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Introduction Low back pain is the single biggest cause of years lived with disability worldwide, and a major challenge to international health systems. (1) In 2018, the Lancet Low Back [...], back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Les lombalgies sont la principale cause d'annees de vie vecues avec une incapacite dans le monde. En 2018, un groupe de travail international a invite l'Organisation mondiale de la Sante a attirer l'attention sur la charge que representent les lombalgies et sur la necessite d'eviter le recours excessif aux solutions medicales. En effet, selon les dernieres recommandations cliniques internationales, de nombreux cas de lombalgie ne necessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommande de limiter la prise d'analgesiques, les injections de steroides et la chirurgie rachidienne, et d'encourager plutot les therapeutiques physiques et psychologiques. Tres souvent, les systemes de sante ne sont pas concus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systemes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous detaillons les principales difficultes de la prise en charge des lombalgies dans le cadre des systemes de sante. Il s'agit notamment des interets financiers des laboratoires pharmaceutiques, entre autres; des systemes de paiement obsoletes qui privilegient la prise en charge medicale a l'autogestion par les patients; et de croyances et traditions medicales profondement ancrees parmi les medecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systemes de sante confrontes de plus en plus souvent a une prise en charge inefficace des lombalgies. Nous suggerons des politiques qui, sans incidence sur les couts, en transferant les ressources allouees aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considerable. De petits ajustements des politiques de sante ne suffiront cependant pas. Les systemes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte societal global dans lequel s'inscrit la sante devront egalement changer. El dolor lumbar es la causa principal de vivir con discapacidad durante anos en todo el mundo. En 2018, un grupo de trabajo internacional pidio a la Organizacion Mundial de la Salud que prestara mas atencion a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente medicas. De hecho, las principales directrices clinicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningun tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgesicos, inyecciones de esteroides y cirugia de la columna vertebral y, en su lugar, promover las terapias fisicas y psicologicas. Muchos sistemas de salud no estan disenados para apoyar este enfoque. En este documento, se expone por que el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atencion del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las companias farmaceuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atencion medica por encima del autocuidado de los pacientes, asi como las tradiciones y las creencias medicas profundamente arraigadas sobre la atencion del dolor de espalda entre los medicos y el publico general. Se presentan ejemplos internacionales de soluciones prometedoras y de politicas y practicas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atencion ineficaz para el dolor lumbar. Se sugieren politicas que, al desplazar los recursos de la atencion innecesaria a la atencion acorde con las directrices para el dolor lumbar, podrian ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequenos ajustes en la politica sanitaria no funcionaran de forma aislada. Los sistemas del lugar de trabajo, los marcos juridicos, las creencias personales, la politica y el contexto social general en el que vivimos la salud tambien tendran que cambiar.

OBJECTIVE: To estimate the difference in confidence to become active despite low back pain in people who were exposed to one of 2 video interventions delivered on social media, compared to no intervention. DESIGN: A proof-of-concept, 3-group randomized controlled trial, in a 1:1:1 ratio. METHODS: Participants aged 18 years and over, with and without low back pain, were recruited via the social media channel Facebook, to view either a humorous video, a neutral video, or to no intervention. The videos were delivered online, explained evidence-based management for low back pain, and were designed to "go viral." The primary outcome was confidence in becoming active despite pain, measured using the Pain Self Efficacy Questionnaire (Item 10) (ranges from 0 [not at all confident] to 6 [completely confident]) immediately after watching the video. We aimed to capture the real-time impact and immediate reactions that contributed to the content's reach. RESULTS: Among 1933 randomized participants (mean [standard deviation] age: 58.9 [14.0] years, 1285 [75%] women), 1232 [70%] had low back pain and 88.8% completed the primary outcome. One thousand two hundred sixty-four participants were randomized to receive a video intervention, and 633 participants did not receive a video. On a 6-point scale, individuals exposed to either video (n = 1088) showed a mean confidence level 0.3 points higher (95% confidence interval: 0.1, 0.6) compared with no video (n = 630). CONCLUSION: Participants who viewed a brief video intervention reported a very small difference in confidence to become active despite low back pain, compared with no intervention. The difference may lack clinical relevance. [ABSTRACT FROM AUTHOR]

The article examines strategies from behavioral economics to enhance adherence to home exercise programs in physiotherapy. Topics discussed include the importance of setting personalized, meaningful goals, collaborative planning of exercise routines, and employing techniques like planning prompts, habit stacking, and temptation bundling to improve adherence and maintain habits.

Introduction: The increasing number of gabapentinoid (pregabalin and gabapentin) harms, including deaths observed across countries is concerning to health‐care professionals and policy makers. However, it is unclear if the public shares these concerns. This study aimed to describe posts related to gabapentinoids, conduct a content analysis to identify common themes and describe adverse events or symptoms. Methods: Keywords of 'pregabalin' or 'Lyrica' or 'gabapentin' or 'Neurontin' were used to search for related tweets posted by people in the community between 8 March and 7 May 2021. Eligible tweets included a keyword in the post. We extracted de‐identified data which included descriptive data of the total number of posts over time; and data on individual tweets including date, number of re‐tweets and post content. Data were exported separately for pregabalin‐ and gabapentin‐related tweets. A 20% random sample was used for the thematic analysis. Results: There were 2931 pregabalin‐related tweets and 2736 gabapentin‐related tweets. Thematic analysis revealed three themes (sharing positive experiences and benefits of taking gabapentinoids, people voicing their negative experiences, and people seeking opinions and sharing information). Positive experiences of gabapentinoids were related to sharing stories and giving advice. This was contrasted to negative experiences including ineffectiveness, withdrawals, side effects and frustration related to cost and insurance coverage. Brain fog was the most common adverse symptom reported. Gabapentinoid‐related deaths were only mentioned in three tweets. Discussion: The increasing public health concern of gabapentinoid‐related deaths was not translated to Twitter discussions. [ABSTRACT FROM AUTHOR]

* OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). * DESIGN: Three-arm parallel-group randomized experiment. * METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. * RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. * CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. [ABSTRACT FROM AUTHOR]

To evaluate the knowledge, skills and barriers to evidence-based practice and the impact of evidence-based practice training for physical therapy clinicians. Physical therapists from a health district in Sydney, Australia were invited to participate. The primary outcome was the Assessing Competency in Evidence-based Medicine scale (range 0–15; 15 is high knowledge and skill) to quantify knowledge and skills. The secondary outcomes were the four subscales of the BARRIERS scale (range 1–4; 4 is high barrier) to quantify barriers. Outcomes were collected at baseline and post an evidence-based practice training program (flipped classroom approach that addressed the core competencies for teaching evidence-based practice) of 3 months duration. Registration: Australian and New Zealand Clinical Trial Register (ACTRN12619000038190). 104 participants completed baseline data and 94 completed post-training data. The mean score for the Assessing Competency in Evidence-based Medicine scale for knowledge and skills at baseline was 9.5 (standard deviation 1.6). The mean BARRIERS subscale scores at baseline were: Healthcare Provider 1.9 (0.5); Research 2.2 (0.5); Setting 2.6 (0.5); and Presentation 2.6 (0.5). On average, training increased the Assessing Competency in Evidence-based Medicine scale score by 0.1 points (95% confidence interval −0.2 to 0.5) and reduced barriers by −0.1 (−0.2 to 0.0; Setting subscale) to −0.2 (−0.3 to −0.1; Healthcare Provider subscale). Physical therapists have knowledge and skill in evidence-based practice that is comparable to other allied health professionals, medical students and medical doctors, and encountered barriers to using high-quality clinical research to guide practice. Training did not change knowledge and skills but did reduce barriers. [ABSTRACT FROM AUTHOR]

Purpose: An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations. Methods: In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses. Results: Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain. Conclusion: Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP. [ABSTRACT FROM AUTHOR]

Importance: Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice.Objective: To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs).Design, Setting, and Participants: This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021.Interventions: Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked.Main Outcomes and Measures: The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation.Results: A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001).Conclusions and Relevance: Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months.Trial Registration: ANZCTR Identifier: ACTRN12619001503112. [ABSTRACT FROM AUTHOR]

Background: Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, surgery, second opinion, seriousness, recovery, work, and physical activities. Methods: Six‐arm online randomized experiment with blinded participants with and without LBP. Participants received one of six labels: 'disc bulge','degeneration','arthritis','lumbar sprain','non‐specific LBP', 'episode of back pain'. The primary outcome was the belief about the need for imaging. Results: A total of 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. The need for imaging was rated lower with the labels 'episode of back pain' (4.2 [2.9]), 'lumbar sprain' (4.2 [2.9]) and 'non‐specific LBP' (4.4 [3.0]) compared to the labels 'arthritis' (6.0 [2.9]), 'degeneration' (5.7 [3.2]) and 'disc bulge' (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery and perceived seriousness compared to 'disc bulge','degeneration' and 'arthritis'. Differences were larger amongst participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels. Conclusions: 'Episode of back pain','lumbar sprain' and 'non‐specific LBP' reduced need for imaging, surgery and second opinion compared to 'arthritis','degeneration' and 'disc bulge' amongst public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant amongst those at risk of poor outcomes (participants with current LBP who had a history of seeking care). [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine, in those who present to the ED with low back pain (LBP): (i) the prevalence of four key diagnostic categories, (ii) trends in lumbar imaging from 2015 to 2019 and (iii) the effect of a new model of care on lumbar imaging in the ED. Methods: We conducted a retrospective analysis of routinely collected medical data of four tertiary hospitals in Sydney, Australia. We analysed ED presentations for LBP between January 2012 and October 2019. Outcomes were the prevalence of four key diagnostic categories of LBP and use of lumbar imaging. We examined trends in lumbar imaging over time and used interrupted time series analysis to determine the impact of model of care implementation on imaging use. Results: There were 31 168 presentations for LBP of which 64.5% were non‐specific LBP, 27.2% were problems beyond the spine, 5.3% were LBP with neurological signs and 2.3% were serious spinal conditions. 28.9% received lumbar imaging; use did not change substantially between 2012 and 2019. Patients diagnosed with serious spinal conditions were more likely to receive imaging (59%) than those diagnosed with non‐specific LBP (29%). Implementation of a state‐wide model of care in November 2016 did not appear to influence imaging use. Conclusion: Most presentations to the ED for LBP are for non‐specific LBP. Around 2% will have specific spinal pathology. Use of imaging in those diagnosed with non‐specific LBP remains high and was unaffected by implementation of a state‐wide model of care. [ABSTRACT FROM AUTHOR]

Introduction: Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non‐specific'. Exercise therapy is recommended by international clinical guidelines as a first‐line treatment for non‐specific CLBP. Aim: This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence‐based guidance concerning exercise prescription for non‐specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals. Methods: We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP. Results/Discussion: Systematic reviews show exercise is effective for small, short‐term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group‐based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain. Conclusion: To promote recovery, sustainable outcomes and self‐management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self‐efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence‐based practical guidance to health professionals who prescribe exercise for people with non‐specific CLBP. [ABSTRACT FROM AUTHOR]

Author(s): Adrian C. Traeger 1,2,*, Nicholas Henschke 3, Markus Hübscher 1,2,*, Christopher M. Williams 4, Steven J. Kamper 5, Christopher G. Maher 5, G. Lorimer Moseley 2,6, James H. McAuley [...], Background Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP. Methods and Findings We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a "treat all" approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings. Conclusions Based on its performance in these cohorts, this five-item prognostic model for patients with acute LBP may be a useful tool for estimating risk of chronic LBP. Further validation is required to determine whether screening with this model leads to a net reduction in unnecessary interventions provided to low-risk patients.

Aim: To compare and contrast the diagnostic codes for spinal causes of low back pain (LBP) in 3 disease classification systems (International Classification of Diseases [ICD]‐10, International Classification of Primary Care [ICPC]‐2 PLUS and Systematized Nomenclature of Medicine Clinical Terms ‐ Australia [SNOMED CT‐AU]) and consider how well they are aligned with the diagnostic approach recommended in contemporary clinical practice guidelines for LBP. Method: This was a descriptive study which included 3 disease classification systems: ICD‐10, ICPC‐2 PLUS and SNOMED CT‐AU. Two independent authors extracted relevant LBP codes from each system and mapped the codes to 3 guideline‐endorsed categories of spine‐related diagnoses for LBP (specific spinal pathology, radicular syndromes, and non‐specific LBP) and the various clinical conditions (sub‐categories) within each of the 3 categories. Results: ICD‐10, ICPC‐2 PLUS, and SNOMED CT‐AU had 126, 118 and 100 codes for LBP, respectively. All systems provided codes that would cover the 3 guideline‐endorsed categories of spine‐related diagnoses for LBP. On the basis of contemporary guidelines, the authors developed lists of discrete sub‐categories of specific spinal pathology (56 sub‐categories), radicular syndromes (7 sub‐categories), and non‐specific LBP (10 sub‐categories). Each of the classification systems was then mapped against these sub‐categories to tally redundancy and determine exhaustiveness. However, no system covered all 73 sub‐categories of LBP, and within each system, there was substantial redundancy with up to 22 codes for the same clinical condition. Conclusion: LBP diagnostic codes used in popular disease classification systems are out of touch with current approaches to diagnosis, as reflected in contemporary LBP guidelines. Our findings suggest these disease classification systems need revision, but precisely how they should be revised is unclear. [ABSTRACT FROM AUTHOR]

Introduction: Clinician time and resources may be underutilised if the treatment they offer does not match patient expectations and attitudes. We developed a questionnaire (AxEL-Q) to guide clinicians toward elements of first-line care that are pertinent to their patients with low back pain.Methods: We used guidance from the COSMIN consortium to develop the questionnaire and evaluated it in a sample of people with low back pain of any duration. Participants were recruited from the community, were over 18 years and fluent in English. Statements that represented first-line care were identified. Semantic scales were used to measure attitude towards these statements. These items were combined to develop the questionnaire draft. Construct validity was evaluated with exploratory factor analysis and hypotheses testing, comparing to the Back Beliefs Questionnaire and modified Pain Self-Efficacy Questionnaire. Reliability was evaluated and floor and ceiling effects calculated.Results: We recruited 345 participants, and had complete data for analysis for 313 participants. The questionnaire draft was reduced to a 3-Factor questionnaire through exploratory factor analysis. Factor 1 comprised 9 items and evaluated Attitude toward staying active, Factor 2 comprised 4 items and evaluated Attitude toward low back pain being rarely caused by a serious health problem, Factor 3 comprised 4 items and evaluated Attitude toward not needing to know the cause of back pain to manage it effectively. There was a strong inverse association between each factor and the Back Beliefs Questionnaire and a moderate positive association with the modified Pain Self-Efficacy Questionnaire. Each independent factor demonstrated acceptable internal consistency; Cronbach α Factor 1 = 0.92, Factor 2 = 0.91, Factor 3 = 0.90 and adequate interclass correlation coefficients; Factor 1 = 0.71, Factor 2 = 0.73, Factor 3 = 0.79.Conclusion: This study demonstrates acceptable construct validity and reliability of the AxEL-Q, providing clinicians with an insight into the likelihood of patients following first-line care at the outset. [ABSTRACT FROM AUTHOR]

Background Few studies have investigated the effects of waiting room communication strategies on health-care behavior. Objective We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED). Methods We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey. Results For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n  = 99; control n  = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI)  =  18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI  =  23% to 35%; odds ratio (OR)  =  0.83, 95% CI  =  0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n  = 170; control n  = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR  =  2.00, 95% CI  =  0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. Conclusion A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality. Trial registration ACTRN12620000300976, 05/03/2020 [ABSTRACT FROM AUTHOR]

Background: Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care.Objective: We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED).Methods: This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019-20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse).Results: Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8-11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0-6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome).Conclusion: In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse. [ABSTRACT FROM AUTHOR]

It has been hypothesised that attentional bias to environmental threats can contribute to persistent pain. It is unclear whether people with acute low back pain (LBP) have an attentional bias to environmental threats. We investigated if attentional bias of threat related words is different in people with acute LBP and pain-free controls. People with acute LBP and pain-free people completed a free viewing eye tracking task. Participants were simultaneously presented with two words, a threat related word and a neutral control word. Threat related words were general threat, affective pain and sensory pain. We conducted linear mixed models to detect differences between acute LBP and pain-free participants on five eye tracking outcome measures (dwell time, first fixation, latency to first fixation, first run dwell time and number of fixations). We calculated absolute reliability, (standard error of measure), and relative reliability (intraclass correlation coefficients [ICC 2,1]) for each eye tracking outcome measures. We recruited 65 people with acute LBP and 65 pain-free controls. Participants with acute LBP had a higher proportion of fixations towards the affective pain words (M=0.5009, 95% CI=0.4941, 0.5076) than the pain-free controls had (M=0.4908, 95% CI=0.4836, 0.4979), mean between group difference = −0.0101, 95% CI [−0.0198, −0.0004], p=0.0422. There was no difference between acute LBP and pain-free controls for the remaining eye tracking outcome measures (all p>0.05). The only outcome measure that had an ICC of more than 0.7 was the latency to first fixation (affective pain words ICC=0.73, general threat words ICC=0.72). When compared with pain-free controls, people with acute LBP looked more often at affective pain words relative to neutral control words. This may indicate a form of engagement bias for people with acute LBP. Attentional bias was not consistent across outcome measures or word groups. Further research is needed to investigate the potential role of attentional bias in the development of persistent pain. [ABSTRACT FROM AUTHOR]

Background: Overuse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.Aim: To explore factors that might influence overuse of lumbar imaging in the Emergency Department.Methods: Participants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.Results: Patients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients' perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.Conclusion and Key Findings: We found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care. [ABSTRACT FROM AUTHOR]

Background: Community awareness of the harms of overdiagnosis remains low. Objective: To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain. Methods: We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes. Results: Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging. Conclusions: Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully. Patient or Public Contribution: We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of information format on intentions to request diagnostic imaging for non-specific low back pain in members of the public.Methods: We performed a three arm, 1:1:1, superiority randomised trial on members of the public. Participants were randomised to one of the three groups: a Standard Care Leaflet group (standard information on low back pain), a Neutral Leaflet group (balanced information on the benefits and harms of imaging) and a Nudge Leaflet group (with behavioural cues to emphasise the harms of unnecessary imaging). Our primary outcome was intention to request imaging for low back pain.Results: 418 participants were randomised. After reading the leaflet, intention to request imaging (measured on an 11-point scale (0 = definitely would not request to 10 = definitely would request) was lower in the Nudge Leaflet group (mean = 4.6, SD = 3.4) compared with the Standard Care Leaflet group (mean = 5.3, SD = 3.3) and the Neutral Leaflet group (mean = 5.3, SD = 3.0) (adjusted mean difference between Nudge and Neutral, -1.0 points, 95%CI -1.6 to -0.4).Conclusion: Framing information to emphasise potential harms from overdiagnosis reduced intention to request diagnostic imaging for low back pain.Practice Implications: Nudge leaflets could help clinicians manage patient pressure for unnecessary tests. [ABSTRACT FROM AUTHOR]