Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chron... more Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chronic low back pain. The temporal development of such hyperalgesia is not well understood. The aim of the present study was to demonstrate whether generalized muscle hyperalgesia can develop within minutes of acute low back pain using a new experimental model of lumbar facet joint pain. Thirteen healthy volunteers were included and baseline pressure pain thresholds were assessed at eight separate sites, outside the area of evoked low back and referred pain. Using ultrasonography, two electrode needles were placed either side of a lumbar facet joint (right L3-4) and used to induce experimental low back pain for 10 min with continuous stimulation. Thresholds, stimulus-response relationships, distribution and quality of the electrically induced pain were recorded. Electrical facet joint stimulation induced low back pain and pain referral into the anterior leg, ipsilaterally, proximal to the knee, similar to what is observed clinically. Pressure pain thresholds did not change significantly before, during and after facet joint stimulation. In conclusion, we describe a novel model of acute experimental low back pain and demonstrate that generalized hyperalgesia did not develop within minutes of acute low back pain.
The Assessment of SpondyloArthritis international Society (ASAS) has previously published criteri... more The Assessment of SpondyloArthritis international Society (ASAS) has previously published criteria for spondyloarthritis (SpA). The objectives in the current study were in a low back pain (LBP) cohort, including an unknown proportion of SpA patients, to: 1) estimate the prevalence of clinical features and MRI findings included in ASAS criteria, and 2) explore the associations between clinical features and MRI findings. Patients aged 18-40 years with persistent LBP referred to an outpatient spine clinic were included. Information on clinical features (incl. HLA-B27 and CRP) and MRI findings of the spine and sacroiliac joints (SIJ) were collected. Of 1020 included patients, 537(53%) had minimum one clinical feature. Three clinical features were common; inflammatory back pain, good response to NSAID and family disposition (15-17% each). MRI sacroiliitis, according to ASAS definition, was present in 217(21%) patients. Of those, 91(42%) had bone marrow oedema (BMO) at the minimum requirement according to ASAS (low BMO score). HLA-B27, peripheral arthritis, good response to NSAID, and preceding infection associated independently with SIJ MRI findings (OR range 1.9-9.0). The remaining eight clinical features did not associate positively with MRI-findings. Importantly, only age associated independently with low BMO score at the SIJ (OR 1.1 per year). In this population, 53% had minimum one clinical feature and 21% had sacroiliitis according to ASAS; furthermore, the associations between the clinical and imaging domains were inconsistent. The results indicate a need for further investigation of the importance of these findings in spondyloarthritis, including investigation of the minimum requirements for defining MRI sacroiliitis. This article is protected by copyright. All rights reserved.
A prospective observational study of patients with sciatica. To describe the 14-month development... more A prospective observational study of patients with sciatica. To describe the 14-month development of disc-related MRI findings in patients with sciatica receiving active conservative treatment. Previous studies of disc changes over time have reported reduction of herniations in 35% to 100% of cases. This wide range may be explained by differences in patient populations and classifications used to describe disc herniations. Data were obtained from patients with radicular pain (n = 181) who were randomly allocated into one of two active conservative treatment regimens lasting 8 weeks. All patients were scanned at baseline and at 14 months of follow-up. Variables of interest in the present study were disc contour and nerve root compromise at the presumed symptomatic disc level. Disc contour was assessed using the recommendations from the Combined Task Forces of NASS, ASSR, and ASNR. In all, 154 patients were included in this study (70 women and 84 men; range, 18-65 years; mean and median age, 45 years). It was possible to identify the symptomatic disc level in 90% of patients. Extrusions or sequestrations were more common in individuals younger than 45 years and in men. Men were also more likely to have nerve root compromise. Only 3% of bulges and 38% of focal protrusions improved, whereas 75% to 100% of broad-based protrusions, extrusions, and sequestrations improved (P < 0.0001). Nerve root compromise improved in 21% to 80% depending on the disc contour. Neither type of treatment nor age had any effect on the development of MRI findings over time. However, nerve root compromise was more likely to improve in men. This classification system could be used to identify the majority of symptomatic disc levels. At 14 months, the MRI outcome was generally good for disc herniations and nerve root compromise. Nerve root compromise had the best MRI prognosis if the disc was extruded at baseline. There were significant differences between men and women in relation to baseline findings as well as in relation to development of MRI findings over time.
Prospective cohort study. To develop clinical indicators and standards in an outpatients&... more Prospective cohort study. To develop clinical indicators and standards in an outpatients' department for sub acute low back pain patients. A systematic quantitative surveillance to assess quality of care was implemented using outcome and performance measures. These measures were developed within the framework of Health Technology Assessment, which comprises the areas of healthcare technology, patient, organization, and economy. A multidisciplinary project group defined 1) clinical indicators in terms of outcome and performance measures and 2) the corresponding standards using the available evidence from literature. Observed outcomes were compared with the standards. Associations between process and outcome measures were investigated. A total of 300 patients were included consecutively. In relation to technology, the standards for the field of application were fulfilled (e.g., not too many patients were x-rayed). With respect to effectiveness, the observed rate of patients reaching a 50% cutoff point of improvement of pain and function did not fulfill the standards. In relation to patient aspects, the standards of, for example, proper understanding of patient education and satisfaction, were fulfilled. In relation to organization, nearly one third of the patients were referred later to the department than the recommended 24 weeks. This refer variable showed an association to a reduced chance of scoring "better" or "much better" in "patients global assessment." The chance was reduced by 50% if patients were referred later than 12 weeks after onset of pain. In relation to economy, the cost of gaining a quality adjusted life-year by a course in the department was considerably lower than by comparison with total hip arthroplasty. Surveillance by clinical indicators in relation to the four areas of health technology assessment provides quantitative information that is meaningful for various stakeholders on important aspects of the quality of care (including consumers), provides a basis for quality improvement, and provides data for analysis of possible important relationships between structure, process, and outcome.
Large-scale clinical registries are increasingly recognized as important resources for quality as... more Large-scale clinical registries are increasingly recognized as important resources for quality assurance and research to inform clinical decision-making and health policy. We established a clinical registry (SpineData) in a conservative care setting where more than 10,000 new cases of spinal pain are assessed each year. This paper describes the SpineData registry, summarizes the characteristics of its clinical population and data, and signals the availability of these data as a resource for collaborative research projects. The SpineData registry is an Internet-based system that captures patient data electronically at the point of clinical contact. The setting is the government-funded Medical Department of the Spine Centre of Southern Denmark, Hospital Lillebaelt, where patients receive a multidisciplinary assessment of their chronic spinal pain. Started in 2011, the database by early 2015 contained information on more than 36,300 baseline episodes of patient care, plus the available...
In a retrospective study, 18 preoperative demographic and physical variables were evaluated for t... more In a retrospective study, 18 preoperative demographic and physical variables were evaluated for their preoperative prognostic value in 261 patients, following first-time lumbar disc surgery. Special reference was given to the Spengler and Finneson index-scores. "Low Back Pain Rating Scale" was used as the outcome assessment instrument. Comprehensive statistical analysis was undertaken in order to separate only the contingently independent variables. Gender was a highly significant prognostic factor. Other independently statistically significant prognostic factors include dermatomal hypoalgesia, smoking, and the Finneson index score. Results of the study are discussed with reference to the available literature.
To determine the value of "Low Back Pain Rating Scale" as a postal questionnair... more To determine the value of "Low Back Pain Rating Scale" as a postal questionnaire, a retrospective study was undertaken of patients who had undergone first-time lumbar disc surgery 14-72 months previously. Rate of response was 86% (261/304). From the results, it was concluded that 87% of the patients felt that a satisfactory surgical outcome was obtained; 67% had minor or major functional restrictions of their daily activities; 65% experienced significant low-back symptoms in the period prior to follow-up examination; and 57% experienced sciatica. Thirty-seven patients were receiving pensions in the postoperative period due to continued back pain. "Low Back Pain Rating Scale" used as a postal questionnaire was found to be useful in determining general overall assessment status in patients who had undergone lumbar surgery. This evaluation method could be used as a quality control in future studies regarding this patient group.
BACKGROUND: Due to ergonomic exposure musicians are at risk of work-related musculoskeletal disor... more BACKGROUND: Due to ergonomic exposure musicians are at risk of work-related musculoskeletal disorders in the neck, back, and upper extremities. The literature confirms musculoskeletal problems in these anatomic regions among orchestra musicians. METHODS: An explorative cross-sectional study among 441 musicians from six Danish symphony orchestras; 216 underwent a clinical examination constructed for the purpose. Prior to the examination the musicians rated their maximally perceived trouble within the last week on a scheme blinded to the examiner. Accessibility to the clinical examination differed between orchestras.The aims were to assess the prevalence of 1) perceived symptoms within the previous week in the neck, back and limbs and of 2) clinical findings in the neck, back, and upper extremities, and 3) to investigate the co-existence of the perceived symptoms and clinical findings. RESULTS: Symptoms and findings were most common in the neck, back, and shoulders. Due to a poor co-e...
Patients with back pain frequently file financial claims concerning causation and disability leve... more Patients with back pain frequently file financial claims concerning causation and disability level. We examined if the financial claim could independently influence the prognosis or if such a tendency was instead caused by a more severe degree of disease. The associations were therefore adjusted for several prognostic factors. After one year the adjusted odds ratio for "no improvement" in patients making a claim was calculated to 4.2 for low-back patients and 17.4 for neck patients. The results indicate an association between financial claim and poor prognosis.
Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chron... more Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chronic low back pain. The temporal development of such hyperalgesia is not well understood. The aim of the present study was to demonstrate whether generalized muscle hyperalgesia can develop within minutes of acute low back pain using a new experimental model of lumbar facet joint pain. Thirteen healthy volunteers were included and baseline pressure pain thresholds were assessed at eight separate sites, outside the area of evoked low back and referred pain. Using ultrasonography, two electrode needles were placed either side of a lumbar facet joint (right L3-4) and used to induce experimental low back pain for 10 min with continuous stimulation. Thresholds, stimulus-response relationships, distribution and quality of the electrically induced pain were recorded. Electrical facet joint stimulation induced low back pain and pain referral into the anterior leg, ipsilaterally, proximal to the knee, similar to what is observed clinically. Pressure pain thresholds did not change significantly before, during and after facet joint stimulation. In conclusion, we describe a novel model of acute experimental low back pain and demonstrate that generalized hyperalgesia did not develop within minutes of acute low back pain.
A prospective observational study of patients with sciatica. To describe the 14-month development... more A prospective observational study of patients with sciatica. To describe the 14-month development of disc-related MRI findings in patients with sciatica receiving active conservative treatment. Previous studies of disc changes over time have reported reduction of herniations in 35% to 100% of cases. This wide range may be explained by differences in patient populations and classifications used to describe disc herniations. Data were obtained from patients with radicular pain (n = 181) who were randomly allocated into one of two active conservative treatment regimens lasting 8 weeks. All patients were scanned at baseline and at 14 months of follow-up. Variables of interest in the present study were disc contour and nerve root compromise at the presumed symptomatic disc level. Disc contour was assessed using the recommendations from the Combined Task Forces of NASS, ASSR, and ASNR. In all, 154 patients were included in this study (70 women and 84 men; range, 18-65 years; mean and median age, 45 years). It was possible to identify the symptomatic disc level in 90% of patients. Extrusions or sequestrations were more common in individuals younger than 45 years and in men. Men were also more likely to have nerve root compromise. Only 3% of bulges and 38% of focal protrusions improved, whereas 75% to 100% of broad-based protrusions, extrusions, and sequestrations improved (P < 0.0001). Nerve root compromise improved in 21% to 80% depending on the disc contour. Neither type of treatment nor age had any effect on the development of MRI findings over time. However, nerve root compromise was more likely to improve in men. This classification system could be used to identify the majority of symptomatic disc levels. At 14 months, the MRI outcome was generally good for disc herniations and nerve root compromise. Nerve root compromise had the best MRI prognosis if the disc was extruded at baseline. There were significant differences between men and women in relation to baseline findings as well as in relation to development of MRI findings over time.
Back pain imposes a substantial economic and social burden, and treatment decisions are distorted... more Back pain imposes a substantial economic and social burden, and treatment decisions are distorted by conflicting evidence. Thus, it is important to include patient preferences in decision making and policy making. To contribute to the understanding of patient preferences in relation to the choice of treatment for low back pain. A discrete choice experiment was conducted with consecutive patients referred to a regional spine center. The respondents (n = 348) were invited to respond to a choice of two hypothetical treatment options and an opt-out option. The treatment attributes included the treatment modality, the risk of relapse, the reduction in pain, and the expected increase in the ability to perform activities of daily living. In addition, the wait time to achieve the treatment effect was used as a payment vehicle. Mixed logit models were created to perform analysis. Subgroup analysis, dividing respondents into sociodemographic and disease-related categories, further explored the willingness to wait. Respondents assigned positive utilities to positive treatment outcomes and disutility to higher risks and longer waits for effects of treatment and to surgical interventions. The model captured significant heterogeneity within the sample for the outcomes of pain reduction and the ability to pursue activities of daily living and for the treatment modality. The subgroup analysis revealed differences in the willingness to wait, especially with regard to treatment modality, the level of pain experienced at the time of data collection, and the respondents' preferences for surgery. The majority of the respondents prefer nonsurgical interventions, but patients are willing to wait for more ideal outcomes and preferred interventions. The results show that health care professionals have a very important task in communicating clearly about the expected results of treatment and the basis of their treatment decisions, as patients' preferences are highly individual.
Quantitative lumbar magnetic resonance imaging (MRI) measurements in children were taken twice an... more Quantitative lumbar magnetic resonance imaging (MRI) measurements in children were taken twice and analyzed for intra- and intertester reproducibility. To evaluate the reproducibility of a variety of lumbar quantitative measurements taken from MRIs of children from the general population. The reproducibility of lumbar quantitative measurements has never been tested on MRIs of children from the general population. This is a prerequisite for a reliable anatomic characterization of the immature spine in normal and pathologic conditions. Lumbar quantitative measurements from 40 T2-weighted lumbar (L1-S1) MRIs of children from the general population were taken twice by 1 tester for intratester reproducibility and compared with the same measurements (L4-S1) of the same MRIs taken by a second tester for intertester reproducibility. The following parameters were measured using the iQ-VIEW system (IMAGE Information Systems Ltd., version 1.2.2, Plauen, Germany): Linear measurements--zygoappophyseal facets and interfacet widths, and vertebral body (VB), pedicle and intervertebral discs heights, widths, and lengths. Angular measurements--zygoappophyseal tranverse superior facet angles, sagittal VB, and disc wedging, lumbar lordosis, and sacral inclination. Statistical analysis included the concordance correlation coefficient (CCC), and Bland and Altman's limits of agreement (LOA). A total of 6160 measurements were analyzed. Good to excellent intratester reproducibility (0.75 < or =CCC < or =0.99) was indicated for all linear measurements (except for pedicle heights) (LOA: -4.76; 5.74 mm) and for angular measurements related to the facets orientation, lumbar lordosis, and sacral inclination (LOA: 11.22 degrees ; 12.34 degrees). VB and disc sagittal wedging manifested poor intratester reproducibility (CCC < 0.75). Good to excellent intertester reproducibility was indicated for 70% of all linear measurements (LOA: -5.83; 4.59 mm) and for all angular measurements in the lumbar spine (L4-S1) (LOA: -9.96 degrees ; 14.62 degrees) except for VB and disc sagittal wedging at L5 (CCC < 0.75). Quantitative lumbar MRI measurements in children from the general population were found to be reproducible indicating a good visualization of immature vertebral anatomic margins on MRIs and an accurate definition of the measurement protocol.
Prospective cohort study. To develop clinical indicators and standards in an outpatients&... more Prospective cohort study. To develop clinical indicators and standards in an outpatients' department for sub acute low back pain patients. A systematic quantitative surveillance to assess quality of care was implemented using outcome and performance measures. These measures were developed within the framework of Health Technology Assessment, which comprises the areas of healthcare technology, patient, organization, and economy. A multidisciplinary project group defined 1) clinical indicators in terms of outcome and performance measures and 2) the corresponding standards using the available evidence from literature. Observed outcomes were compared with the standards. Associations between process and outcome measures were investigated. A total of 300 patients were included consecutively. In relation to technology, the standards for the field of application were fulfilled (e.g., not too many patients were x-rayed). With respect to effectiveness, the observed rate of patients reaching a 50% cutoff point of improvement of pain and function did not fulfill the standards. In relation to patient aspects, the standards of, for example, proper understanding of patient education and satisfaction, were fulfilled. In relation to organization, nearly one third of the patients were referred later to the department than the recommended 24 weeks. This refer variable showed an association to a reduced chance of scoring "better" or "much better" in "patients global assessment." The chance was reduced by 50% if patients were referred later than 12 weeks after onset of pain. In relation to economy, the cost of gaining a quality adjusted life-year by a course in the department was considerably lower than by comparison with total hip arthroplasty. Surveillance by clinical indicators in relation to the four areas of health technology assessment provides quantitative information that is meaningful for various stakeholders on important aspects of the quality of care (including consumers), provides a basis for quality improvement, and provides data for analysis of possible important relationships between structure, process, and outcome.
ABSTRACT Cross-sectional, population-based survey. To investigate the pattern of comorbidity with... more ABSTRACT Cross-sectional, population-based survey. To investigate the pattern of comorbidity with low back pain in adolescents. Low back pain is usually dealt with as a specific and independent entity. However, the existing literature shows comorbidity to be common with low back pain, suggesting that low back pain may be part of a broader pattern of general health. The present knowledge is based on studies of adult populations; therefore, associations could be explained by work and lifestyle factors. Information in this area is lacking regarding subjects still unaffected by such factors. A questionnaire-survey about general health, including low back pain, was carried out among twins registered in the population-based Danish Twin Registry. Associations between disorders were calculated and patterns of comorbidity investigated, by means of logistic regression and a finite mixture model. Finally a twin-control study was conducted. A total of 9,567 individuals, 12 to 22 years of age, responded to the questionnaire. Positive associations between low back pain and asthma and headache/migraine were demonstrated, mainly because of study participants with several disorders. No association between low back pain and atopic dermatitis/hay fever was found. The presence of two other disorders increased the probability of low back pain considerably more than the presence of only one other disorder. The finite mixture model indicated that the probability of belonging to a frail subgroup decreased from 60% at age 13 to 25% at age 21, and in the frail subgroups nearly all report low back pain and headache in the older ages. Furthermore, increasing duration of low back pain increased the likelihood of having other disorders. Results from the twin-control study were similar. Young people are more likely to suffer from asthma and headache, but not from atopic dermatitis/hay fever, if they have low back pain. All of the investigated disorders cluster in some individuals. A model of common origin for these seemingly independent disorders should be considered.
To investigate whether poor outcome after spinal pain episodes is linked with the claim process a... more To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine-related leg or arm pain. A 1-year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non-surgical spine clinics. Patients with low back pain (LBP) radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow-up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers' compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics. Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 (95% CI 2.8-6.2) for the LBP/leg patients and 17.4 (95% CI 5.1-60.1) for the neck/arm patients. A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low-back or neck.
Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chron... more Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chronic low back pain. The temporal development of such hyperalgesia is not well understood. The aim of the present study was to demonstrate whether generalized muscle hyperalgesia can develop within minutes of acute low back pain using a new experimental model of lumbar facet joint pain. Thirteen healthy volunteers were included and baseline pressure pain thresholds were assessed at eight separate sites, outside the area of evoked low back and referred pain. Using ultrasonography, two electrode needles were placed either side of a lumbar facet joint (right L3-4) and used to induce experimental low back pain for 10 min with continuous stimulation. Thresholds, stimulus-response relationships, distribution and quality of the electrically induced pain were recorded. Electrical facet joint stimulation induced low back pain and pain referral into the anterior leg, ipsilaterally, proximal to the knee, similar to what is observed clinically. Pressure pain thresholds did not change significantly before, during and after facet joint stimulation. In conclusion, we describe a novel model of acute experimental low back pain and demonstrate that generalized hyperalgesia did not develop within minutes of acute low back pain.
The Assessment of SpondyloArthritis international Society (ASAS) has previously published criteri... more The Assessment of SpondyloArthritis international Society (ASAS) has previously published criteria for spondyloarthritis (SpA). The objectives in the current study were in a low back pain (LBP) cohort, including an unknown proportion of SpA patients, to: 1) estimate the prevalence of clinical features and MRI findings included in ASAS criteria, and 2) explore the associations between clinical features and MRI findings. Patients aged 18-40 years with persistent LBP referred to an outpatient spine clinic were included. Information on clinical features (incl. HLA-B27 and CRP) and MRI findings of the spine and sacroiliac joints (SIJ) were collected. Of 1020 included patients, 537(53%) had minimum one clinical feature. Three clinical features were common; inflammatory back pain, good response to NSAID and family disposition (15-17% each). MRI sacroiliitis, according to ASAS definition, was present in 217(21%) patients. Of those, 91(42%) had bone marrow oedema (BMO) at the minimum requirement according to ASAS (low BMO score). HLA-B27, peripheral arthritis, good response to NSAID, and preceding infection associated independently with SIJ MRI findings (OR range 1.9-9.0). The remaining eight clinical features did not associate positively with MRI-findings. Importantly, only age associated independently with low BMO score at the SIJ (OR 1.1 per year). In this population, 53% had minimum one clinical feature and 21% had sacroiliitis according to ASAS; furthermore, the associations between the clinical and imaging domains were inconsistent. The results indicate a need for further investigation of the importance of these findings in spondyloarthritis, including investigation of the minimum requirements for defining MRI sacroiliitis. This article is protected by copyright. All rights reserved.
A prospective observational study of patients with sciatica. To describe the 14-month development... more A prospective observational study of patients with sciatica. To describe the 14-month development of disc-related MRI findings in patients with sciatica receiving active conservative treatment. Previous studies of disc changes over time have reported reduction of herniations in 35% to 100% of cases. This wide range may be explained by differences in patient populations and classifications used to describe disc herniations. Data were obtained from patients with radicular pain (n = 181) who were randomly allocated into one of two active conservative treatment regimens lasting 8 weeks. All patients were scanned at baseline and at 14 months of follow-up. Variables of interest in the present study were disc contour and nerve root compromise at the presumed symptomatic disc level. Disc contour was assessed using the recommendations from the Combined Task Forces of NASS, ASSR, and ASNR. In all, 154 patients were included in this study (70 women and 84 men; range, 18-65 years; mean and median age, 45 years). It was possible to identify the symptomatic disc level in 90% of patients. Extrusions or sequestrations were more common in individuals younger than 45 years and in men. Men were also more likely to have nerve root compromise. Only 3% of bulges and 38% of focal protrusions improved, whereas 75% to 100% of broad-based protrusions, extrusions, and sequestrations improved (P < 0.0001). Nerve root compromise improved in 21% to 80% depending on the disc contour. Neither type of treatment nor age had any effect on the development of MRI findings over time. However, nerve root compromise was more likely to improve in men. This classification system could be used to identify the majority of symptomatic disc levels. At 14 months, the MRI outcome was generally good for disc herniations and nerve root compromise. Nerve root compromise had the best MRI prognosis if the disc was extruded at baseline. There were significant differences between men and women in relation to baseline findings as well as in relation to development of MRI findings over time.
Prospective cohort study. To develop clinical indicators and standards in an outpatients&... more Prospective cohort study. To develop clinical indicators and standards in an outpatients' department for sub acute low back pain patients. A systematic quantitative surveillance to assess quality of care was implemented using outcome and performance measures. These measures were developed within the framework of Health Technology Assessment, which comprises the areas of healthcare technology, patient, organization, and economy. A multidisciplinary project group defined 1) clinical indicators in terms of outcome and performance measures and 2) the corresponding standards using the available evidence from literature. Observed outcomes were compared with the standards. Associations between process and outcome measures were investigated. A total of 300 patients were included consecutively. In relation to technology, the standards for the field of application were fulfilled (e.g., not too many patients were x-rayed). With respect to effectiveness, the observed rate of patients reaching a 50% cutoff point of improvement of pain and function did not fulfill the standards. In relation to patient aspects, the standards of, for example, proper understanding of patient education and satisfaction, were fulfilled. In relation to organization, nearly one third of the patients were referred later to the department than the recommended 24 weeks. This refer variable showed an association to a reduced chance of scoring "better" or "much better" in "patients global assessment." The chance was reduced by 50% if patients were referred later than 12 weeks after onset of pain. In relation to economy, the cost of gaining a quality adjusted life-year by a course in the department was considerably lower than by comparison with total hip arthroplasty. Surveillance by clinical indicators in relation to the four areas of health technology assessment provides quantitative information that is meaningful for various stakeholders on important aspects of the quality of care (including consumers), provides a basis for quality improvement, and provides data for analysis of possible important relationships between structure, process, and outcome.
Large-scale clinical registries are increasingly recognized as important resources for quality as... more Large-scale clinical registries are increasingly recognized as important resources for quality assurance and research to inform clinical decision-making and health policy. We established a clinical registry (SpineData) in a conservative care setting where more than 10,000 new cases of spinal pain are assessed each year. This paper describes the SpineData registry, summarizes the characteristics of its clinical population and data, and signals the availability of these data as a resource for collaborative research projects. The SpineData registry is an Internet-based system that captures patient data electronically at the point of clinical contact. The setting is the government-funded Medical Department of the Spine Centre of Southern Denmark, Hospital Lillebaelt, where patients receive a multidisciplinary assessment of their chronic spinal pain. Started in 2011, the database by early 2015 contained information on more than 36,300 baseline episodes of patient care, plus the available...
In a retrospective study, 18 preoperative demographic and physical variables were evaluated for t... more In a retrospective study, 18 preoperative demographic and physical variables were evaluated for their preoperative prognostic value in 261 patients, following first-time lumbar disc surgery. Special reference was given to the Spengler and Finneson index-scores. "Low Back Pain Rating Scale" was used as the outcome assessment instrument. Comprehensive statistical analysis was undertaken in order to separate only the contingently independent variables. Gender was a highly significant prognostic factor. Other independently statistically significant prognostic factors include dermatomal hypoalgesia, smoking, and the Finneson index score. Results of the study are discussed with reference to the available literature.
To determine the value of "Low Back Pain Rating Scale" as a postal questionnair... more To determine the value of "Low Back Pain Rating Scale" as a postal questionnaire, a retrospective study was undertaken of patients who had undergone first-time lumbar disc surgery 14-72 months previously. Rate of response was 86% (261/304). From the results, it was concluded that 87% of the patients felt that a satisfactory surgical outcome was obtained; 67% had minor or major functional restrictions of their daily activities; 65% experienced significant low-back symptoms in the period prior to follow-up examination; and 57% experienced sciatica. Thirty-seven patients were receiving pensions in the postoperative period due to continued back pain. "Low Back Pain Rating Scale" used as a postal questionnaire was found to be useful in determining general overall assessment status in patients who had undergone lumbar surgery. This evaluation method could be used as a quality control in future studies regarding this patient group.
BACKGROUND: Due to ergonomic exposure musicians are at risk of work-related musculoskeletal disor... more BACKGROUND: Due to ergonomic exposure musicians are at risk of work-related musculoskeletal disorders in the neck, back, and upper extremities. The literature confirms musculoskeletal problems in these anatomic regions among orchestra musicians. METHODS: An explorative cross-sectional study among 441 musicians from six Danish symphony orchestras; 216 underwent a clinical examination constructed for the purpose. Prior to the examination the musicians rated their maximally perceived trouble within the last week on a scheme blinded to the examiner. Accessibility to the clinical examination differed between orchestras.The aims were to assess the prevalence of 1) perceived symptoms within the previous week in the neck, back and limbs and of 2) clinical findings in the neck, back, and upper extremities, and 3) to investigate the co-existence of the perceived symptoms and clinical findings. RESULTS: Symptoms and findings were most common in the neck, back, and shoulders. Due to a poor co-e...
Patients with back pain frequently file financial claims concerning causation and disability leve... more Patients with back pain frequently file financial claims concerning causation and disability level. We examined if the financial claim could independently influence the prognosis or if such a tendency was instead caused by a more severe degree of disease. The associations were therefore adjusted for several prognostic factors. After one year the adjusted odds ratio for "no improvement" in patients making a claim was calculated to 4.2 for low-back patients and 17.4 for neck patients. The results indicate an association between financial claim and poor prognosis.
Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chron... more Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chronic low back pain. The temporal development of such hyperalgesia is not well understood. The aim of the present study was to demonstrate whether generalized muscle hyperalgesia can develop within minutes of acute low back pain using a new experimental model of lumbar facet joint pain. Thirteen healthy volunteers were included and baseline pressure pain thresholds were assessed at eight separate sites, outside the area of evoked low back and referred pain. Using ultrasonography, two electrode needles were placed either side of a lumbar facet joint (right L3-4) and used to induce experimental low back pain for 10 min with continuous stimulation. Thresholds, stimulus-response relationships, distribution and quality of the electrically induced pain were recorded. Electrical facet joint stimulation induced low back pain and pain referral into the anterior leg, ipsilaterally, proximal to the knee, similar to what is observed clinically. Pressure pain thresholds did not change significantly before, during and after facet joint stimulation. In conclusion, we describe a novel model of acute experimental low back pain and demonstrate that generalized hyperalgesia did not develop within minutes of acute low back pain.
A prospective observational study of patients with sciatica. To describe the 14-month development... more A prospective observational study of patients with sciatica. To describe the 14-month development of disc-related MRI findings in patients with sciatica receiving active conservative treatment. Previous studies of disc changes over time have reported reduction of herniations in 35% to 100% of cases. This wide range may be explained by differences in patient populations and classifications used to describe disc herniations. Data were obtained from patients with radicular pain (n = 181) who were randomly allocated into one of two active conservative treatment regimens lasting 8 weeks. All patients were scanned at baseline and at 14 months of follow-up. Variables of interest in the present study were disc contour and nerve root compromise at the presumed symptomatic disc level. Disc contour was assessed using the recommendations from the Combined Task Forces of NASS, ASSR, and ASNR. In all, 154 patients were included in this study (70 women and 84 men; range, 18-65 years; mean and median age, 45 years). It was possible to identify the symptomatic disc level in 90% of patients. Extrusions or sequestrations were more common in individuals younger than 45 years and in men. Men were also more likely to have nerve root compromise. Only 3% of bulges and 38% of focal protrusions improved, whereas 75% to 100% of broad-based protrusions, extrusions, and sequestrations improved (P < 0.0001). Nerve root compromise improved in 21% to 80% depending on the disc contour. Neither type of treatment nor age had any effect on the development of MRI findings over time. However, nerve root compromise was more likely to improve in men. This classification system could be used to identify the majority of symptomatic disc levels. At 14 months, the MRI outcome was generally good for disc herniations and nerve root compromise. Nerve root compromise had the best MRI prognosis if the disc was extruded at baseline. There were significant differences between men and women in relation to baseline findings as well as in relation to development of MRI findings over time.
Back pain imposes a substantial economic and social burden, and treatment decisions are distorted... more Back pain imposes a substantial economic and social burden, and treatment decisions are distorted by conflicting evidence. Thus, it is important to include patient preferences in decision making and policy making. To contribute to the understanding of patient preferences in relation to the choice of treatment for low back pain. A discrete choice experiment was conducted with consecutive patients referred to a regional spine center. The respondents (n = 348) were invited to respond to a choice of two hypothetical treatment options and an opt-out option. The treatment attributes included the treatment modality, the risk of relapse, the reduction in pain, and the expected increase in the ability to perform activities of daily living. In addition, the wait time to achieve the treatment effect was used as a payment vehicle. Mixed logit models were created to perform analysis. Subgroup analysis, dividing respondents into sociodemographic and disease-related categories, further explored the willingness to wait. Respondents assigned positive utilities to positive treatment outcomes and disutility to higher risks and longer waits for effects of treatment and to surgical interventions. The model captured significant heterogeneity within the sample for the outcomes of pain reduction and the ability to pursue activities of daily living and for the treatment modality. The subgroup analysis revealed differences in the willingness to wait, especially with regard to treatment modality, the level of pain experienced at the time of data collection, and the respondents' preferences for surgery. The majority of the respondents prefer nonsurgical interventions, but patients are willing to wait for more ideal outcomes and preferred interventions. The results show that health care professionals have a very important task in communicating clearly about the expected results of treatment and the basis of their treatment decisions, as patients' preferences are highly individual.
Quantitative lumbar magnetic resonance imaging (MRI) measurements in children were taken twice an... more Quantitative lumbar magnetic resonance imaging (MRI) measurements in children were taken twice and analyzed for intra- and intertester reproducibility. To evaluate the reproducibility of a variety of lumbar quantitative measurements taken from MRIs of children from the general population. The reproducibility of lumbar quantitative measurements has never been tested on MRIs of children from the general population. This is a prerequisite for a reliable anatomic characterization of the immature spine in normal and pathologic conditions. Lumbar quantitative measurements from 40 T2-weighted lumbar (L1-S1) MRIs of children from the general population were taken twice by 1 tester for intratester reproducibility and compared with the same measurements (L4-S1) of the same MRIs taken by a second tester for intertester reproducibility. The following parameters were measured using the iQ-VIEW system (IMAGE Information Systems Ltd., version 1.2.2, Plauen, Germany): Linear measurements--zygoappophyseal facets and interfacet widths, and vertebral body (VB), pedicle and intervertebral discs heights, widths, and lengths. Angular measurements--zygoappophyseal tranverse superior facet angles, sagittal VB, and disc wedging, lumbar lordosis, and sacral inclination. Statistical analysis included the concordance correlation coefficient (CCC), and Bland and Altman's limits of agreement (LOA). A total of 6160 measurements were analyzed. Good to excellent intratester reproducibility (0.75 < or =CCC < or =0.99) was indicated for all linear measurements (except for pedicle heights) (LOA: -4.76; 5.74 mm) and for angular measurements related to the facets orientation, lumbar lordosis, and sacral inclination (LOA: 11.22 degrees ; 12.34 degrees). VB and disc sagittal wedging manifested poor intratester reproducibility (CCC < 0.75). Good to excellent intertester reproducibility was indicated for 70% of all linear measurements (LOA: -5.83; 4.59 mm) and for all angular measurements in the lumbar spine (L4-S1) (LOA: -9.96 degrees ; 14.62 degrees) except for VB and disc sagittal wedging at L5 (CCC < 0.75). Quantitative lumbar MRI measurements in children from the general population were found to be reproducible indicating a good visualization of immature vertebral anatomic margins on MRIs and an accurate definition of the measurement protocol.
Prospective cohort study. To develop clinical indicators and standards in an outpatients&... more Prospective cohort study. To develop clinical indicators and standards in an outpatients' department for sub acute low back pain patients. A systematic quantitative surveillance to assess quality of care was implemented using outcome and performance measures. These measures were developed within the framework of Health Technology Assessment, which comprises the areas of healthcare technology, patient, organization, and economy. A multidisciplinary project group defined 1) clinical indicators in terms of outcome and performance measures and 2) the corresponding standards using the available evidence from literature. Observed outcomes were compared with the standards. Associations between process and outcome measures were investigated. A total of 300 patients were included consecutively. In relation to technology, the standards for the field of application were fulfilled (e.g., not too many patients were x-rayed). With respect to effectiveness, the observed rate of patients reaching a 50% cutoff point of improvement of pain and function did not fulfill the standards. In relation to patient aspects, the standards of, for example, proper understanding of patient education and satisfaction, were fulfilled. In relation to organization, nearly one third of the patients were referred later to the department than the recommended 24 weeks. This refer variable showed an association to a reduced chance of scoring "better" or "much better" in "patients global assessment." The chance was reduced by 50% if patients were referred later than 12 weeks after onset of pain. In relation to economy, the cost of gaining a quality adjusted life-year by a course in the department was considerably lower than by comparison with total hip arthroplasty. Surveillance by clinical indicators in relation to the four areas of health technology assessment provides quantitative information that is meaningful for various stakeholders on important aspects of the quality of care (including consumers), provides a basis for quality improvement, and provides data for analysis of possible important relationships between structure, process, and outcome.
ABSTRACT Cross-sectional, population-based survey. To investigate the pattern of comorbidity with... more ABSTRACT Cross-sectional, population-based survey. To investigate the pattern of comorbidity with low back pain in adolescents. Low back pain is usually dealt with as a specific and independent entity. However, the existing literature shows comorbidity to be common with low back pain, suggesting that low back pain may be part of a broader pattern of general health. The present knowledge is based on studies of adult populations; therefore, associations could be explained by work and lifestyle factors. Information in this area is lacking regarding subjects still unaffected by such factors. A questionnaire-survey about general health, including low back pain, was carried out among twins registered in the population-based Danish Twin Registry. Associations between disorders were calculated and patterns of comorbidity investigated, by means of logistic regression and a finite mixture model. Finally a twin-control study was conducted. A total of 9,567 individuals, 12 to 22 years of age, responded to the questionnaire. Positive associations between low back pain and asthma and headache/migraine were demonstrated, mainly because of study participants with several disorders. No association between low back pain and atopic dermatitis/hay fever was found. The presence of two other disorders increased the probability of low back pain considerably more than the presence of only one other disorder. The finite mixture model indicated that the probability of belonging to a frail subgroup decreased from 60% at age 13 to 25% at age 21, and in the frail subgroups nearly all report low back pain and headache in the older ages. Furthermore, increasing duration of low back pain increased the likelihood of having other disorders. Results from the twin-control study were similar. Young people are more likely to suffer from asthma and headache, but not from atopic dermatitis/hay fever, if they have low back pain. All of the investigated disorders cluster in some individuals. A model of common origin for these seemingly independent disorders should be considered.
To investigate whether poor outcome after spinal pain episodes is linked with the claim process a... more To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine-related leg or arm pain. A 1-year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non-surgical spine clinics. Patients with low back pain (LBP) radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow-up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers' compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics. Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 (95% CI 2.8-6.2) for the LBP/leg patients and 17.4 (95% CI 5.1-60.1) for the neck/arm patients. A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low-back or neck.
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Papers by Claus Manniche