: The training package was appropriate for clinical staff, but did not always meet the needs of non-clinical staff and may require modification for this group. A generic educator can successfully lead multidisciplinary educational sessions addressing clinical issues.

Froud R, Eldridge S, Lall R, Underwood M. · Centre for Health Sciences, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK. · BMC Med Res Methodol. · Pubmed #19519911 links to  free full text

Abstract: BACKGROUND: Reporting numbers needed to treat (NNT) improves interpretability of trial results. It is unusual that continuous outcomes are converted to numbers of individual responders to treatment (i.e., those who reach a particular threshold of change); and deteriorations prevented are only rarely considered. We consider how numbers needed to treat can be derived from continuous outcomes; illustrated with a worked example showing the methods and challenges. METHODS: We used data from the UK BEAM trial (n = 1, 334) of physical treatments for back pain; originally reported as showing, at best, small to moderate benefits. Participants were randomised to receive 'best care' in general practice, the comparator treatment, or one of three manual and/or exercise treatments: 'best care' plus manipulation, exercise, or manipulation followed by exercise. We used established consensus thresholds for improvement in Roland-Morris disability questionnaire scores at three and twelve months to derive NNTs for improvements and for benefits (improvements gained+deteriorations prevented). RESULTS: At three months, NNT estimates ranged from 5.1 (95% CI 3.4 to 10.7) to 9.0 (5.0 to 45.5) for exercise, 5.0 (3.4 to 9.8) to 5.4 (3.8 to 9.9) for manipulation, and 3.3 (2.5 to 4.9) to 4.8 (3.5 to 7.8) for manipulation followed by exercise. Corresponding between-group mean differences in the Roland-Morris disability questionnaire were 1.6 (0.8 to 2.3), 1.4 (0.6 to 2.1), and 1.9 (1.2 to 2.6) points. CONCLUSION: In contrast to small mean differences originally reported, NNTs were small and could be attractive to clinicians, patients, and purchasers. NNTs can aid the interpretation of results of trials using continuous outcomes. Where possible, these should be reported alongside mean differences. Challenges remain in calculating NNTs for some continuous outcomes. TRIAL REGISTRATION: UK BEAM trial registration: ISRCTN32683578.

Savigny P, Watson P, Underwood M, Anonymous00039. · National Collaborating Centre for Primary Care, Royal College of General Practitioners, London SW7 1PU. · BMJ. · Pubmed #19502217 No free full text.

This publication has no abstract.

Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, Wyatt M, Cassidy JD, Rossignol M, Leboeuf-Yde C, Hartvigsen J, Leino-Arjas P, Latza U, Reis S, Gil Del Real MT, Kovacs FM, Oberg B, Cedraschi C, Bouter LM, Koes BW, Picavet HS, van Tulder MW, Burton K, Foster NE, Macfarlane GJ, Thomas E, Underwood M, Waddell G, Shekelle P, Volinn E, Von Korff M. · Population Health Research Unit, (URESP) Research Centre of the Laval University Affiliated Hospital, Québec, QC, Canada. · Spine (Phila Pa 1976). · Pubmed #18165754 No free full text.

Abstract: STUDY DESIGN: A modified Delphi study conducted with 28 experts in back pain research from 12 countries. OBJECTIVE: To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. SUMMARY OF BACKGROUND DATA: Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. METHODS: Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. RESULTS: Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. CONCLUSION: These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Parsons S, Breen A, Foster NE, Letley L, Pincus T, Vogel S, Underwood M. · Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, UK. · Fam Pract. · Pubmed #17602173 links to  free full text

Abstract: BACKGROUND: Chronic pain has large health care costs and a major impact on the health of those affected. Few studies have also considered the severity of pain in different parts of the body across all age groups. OBJECTIVES: To measure the prevalence and troublesomeness of musculoskeletal pain in different body locations and age groups, in a consistent manner, without using location specific health outcome measures. METHODS: A cross-sectional postal survey of 4049 adults registered with 16 MRC General Practice Research Framework practices. Frequency of chronic pain overall and troublesome pain by location and age was calculated. Logistic regression was undertaken to explore the relationship between chronic pain and demographic factors. RESULTS: We received 2504 replies; response rate 60%. The prevalence of chronic pain was 41%. The prevalence of chronic pain rose from 23% in 18-24 year olds reaching a peak of 50% in 55-64 year olds. Troublesome pain over the last 4 weeks was commonest in the lower back (25%), neck (18%), knee (17%) and shoulder (17%). Troublesome wrist, elbow, shoulder, neck and lower back pain were most prevalent in the 45- to 64-year-age groups. Troublesome hip/thigh, knee and ankle/foot pain were most prevalent in those aged 75 or more. CONCLUSIONS: Great efforts have been made to develop and test treatments for low back pain. Our findings suggest that the overall prevalence of troublesome neck, knee and shoulder pain approaches that of troublesome low back pain and that similar efforts may be required to improve the management these pains.

Pincus T, Foster NE, Vogel S, Santos R, Breen A, Underwood M. · Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX, UK. · Man Ther. · Pubmed #16914363 No free full text.

Abstract: Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group (n=900). Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations.

Carnes D, Ashby D, Underwood M. · Institute of Health Sciences Education, Barts and The London, Queen Mary's School of Medicine and Dentistry, London, UK. · Clin J Pain. · Pubmed #16772800 No free full text.

Abstract: OBJECTIVES: The use of pain drawings to identify the psychologic "state" of patients has been advocated. They are used for psychologic screening before considering treatments, such as surgery. For pain drawings to be clinically useful as a psychologic screen they need good positive and negative predictive values. We systematically reviewed the literature that directly compared pain drawing scoring systems with measures of psychologic state. METHOD: We searched 12 medical and social science databases, using key words and their derivatives. Nineteen articles were suitable for analysis. The majority focused on low back pain (79%) in secondary or tertiary care (90%). Pain drawings were evaluated against psychologic tools testing: somatization, depression, anxiety, and distress. RESULTS: Three studies concluded that the association between pain drawings and psychologic state was sufficient for clinical use; of these only 1 showed reasonable sensitivity and specificity data. Six reported a statistical association and 10/19 studies reported inconclusive results and weak association. The pooled median sensitivity score was 56% (range 24% to 93%), specificity 79.5% (range 44% to 91%), positive predictive value 71.5% (range 28% to 94%), and negative predictive value 88% (range 35% to 100%). The predictive data were too low, wide-ranging, and inconsistent to accept the pain drawing as a clinical diagnostic tool to predict psychologic state. CONCLUSIONS: We conclude that the available data do not support the assumption that unusual pain drawings or extensive marking indicate disturbed psychologic state. There is no high quality evidence to support pain-drawing use as a psychologic assessment tool; therefore, pain drawings are not recommended for this purpose.

Pincus T, Vogel S, Santos R, Breen A, Foster N, Underwood M. · Department of Psychology, Royal Holloway, University of London, Egham, Surrey, UK. · Clin J Pain. · Pubmed #16691092 No free full text.

Abstract: OBJECTIVES: Little is known about practitioners' beliefs and attitudes to the treatment of low back pain, and whether these influence their clinical decisions, intervention strategies, and patient-centered outcomes. This study aimed to develop, test, and explore the underlying dimensions of a new questionnaire, the Attitudes to Back Pain Scale (ABS), in a specific group of clinicians, practitioners who specialize in musculoskeletal therapy. METHODS: Items for the draft questionnaire were derived from interviews with practitioners (chiropractors, osteopaths, and physiotherapists). The draft questionnaire (52 items) sought to assess practitioners' attitudes concerning role and self-image plus their beliefs about treatment goals and prognosis of low back pain. The questionnaire was sent to a random selection of 300 practitioners from each professional group, and 546 (61%) responded. Split-sample analyses were performed using exploratory and confirmatory factor analysis. RESULTS: Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains: limitations on sessions, psychologic, connection to health care system, confidence and concern, reactivation, and biomedical. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorization and low levels of difficulty in categorizing the items. CONCLUSIONS: The internal structure of the new questionnaire not only shows excellent psychometric properties and good face validity, but also has the added advantage of being developed with a specific clinical context in mind. Additional evaluation is required to fully describe the psychometric integrity of this instrument.

Pincus T, Vogel S, Breen A, Foster N, Underwood M. · Department of Psychology, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK. · Eur J Pain. · Pubmed #16291300 No free full text.

Abstract: AIMS: (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving. METHODS: A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves. RESULTS: At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void. CONCLUSION: Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.

Farrin A, Russell I, Torgerson D, Underwood M, Anonymous00246. · York Trials Unit, Department of Health Sciences, University of York, Heslington, UK. · Clin Trials. · Pubmed #16279133 No free full text.

Abstract: BACKGROUND: Cluster randomized trials, which randomize groups of patients rather than individuals, are commonly used to evaluate healthcare interventions such as training programmes targeted at health professionals. This article reports the dangers of randomizing entire primary care practices when participants cannot be identified before randomization, as shown by a UK national trial. METHOD: The UK BEAM trial, a national cluster randomized 3 x 2 x 2 factorial trial, was designed to evaluate three treatments for back pain in primary care: "active management"; randomized by practice; and spinal manipulation and exercise classes, both randomized by individual. RESULTS: Two hundred and thirty-one participants were recruited in the feasibility study, 165 (141% of expected recruitment) from active (management) practices but only 66 (54% of expected recruitment) from traditional (management) practices. The participants in active practices were significantly different from those in traditional practices, notably in suffering from milder back pain. CONCLUSIONS: The feasibility study highlighted the dangers of randomizing clusters when individuals cannot be identified beforehand. Different numbers and types of participants were recruited in the two types of cluster. This differential recruitment led us to change the main trial design by abandoning practice level randomization. Instead all practices were trained in active management to maximize recruitment. Ideally cluster randomized trials should identify patients beforehand, to minimize the chance of selection bias. If this is not possible, patient recruitment should be independent in both intervention and control clusters. Pilot studies are especially important for cluster randomized trials, to identify unforeseen problems.

Evans DW, Foster NE, Underwood M, Vogel S, Breen AC, Pincus T. · School of Health and Rehabilitation, Keele University, Staffordshire, UK. · BMC Musculoskelet Disord. · Pubmed #16033646 links to  free full text

Abstract: BACKGROUND: Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines. Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level. METHODS: The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.

Underwood M. · Institute of Community Health Sciences, Barts and the London, London, England, UK. · ACP J Club. · Pubmed #15230561 No free full text.

This publication has no abstract.

Froud R, Underwood M. · No affiliation provided · Br J Gen Pract. · Pubmed #19275836 No free full text.

This publication has no abstract.

Breen A, Vogel S, Pincus T, Foster N, Underwood M, Anonymous00666. · No affiliation provided · J R Soc Med. · Pubmed #16738363 links to  free full text

This publication has no abstract.