PCPs are front line defense in diagnosing serious illness in patients with acute lower back pain
The World Health Organization (WHO) estimates that the worldwide prevalence of back pain can be as high as 42%. Pain that occurs in the lower back interrupts the daily routine, such as work, school or activities, and is a leading cause of visits to primary care physicians (PCP). According to the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH), back pain is the second most common neurological disease in the United States NINDS estimates that Americans spend at least $ 50 billion each year due to back pain, a leading contributor to missed work and job related disability.
In this study a total of 170 general practitioners (Australian equivalent to the PCP), were recruited physiotherapists and chiropractors in the Sydney area. Between 2003 and 2005, with 3184 controlled trials of 1172 patients presenting with acute low back pain. These patients were evaluated for the presence of red flags of serious disease. The term “red flag means danger and is used as a warning sign. In health facilities “red flag”, the clinical features, such as unexplained weight loss, are used by PCP for the detection of low back pain patients who are more likely to have a serious illness, and therefore require work broader diagnostic-up.
Patients over 14 years, presenting for the first consultation of the current episode of acute low back pain were included in this study. The researchers monitored the patients for 12 months after the initial consultation to determine if the fracture, infection, arthritis or cancer was the cause of your pain. The results showed that the PCP identified 5 of the 11 cases of previously undiagnosed serious illness in the initial consultation.
The researchers, led by Christopher Maher, Ph.D., noted 8 cases of vertebral fractures, the most common serious illness identified and the only disease for which researchers were able to create a standard for diagnosis. The rule contained 4 variables: female, age> 70 years, major trauma (higher in younger patients, lower in older patients), and prolonged use of corticosteroids. When at least 1 of the flag of “red” question is positive, the odds ratio (fracture) was 1.8, with at least 2 positive, the proportion increased to 15.5 and with 3 positive aspects rose to 218.3. “Our rule suggests that when a 3 of the 4” red flags “are positive, the probability of vertebral fracture greatly increases (eg, from 0.5% to 52%), said Professor Maher.
The study also found that there are high rates of false positives with some red flag questions. A red flag approach is given any positive course would lead to unnecessary referrals to specialists and unnecessary investigation of patients. The authors suggest, “A better approach would be to evaluate a combination of red flag questions that identify severe illness and reduce the number of false positives.” Primary care plays a vital role in early detection of serious diseases and the authors recommend further research into the diagnostic accuracy of red flags in the low back pain is necessary.
More information: “Prevalence of and Screening for Serious Spinal Pathology in Patients Presenting to Primary Care Settings With Acute Low Back Pain” Nicholas Henschke, Christopher G. Maher, Kathryn M. Refshauge, Robert D. Herbert, Robert G. Cumming, Jane Bleasel, John York, Anurina Das, and James H. McAuley. Arthritis & Rheumatism; Published Online: September 29, 2009 (DOI 10.1002/art.24853); Print Issue Date: October 2009.
Source: Wiley (web)
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