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Paul Campbell,1 Kate Hope,2 Kate M Dunn1 1Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, 2Keele Medical School, Keele University, Keele, Staffordshire, UK Abstract: Low back pain (LBP) is common, impacts on the individual and society, and is a major health concern. Psychological consequences of LBP, such as depression, are significant barriers to recovery, but mechanisms for the development of depression are less well understood. One potential mechanism is the individual’s health locus of control (HLoC), that is, perception of the level of control an individual has over their health. The objective of this study is to investigate the moderation effect of HLoC on the pain–depression–disability pathway in those with LBP. The design is a nested cross-sectional analysis of two existing cohorts of patients (n=637) who had previously consulted their primary care physician about LBP. Measures were taken of HLoC, pain intensity and interference, depression, disability, and bothersomeness. Structural Equation Modeling analysis was applied to two path models that examined the pain to depression to disability pathway moderated by the HLoC constructs of Internality and Externality, respectively. Critical ratio (CR) difference tests were applied to the coefficients using pairwise comparisons. The results show that both models had an acceptable model fit and pathways were significant. CR tests indicated a significant moderation effect, with stronger pathway coefficients for depression for those who report low Internality (β 0.48), compared to those with high Internality (β 0.28). No moderation effects were found within the Externality model. HLoC Internality significantly moderates the pain–depression pathway in those with LBP, meaning that those who have a low perception of control report greater levels of depression. HLoC may signify depression among people with LBP, and could potentially be a target for intervention. Keywords: low back pain, health locus of control, moderation, depression, disability, Structural Equation Modeling

Paul Campbell,1 Jonathan C Hill,1 Joanne Protheroe,1 Ebenezer K Afolabi,1 Martyn Lewis,1 Ruth Beardmore,1 Elaine M Hay,1 Christian D Mallen,1 Bernadette Bartlam,1 Benjamin Saunders,1 Danielle A van der Windt,1 Sue Jowett,2 Nadine E Foster,1 Kate M Dunn1 1Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, 2Health Economics Unit, University of Birmingham, Birmingham, UK Abstract: Musculoskeletal conditions represent a considerable burden worldwide, and are predominantly managed in primary care. Evidence suggests that many musculoskeletal conditions share similar prognostic factors. Systematically assessing patient’s prognosis and matching treatments based on prognostic subgroups (stratified care) has been shown to be both clinically effective and cost-effective. This study (Keele Aches and Pains Study) aims to refine and examine the validity of a brief questionnaire (Keele STarT MSK tool) designed to enable risk stratification of primary care patients with the five most common musculoskeletal pain presentations. We also describe the subgroups of patients, and explore the acceptability and feasibility of using the tool and how the tool is best implemented in clinical practice. The study design is mixed methods: a prospective, quantitative observational cohort study with a linked qualitative focus group and interview study. Patients who have consulted their GP or health care practitioner about a relevant musculoskeletal condition will be recruited from general practice. Participating patients will complete a baseline questionnaire (shortly after consultation), plus questionnaires 2 and 6 months later. A subsample of patients, along with participating GPs and health care practitioners, will be invited to take part in qualitative focus groups and interviews. The Keele STarT MSK tool will be refined based on face, discriminant, construct, and predictive validity at baseline and 2 months, and validated using data from 6-month follow-up. Patient and clinician perspectives about using the tool will be explored. This study will provide a validated prognostic tool (Keele STarT MSK) with established cutoff points to stratify patients with the five most common musculoskeletal presentations into low-, medium-, and high-risk subgroups. The qualitative analysis of patient and health care perspectives will inform practitioners on how to embed the tool into clinical practice using established general practice IT systems and clinician-support packages. Keywords: musculoskeletal, stratified care, pain, predictive, risk, primary care

Background: Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.Objective: To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.Design: Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.Setting: HMO.Patients: 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.Measurements: Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.Results: 51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.Limitations: Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.Conclusion: Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.Primary Funding Source: National Institute of Drug Abuse. [ABSTRACT FROM AUTHOR]

Introduction: Clinicians require brief, practical tools to help identify low back pain (LBP) subgroups requiring early, targeted secondary prevention. The STarT Back Tool (SBT) was recently validated to subgroup LBP patients into early treatment pathways.Aim: To test the SBT's concurrent validity against an existing, popular LBP subgrouping tool, the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ), and to compare the clinical characteristics of subgroups identified by each tool.Methods: Two hundred and forty-four consecutive 'non-specific' LBP consulters at 8 UK GP practices aged 18-59years were invited to complete a questionnaire. Measures included the OMPSQ and SBT, disability, fear, catastrophising, pain intensity, episode duration and demographics. Instruments were compared using Spearman's correlations, tests for subgroup agreement and discriminant analysis of subgroup characteristics according to reference standards.Results: Completed SBT (9-items) and OMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and OMPSQ scores was 'excellent (rs=0.80). Subgroup characteristics were similar across the low, medium and high subgroups, but, the proportions allocated to 'low', 'medium' and 'high' risk groups were different, with fewer patients in the SBT's high risk group. Both instruments similarly discriminated for reference standards such as disability, catastrophising, fear, comorbid pain and time off work. The OMPSQ was better at discriminating pain intensity, while the SBT was better for discriminating bothersomeness of back pain and referred leg pain.Conclusions: The SBT baseline psychometrics performed similarly to the OMPSQ, but the SBT is shorter and easier to score and is an appropriate alternative for identifying high risk LBP patients in primary care. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Review of studies on sciatica prevalence and synthesis of available evidence. OBJECTIVE: To assess the studies on sciatica prevalence, discuss reasons for variation in estimates, provide suggestions for improving accuracy of recording sciatica in epidemiological and outcome studies so as to enable better evaluation of natural history and treatment effect in the presence of low back pain related sciatica. SUMMARY OF BACKGROUND DATA: Sciatica is a common cause of pain and disability. It is more persistent and severe than low back pain, has a less favorable outcome and consumes more health resources. However, sciatica prevalence rates reported in different studies and reviews vary considerably and provide no clear picture about sciatica prevalence. METHODS: A literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1980-2006. Two reviewers extracted data on sciatica prevalence and definitions from the identified articles. RESULTS: Of the papers retrieved, 23 were included in the review. Only 2 studies out of the 23 used clinical assessment for assessing sciatic symptoms, and definitions of sciatica varied widely. Sciatica prevalence from different studies ranged from 1.2% to 43%. CONCLUSION: Sciatica prevalence estimates vary considerably between studies. This may be due to differences in definitions, methods of data collection and perhaps populations studied. Suggestions are made on how to improve accuracy of capturing sciatica in epidemiological studies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Estimating the future course of musculoskeletal pain is an important consideration in the primary care consultation for patients and healthcare professionals. Studies of prognostic indicators tend to have been viewed in relation to each site separately, however, an alternative view is that some prognostic indicators may be common across different sites of musculoskeletal pain. AIM: To identify generic prognostic indicators for patients with musculoskeletal pain in primary care. DESIGN OF STUDY: Systematic review. SETTING: Observational cohort studies in primary care. METHOD: MEDLINE, EMBASE, PsychINFO and CINAHL electronic databases were searched from inception to April 2006. Inclusion criteria were that the study was a primary care-based cohort, published in English and contained information on prognostic indicators for musculoskeletal conditions. RESULTS: Forty-five studies were included. Eleven factors, assessed at baseline, were found to be associated with poor outcome at follow up for at least two different regional pain complaints: higher pain severity at baseline, longer pain duration, multiple-site pain, previous pain episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction. CONCLUSION: Despite substantial heterogeneity in the design and analysis of original studies, this review has identified potential generic prognostic indicators that may be useful when assessing any regional musculoskeletal pain complaint. However, Its unclear whether these indicators, used alone, or in combination, can correctly estimate the likely course of individual patients' problems. Further research is needed, particularly in peripheral joint pain and using assessment methods feasible for routine practice. [ABSTRACT FROM AUTHOR]

Objective: To investigate a new definition of pain episodes among primary care low back pain consulters. Methods: Consecutive primary care low back pain consulters aged 30-59 years were mailed self-completion questionnaires. In the pilot phase [N = 259], two open-ended questions on episode inception were compared; four respondents were also interviewed in depth. In the main study, the reliability [N = 447] and validity [N = 189] of a question with discrete response categories were estimated. Results: Only 23 percent of pilot study participants gave comparable responses to the two episode inception questions. Interviews illustrated the difficulties patients found in answering the questions. Good reliability and validity of the question completed in the main study were indicated. Seventy-six percent of respondents gave consistent responses to the last pain-free month question at baseline and six months, and 79 percent of people gave responses at six-months that were consistent with their monthly questionnaires. Conclusions: Problems recalling the start of low back pain episodes indicate that wording of questions could lead to misclassification of patients. A question asking about the 'last pain-free month' shows promise as a standard simple epidemiological measure of episode inception. [ABSTRACT FROM AUTHOR]

Study Design: Prospective inception cohort.Objective: To investigate the validity and use of a single question on the bothersomeness of low back pain (LBP) as a method of classifying the severity of symptoms among patients seen in clinical practice.Summary Of Background Data: There is no widely accepted method for classifying patients with nonspecific LBP in clinical practice. There have been no previous reports of the validity and use of a question on bothersomeness as a method of classifying patients with LBP.Methods: Consecutive patients (30-59 years old) with LBP consulting at 5 United Kingdom general practices (n = 1464) were mailed a questionnaire after consultation and 6 months later. Construct validity was assessed by comparing baseline responses on the single bothersomeness question with pain, disability, general health, and psychologic health measures. The ability of bothersomeness to predict outcomes at 6 months was assessed against pain, disability, work absence, and health care use.Results: A total of 935 patients (65%) completed baseline questionnaires. There were 776 (83%) patients who consented to enter the follow-up study, and 447 returned the 6-month questionnaire. At baseline, bothersomeness correlated with pain, disability, and other measures (P < 0.001), and had 80% sensitivity (61% specificity) to detect people in the highest category of pain and disability. People with bothersome LBP at baseline evaluation had an increased risk of work absence or health care consultations for LBP 6 months later (relative risks 2.8 and 1.9, respectively).Conclusions: There is evidence for the validity of a single bothersomeness question as a measure of LBP severity. It has the potential to provide a practical standard scheme for classifying patients with LBP in clinical practice. However, further work is needed to clarify its usefulness in a clinical setting. [ABSTRACT FROM AUTHOR]

Background: There has been little research carried out on the prevalence and types of sexual dysfunction in the general population, although the indications are that such problems are relatively common. Most common sexual problems are potentially treatable. However GPs have estimated the prevalence of sexual problems to be far lower than survey estimates.Objective: To provide an estimate of the prevalence of sexual problems in the general population, and assess the use of and need for professional help for such problems.Methods: We used an anonymous postal questionnaire survey. The study was set in four general practices in England*, and the study population was a stratified random sample of the adult general population (n = 4000). The subjects were 789 men and 979 women who responded to the questionnaire. The main outcome measures were the presence and type of current sexual problems in men and women, and the provision and use of treatments for sexual problems.Results: A response rate of 44% was obtained. The median age of the responders was 50 years. A third of men (34%) and two-fifths of women (41 %) reported having a current sexual problem. The most common problems were erectile dysfunction (n = 170) and premature ejaculation (n = 88) in men; in women the most widely reported problems were vaginal dryness (n = 186) and infrequent orgasm (n = 166). In men, the proportion of responders reporting sexual problems increased with age, but there was no similar trend in women. Of those responders who reported a sexual problem, 52% said that they would like to receive professional help for this problem, but only one in ten of these people (n = 50) had received such help.Conclusion: Among responders there was a high level of reported sexual problems. The most frequently reported problems (vaginal dryness, erectile problems) may be amenable to physical treatment in practice, and yet few had sought or received help. However, many said that they would like to receive help. These figures suggest that there may be an important burden of potentially reversible sexual problems in the general population. [ABSTRACT FROM AUTHOR]

Background/Objectives : In response to the COVID-19 pandemic, Australian state and federal governments enacted boarder closures, social distancing measures, and lockdowns. By the end of October 2020, the 112-day lockdown in the Australian state of Victoria was the longest continuous lockdown period internationally. Previous studies have examined how the COVID-19 pandemic and government restrictions have affected Australians' mental health and well-being; however, less is known about the relationship between psychological variables and well-being. Methods : We administered a national survey of Australians aged 16 years and over ( N = 1380) in November 2020 to examine the psychological factors that promoted and hindered Australians' well-being and resilience during the first year of the pandemic. Results : Our study found that Australians reported normal to moderate levels of anxiety, moderate stress, mild depression, and moderate to high loneliness. Interpersonal trust was consistently a protective factor for well-being and resilience and was associated with less depression, anxiety, stress, and loneliness, and greater resilience. Participants with greater inhibitory anxiety (intolerance of uncertainty) and an external locus of control were more likely to be depressed, anxious, stressed, and lonely, and less resilient, compared with those with less inhibitory anxiety and those who believed that these outcomes were determined by their own actions. COVID-19 beliefs were associated with more depression, anxiety, stress, and resilience. Conclusions : This study seeks to inform the development of mental-health, well-being, and resilience strategies by government agencies, non-government organisations, and healthcare providers in times of crisis and in "ordinary" times.

Abstract: There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes., (Copyright © 2024 International Association for the Study of Pain.)

The aim of this research was to describe the epidemiology, presentation and healthcare use in primary care for foot and ankle problems in children and young people (CYP) across England. We undertook a population-based cohort study using data from the Clinical Practice Research Datalink Aurum database, a database of anonymised electronic health records from general practices across England. Data was accessed for all CYP aged 0-18 years presenting to their general practitioner between January 2015 and December 2021 with a foot and/or ankle problem. Consultation rates were calculated and used to estimate numbers of consultations in an average practice. Hierarchical Poisson regression estimated relative rates of consultations across sociodemographic groups and logistic regression evaluated factors associated with repeat consultations. A total of 416,137 patients had 687,753 foot and ankle events, of which the majority were categorised as "musculoskeletal" (34%) and "unspecified pain" (21%). Rates peaked at 601 consultations per 10,000 patient-years among males aged 10-14 years in 2018. An average practice might observe 132 (95% CI 110 to 155) consultations annually. Odds for repeat consultations were higher among those with pre-existing diagnoses including juvenile arthritis (OR 1.73, 95% CI 1.48 to 2.03).    Conclusions: Consultations for foot and ankle problems were high among CYP, particularly males aged 10 to 14 years. These data can inform service provision to ensure CYP access appropriate health professionals for accurate diagnosis and treatment. What is Known: • Foot and ankle problems can have considerable impact on health-related quality of life in children and young people (CYP). • There is limited data describing the nature and frequency of foot and ankle problems in CYP. What is New: • Foot and ankle consultations were higher in English general practice among CYP aged 10 to 14 years compared to other age groups, and higher among males compared to females. • The high proportion of unspecified diagnoses and repeat consultations suggests there is need for greater integration between general practice and allied health professionals in community-based healthcare settings., (© 2024. The Author(s).)