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Chronic Low Back Pain, Considerations About: Natural Course, Diagnosis

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Chronic Low Back Pain, Considerations About: Natural Course, Diagnosis Chronic low back pain, considerations about Natural Course, Diagnosis, Interventional Treatment and Costs Coen Itz P Copyright Coen Itz 2016 UM ISBN 978 94 6159 625 3 UNIVERSITAIRE PERS MAASTRICHT Production / print Datawyse | Universitaire Pers Maastricht Chronic low back pain, considerations about: Natural Course, Diagnosis, Interventional Treatment and Costs Ter verkrijging van de graad van doctor aan de Iniversiteit Maastricht, Op gezag van rector Magnificus: Prof. dr. Rianne M. Letschert Volgens het besluit van het College van Dekanen, In het openbaar te verdedigen op woensdag 16 november 2016 om 12.00 door Coenraad Johannes Itz Promotores Prof. dr. Maarten van Kleef Prof. dr. Frank Huygen Co-promotor Dr. Bram Ramaekers Assessment Committee Prof. dr. Bert Joosten (chairman) Prof. dr. Emile Curfs Prof. dr. Manuela Joore Prof. dr. Roberto Perez Prof. dr. Rob Smeets Het was een verre reis Zul je voorzichtig zijn? Ik weet wel dat je maar een boodschap doet hier om de hoek en dat je niet gekleed bent voor een lange reis. Je kus is licht, je blik gerust en vredig zijn je hand en voet. Maar achter deze hoek een werelddeel, achter dit ogenblik een zee van tijd. Zul je voorzichtig zijn? (vrij naar adriaan morrien) CONTENTS Chapter 1 Introduction 9 Chapter 2 Clinical course of Nonspecific Low Back Pain: A Systematic Review of Prospective Cohort Studies Set in Primary Care 17 (Itz, EJP accepted April 2013) Chapter 3 Dutch multidisciplinary guideline for invasive treatment of pain syndromes of the lumbosacral spine 37 (Itz, Pain Practice accepted April 2015) Chapter 4 Medical specialists care and hospital costs for low back pain in The Netherlands 73 (Itz, EJP accepted October 2016) Chapter 5 A proposal for the organization of the referral of patients with chronic non-specific low back pain 91 (Itz, CMRO accepted July 2016) Chapter 6 General Discussion 105 Summary 115 Nederlandse samenvatting 121 Valorisation Addendum 127 Dankbetuigingen 133 Curriculum Vitae 137 7 Chapter 1 Introduction 9 Introduction Eighty percent of the population has at least one episode of Low Back Pain (LBP) during their life. (1) In some studies this figure even mounts to 90%, which means that the vast majority of adults have experienced at least one episode of LBP. Waddell described LBP as a twentieth century health care enigma; he referred to the size of the problem but also to the different factors influencing the experience and outcome of LBP. (2) In his book “The back pain revolution” Waddell states that humans have always had back pain, and that this low back pain is no more common or severe now than it was in earli- er times.(3) He made a plea for less medicalization of back pain and directing patients with acute and sub acute problems to the general practitioner (GP) for conservative management. The most recent NICE guidance (4) recommends advising patients to continue normal activities as much as possible. BURDEN OF LOW BACK PAIN Ehrlich (5) describes low back pain as “neither a disease nor a diagnostic entity of any sort. The term refers to pain of variable duration in an area of the anatomy afflicted so often that it is has become a paradigm of responses to external and internal stimuli “ In the NICE guidance the anatomic region is defined as “the back between the bottom of the rib cage and the buttock creases”.(4) Reviews of epidemiological studies on low back pain highlighted their heterogeneity in definition, age group, data collection, recall period etc. thus making the poolability very difficult. (6) LBP was reported to have a point prevalence ranging from 12% to 33%, 1-year prevalence between 22% and 65%, and lifetime prevalence ranging from 11% to 84%. (7) Defining the prevalence of chronic low back pain (CLBP) is complicated by the hetero- geity of its definition, and national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability.(8) The Global Burden of Disease study found LBP to be the number one cause of years lived with disability. (9) THE COURSE OF LBP The natural course of LBP is poorly documented. Spitzer et al (10) came in 1987 to the conclusion that about 8% of all patients would still have back pain one year after the first consultation. However, a more recent review of studies, conducted in patients, repre- sentative for the general patient population, showed that 62% of the patients still expe- rienced pain after 12 months. (11) Another systematic review found that in a cohort of patients with LBP at baseline, 75% and 73%, reported to not to be pain free at the 5- and 10- years of follow-up, respectively. (12) These observations contradict the common believe that the course of LBP is generally favorable. This favorable course is based on 11 CHAPTER 1 occupational studies in which ‘return to work’ or ‘recovery from disability’ is investigat- ed.(13) However, this presumed favorable course has recently been questioned. (14) A better understanding of the natural course of low back pain should facilitate defining the research question for epidemiological studies, and improve the therapeutic decisions. CHRONIC LBP HAS NO UNIFORM LANGUAGE Already in 1982 Nachemson et al. (15) that a commonly used classification of low-back disorders was required to improve epidemiology and treatment studies. Spitzer used the classification specific and non-specific low back pain. (16) While Bogduk differenti- ates between nociceptive, somatic referred or neuropathic pain, such as radicular pain and radiculopathy (17) Jenkins described a classifications of mechanical low back pain, low back pain with radiculopathy, serious pathological low back pain and low back pain with psychological overlay.(18) Schwarzer (19) subdivided the mechanical low back pain into: facet joint pain, discogenic pain and sacro-iliac joint pain pointing towards to po- tential causal structure. To improve the communication between health care professionals and optimize treatment selection a globally accepted and used classification system is required. DIAGNOSTIC AND TREATMENT OF LBP When patients suffer “specific” LBP, meaning that an underlying pathology can be iden- tified, the treatment will address the cause and pain management is auxiliary. As al- ready indicated, “non-specific” LBP should be further can be subdivided in mechanical LBP and LBP with radiation into the leg, lumbosacral radicular pain. Efforts should be made to identify the structure responsible for mechanical low back pain. Hancock et al. (20) systematically reviewed the literature to assess the accuracy of the tests to identify the facet joints, the intervertebral disc and the sacro-iliac joints as source of low back pain. They found that there are tests for disc and SIJ that have some diagnostic value. The tests for pain originating from the facet joint are less reliable (20) When conservative treatment, consisting of pharmacological management and where appropriate exercise therapy, fails to provide satisfactory pain relief or medica- tion causes intolerable side effects, interventional treatment like anesthesiology treat- ment or surgery, may be considered. (21) The possible anesthesiological treatments are: injection techniques, radiofrequency treatment and Spinal Cord Stimulation (SCS). Injection treatment relies on the principles of regional anesthesia, where local anesthetic with or without corticosteroid is injected in the vicinity of the nerve. Radiofrequency treatment aims at changing the pain con- duction through the nerve by applying a high frequency current. Spinal cord stimulation 12 Introduction changes the pain conduction/perception through application of electrical stimulation at the spinal cord. Spine surgical treatments aim at decompressing the causative structure. The treatment selection should be based on the best available evidence. (21) A guideline reviewing the available evidence per diagnosis and assessing the value of the evidence in a systematic manner would help the clinician in the treatment selection MEDICAL SPECIALIST CARE AND COSTS OF LBP Treatment guidelines recommend a stepwise approach often involving a multidiscipli- nary team. The GP, also described, as the health care provider who is closest to the patient and his/her family, ideally should has a coordinating role. When conservative treatment fails, the GP can select from about 15 different specialists where to refer to patient, which is a difficult task. In absence of a referral algorithm it is not clear how patients with LBP should be referred to second line care and between specialties within the hospital. This information may help designing a LBP treatment pathway that opti- mizes the use of health care resources, improves treatment outcome and reduces costs. For this purpose, there is need for more information regarding the current organization and costs of LBP care. Moreover, based on these data, proposals for possible improve- ments of the organization of LBP care may be provided. Considering the issues raised above, the main objective of this thesis is: to examine the natural course, costs and organization of care for LBP patients and explore alternative disease classifications systems to enable tailored treatment. This objective is subdivided into 5 research questions: 1. What is the natural course of pain in patients with non-specific LBP of less than 3 months of duration, with a follow-up of at least 12 months, and set in primary care? Chapter 2 2. Can LBP be classified in such a way that it helps identifying the potential cause and thus directs referral and treatment? Chapter 3 3. What is the available evidence for the interventional management of the differ- ent sub-diagnoses of LBP, what is the value of this evidence and how can these findings be summarized? Chapter 3. 4. What is the medical specialist care in terms of the order of consultation of the dif- ferent medical specialisms upon referral of LBP patients to the hospital? What are the hospital costs for LBP patients in total and per specialism? Chapter 4 13 CHAPTER 1 5.
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