Content Analysis of General Practitioner Requested Lumbar Spine X-ray Reports

Aims and Background X-rays of patients with low back pain rarely show serious pathology but frequently reveal incidental age-related changes and always expose people to radiation. Patients who have X-rays are more satisfied but report worse pain and disability. Psychological factors such as illness beliefs,catastrophizing and fear avoidance have been shown to be predictors of chronicity/disability. Authorities suggest that the way X-ray information is transmitted and interpreted by patients may influence outcome, therefore this study was designed to determine the words used by radiologists to describe lumbar spine Xrays. Methods: 120 consecutive X-ray reports for patients referred by primary care physicians were anonymised. A formal summative content analysis was undertaken. The coded words were grouped into categories according to their perceived meaning, and the process was refined until there were only three mutually exclusive categories. Results: Half the sample was aged 60 years or younger. Three categories were identified: anatomical, pathological and descriptive. In the pathological category, 33% of words described normal appearances, 47% described age-related changes and 20% described other features. In only 2% of cases were pathological words used to describe conditions as being "normal for age". Overall, 89 (74%) of the 120 reports contained at least one phrase containing words indicating the presence of degenerative changes. Conclusions: Almost three-quarters of lumbar spine X-ray reports use pathological words such as 'degenerative changes' to describe age-related changes but rarely describe them as being "normal for age"

Exploring joint hypermobility syndrome, developmental coordination disorder and pain

INTRODUCTION Floppy, clumsy, hypermobile children are increasingly referred to occupational and physical therapy under the label of dyspraxia. Motor impairments associated with the umbrella diagnosis of developmental coordination disorder (DCD) have been reported as persisting into adolescence and adulthood and subsequently affecting functional abilities (Cousins and Smyth 2003). Within this heterogeneous condition the underlying mechanisms causing the motor difficulties remains unclear. Ayers (1985) hypothesised that some individuals might have somatosensory processing issues contributing to their poor motor planning and coordination difficulties. Similarities in functional difficulties have been noted in children with a diagnosis of DCD and joint hypermobility syndrome (JHS) (Kirby and Davies 2006). There is limited understanding of the relationship between the two conditions. JHS is a multisystemic inherited connective tissue disorder, in which hypermobile joints, pain, clumsiness, poor proprioception and dislocations are familiar features (Grahame and Hakim 2006; Adib et al 2005). It has been suggested that adults with JHS show poor movement patterns which contribute to biomechanical dysfunction and continuing pain (Clark et al 2009). Pain and disability reported in adults with JHS often leads to anxiety, depression, work incapacity and social isolation (Grahame and Hakim 2006). The purpose of this study was to explore the association between adults with JHS and DCD and long term pain. METHODOLOGY/ METHODS A mixed methods design influenced by a pragmatic paradigm was utilised. Subjects: 90 patients with JHS (18-65 years) recruited from a hypermobility clinic were compared, using a questionnaire, with 113 healthy volunteers (18-65 years) with no pain recruited from a university. Analysis: Quantitative data were described and examined by regression, odds ratios were calculated. Qualitative data was analysed thematically FINDINGS The percentage of subjects who reported DCD in patients with JHS and healthy volunteers were 56% and 19% respectively. A significant association between patients with JHS and DCD was noted, chi square = 30.11, p < .001. Patients with JHS were 6 times [95% CI 2.9 – 10.3] more likely to report DCD than healthy volunteers. Pain was a significant feature with an average of 9.8 pain sites reported (out of a total of 17). Open ended questions revealed many patients recalling pain starting in early childhood and adolescence. DISCUSSION These results suggest a significant association between patients with JHS and DCD and the reporting of long term pain. Early recognition and understanding of the needs of children with DCD who present with somatosensory impairment, pain modulation and JHS is therefore essential. Sensory integration therapy as part of a comprehensive early intervention program has the potential to mitigate long term problems. A multidisciplinary approach which involves health professionals and teachers is also recommended. CONCLUSION This research may be considered an early step in the identification of an association of DCD and JHS. Further studies are required to explore somatosensory processing issues experienced by those with DCD and JHS as this might be an important underlying mechanism

Abstract: Pain poses a significant health burden in those with Joint Hypermobility Syndrome

Background Joint hypermobility Syndrome (JHS) is a complex multisystemic connective tissue disorder. JHS is acknowledged as a common clinical entity in musculoskeletal medicine with a prevalence of between 30%-60% in those presenting with musculoskeletal pain. It is more prevalent in females than males may present in childhood and shares symptom overlap with Ehlers-Danlos Syndrome, Marfan Syndrome and Ostegenesis Imperfecta. Patients with JHS report a variety of symptoms associated with this condition. These symptoms include: chronic pain, dislocations, impaired coordination, autonomic nervous system (ANS) and Gastrointestinal (GI) symptoms. Aims The purpose of this study was to investigate the health burden in those with JHS and to understand which symptoms are considered to be most troublesome. Methods A sample of 89 patients with JHS (mean age 34.6 ± 9.9 years, 82 female), diagnosed by a consultant rheumatologist according to the Brighton Criteria were compared with 113 healthy volunteers (mean age 35.7 ± 12.9, 82 female) with no musculoskeletal pain. Information relating to dislocations, ANS, GI symptoms and impaired coordination was collected by means of a self-report questionnaire. Data relating to the reporting of pain for >3 months was collected on a pain chart and the SF-12 was employed for assessing quality of life. SF-12 data is reported as Physical Component Summary (PCS) scores and Mental Component Summary (MCS) Scores. A difference in either the PCS or MCS scores of 5 points is considered to be a clinically important difference. Numerical data were analysed using independent sample t-tests and regression analysis. Results Patients with JHS reported significantly lower mean PCS scores (M = 29.70 SD 10.63) than healthy volunteers (M = 54.45 SD 5.74), t (127.701) = 19.81, p<0.001 (2-tailed). The mean difference was 24.75 points [95%CI 22.44 - 27.06] - a statistically significant and clinically important difference. Patients with JHS were significantly more likely to report the following than healthy volunteers; subluxations/dislocations, GI and ANS symptoms and impaired coordination. The average number of pain sites reported was 10/17. Regression analysis of the reported symptoms revealed the number of pain sites as the only significant predictor of a lowered PCS score (p< 0.01) in a model explaining 23% of the variance. MCS scores of patients with JHS (M = 41.13 SD 11.60) were significantly lower than those of healthy volunteers (M = 45.64 SD 10.95), t (200) = 2.65, p<0.01. The mean difference was <5 points - this might not be clinically important. Conclusion Patients with JHS in this study reported a statistically significant reduction in both PCS and MCS scores compared with healthy volunteers. The large difference in PCS scores is likely to be clinically important. Although multisystemic symptoms were reported multisite pain was the only symptom which contributed significantly to a lowered PCS score of the SF-12. This study high lights the health and personal burden of those with JHS and the importance of recognising and understanding the contribution of multisite pain in this population

An Exploration of Neurophysiological Symptoms in Patients with Joint Hypermobility Syndrome and their Impact on Quality of Life.

Purpose: The purpose of this study was to explore the prevalence of neurophysiological symptoms in patients with Joint Hypermobility Syndrome (JHS) and their impact on quality of life. Relevance: Clinical experience suggests patients with JHS suffer from neurophysiological symptoms contributing to skill and health impairments affecting quality of life. MethodsA sample of 90 JHS-patients (mean age 34.7 ± 9.9 years), diagnosed according to the Brighton Criteria were compared with 113 healthy volunteers (mean age 35.7 ± 12.9) with no musculoskeletal pain. Neurophysiological symptoms were collected in a self report questionnaire. The Functional Difficulties Questionnaire was used for the assessment of developmental coordination disorder (DCD). A pain chart was employed to collect data relating to musculoskeletal pain. The SF-12 medical outcomes questionnaire was used for assessing quality of life. Analysis: Chi-square was employed to compare group proportions. Continuous numerical data comparisons were analysed using independent sample t-tests. Regression analysis was employed to analyse multiple variables. Results: Patients with JHS were significantly more likely to report the following than healthy volunteers; autonomic symptoms (70%, 12%); gastrointestinal symptoms (71%, 9%); DCD (56%, 19%) and chronic fatigue syndrome (31%, 1%). The mean number of pain sites reported for patients with JHS were 9.83 ± 4.18. Patients with JHS reported significantly lower physical component summary scores (PCS) of the SF-12 than healthy volunteers (p < 0.001). Pain was a significant predictor of reduced PCS of the SF-12 (p < 0.001) in a model that explained 23% of the variance. Conclusions Neurophysiological symptoms were common. Pain was a significant contributor to the health burden of patients with JHS. Research is required to explore the connectivity and implications of these symptoms in relation to the central nervous system. Implications: There is a requirement to acknowledge and understand the multidimensional nature of JHS

Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective

This study sought to explore the impact of the psychological variables anxiety and depression, on pain experience over time following surgery. Eighty-five women having major gynaecological surgery were assessed for anxiety, depression and pain after surgery. To gain further understanding, 37 patients participated in a semi-structured taped telephone interview 4–6 weeks post-operatively. Pre-operative anxiety was found to be predictive of post-operative anxiety on Day 2, with patients who experienced high levels of anxiety before surgery continuing to feel anxious afterwards. By Day 4 both anxiety and depression scores increased as pain increased and one-third of the sample experienced levels of anxiety in psychiatric proportions whilst under one-third experienced similar levels of depression. These findings have significant implications for the provision of acute pain management after surgery. Future research and those managing acute pain services need to consider the multidimensional effect of acute pain and the interface between primary and secondary care

Hypermobility, coordination and spinal pain: an inherent association

Purpose: Joint hypermobility syndrome (JHS) is a multisystem connective tissue disorder. Pain enhancement, chronic pain, dislocations, and soft tissue rheumatism are some of the symptoms associated with this common but largely unrecognised condition (Grahame and Hakim 2006). It has been suggested that some patients with JHS show poor coordination and movement patterns which contribute to biomechanical dysfunction and chronic pain (Clark et al 2009). Pain and coordination difficulties have been observed in children with JHS (Adib et al 2005) and there are similarities in the functional difficulties reported by children with either a diagnosis of JHS or developmental coordination disorder (DCD) (Kirby and Davies 2006). Symptoms of DCD include poor proprioception, motor planning, visual spatial awareness and the retention of primitive reflexes which impact on activities of daily living. Motor impairments associated with DCD are known to persist into adulthood, and may continue to significantly affect the lives of adults with the condition (Cousin and Smyth 2003). The purpose of the study was to investigate the association of JHS and DCD and report on the prevalence of spinal pain. Relevance: Adults with JHS frequently report accessing a range of health professionals throughout their lives. Multiple joint instabilities, soft tissue injuries and chronic spinal pain are thought to contribute to de-conditioning and the continuing cycle of pain and poor biomechanics. It is suggested that impaired motor control may not be just as a result of pain, but related to inherent coordination difficulties linked to DCD. Participants: Participants (aged 18-65 years) included 90 with JHS recruited from a hypermobility clinic and 113 healthy volunteers with no pain recruited from a university setting. Methods: Case comparison study in which the two study groups were compared using responses from questionnaires. Analysis: Regression analysis to ascertain the association between age, gender, education and DCD. Pearson's chi square to investigate the correlation between JHS and DCD, odds ratios were calculated. Results: There was no significant association between age, gender or education between the groups and their corresponding DCD scores. The percentage of participants who reported DCD in the JHS and healthy volunteer groups were (55.6%) and (18.6%) respectively. A significant association between group membership and the reporting of DCD was noted, chi square = 30.11, p < .001. Participants with JHS were 6 [95% CI 2.9 - 10.3] times more likely to report DCD than healthy volunteers. The percentage of participants with JHS who reported spinal pain at one site was 93%; the distribution of pain was; neck (67%), upper back (57%) and lower back (83%). Conclusions: Participants with JHS were six times more likely to report DCD than healthy volunteers. Spinal pain is a major symptom for adults presenting with JHS. Implications: There is a significant association between JHS and DCD in adults many of whom report spinal pain. It is suggested that interventions should address the integration of all sensory components contributing to motor control. JHS and DCD are genetic conditions which present at an early age. Early recognition and appropriate intervention may prevent long term pain, motor and functional impairments

Evaluating the Relationship between Well-Being and Living with a Dog for People with Chronic Low Back Pain: A Feasibility Study

Chronic low back pain is a significant societal and personal burden that negatively impacts quality of life. Dog ownership has been associated with health benefits. This study evaluated the feasibility of surveying people with chronic low back pain to assess the relationship between dog ownership and well-being. A mail-out survey was sent to 210 adult patients with chronic low back pain. Measures of quality of life, pain, physical activity, emotional health, social ties and dog ownership were included. Feasibility was assessed by examining survey response rate, responses to established and newly developed measures, and the potential relationships between dog ownership and a number of key well-being variables in this patient population. There were 56 completed surveys returned (n = 36 non-dog owners and n = 20 dog owners). Established, adapted and newly developed scales revealed promising results. Dog owners reported fewer depression and anxiety symptoms, and more social ties than non-dog owners. Living with a dog may be associated with improved well-being for people with chronic pain. The findings from this feasibility study will inform a general population survey, to be conducted with a larger, more representative sample of people living with chronic pain