7403
document
The role of radiography in primary care patients with low back pain of at least 6 weeks duration : a randomised ( unblinded ) controlled trial . OBJECTIVES To test the hypotheses that : ( 1 ) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes , including pain , disability , health status , sickness absence , reassurance , and patient satisfaction or belief in the value of radiography . ( 2 ) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management , including medication use , and the use of primary and secondary care services , physical therapies and complementary therapies . ( 3 ) Participants choosing their treatment group ( i.e . radiography or no radiography ) do not have better outcomes than those randomised to a treatment group . ( 4 ) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography . DESIGN A randomised unblinded controlled trial . SETTING Seventy-three general practices in Nottingham , North Nottinghamshire , Southern Derbyshire , North Lincolnshire and North Leicestershire . Fifty-two practices recruited participants to the trial . SUBJECTS Randomised arm : 421 participants with low back pain , with median duration of 10 weeks . Patient preference arm : 55 participants with low back pain , with median duration of 11 weeks . INTERVENTION Lumbar spine radiography and usual care versus usual care without radiography . MAIN OUTCOME MEASURES Roland adaptation of the Sickness Impact Profile , visual analogue pain scale , health status scale , EuroQol , use of primary and secondary care services , and physical and complementary therapies , sickness absence , medication use , patient satisfaction , reassurance and belief in value of radiography at 3 and 9 months post-randomisation . RESULTS Participants randomised to receive an X-ray were more likely to report low back pain at 3 months ( odds ratio ( OR ) = 1.56 ; 95 % confidence interval ( CI ) , 1.02 to 2.40 ) and had a lower overall health status score ( p = 0.02 ) . There were no differences in health or functional status at 9 months . A higher proportion of participants consulted the general practitioner ( GP ) in the 3 months following an X-ray ( OR = 2.72 ; 95 % CI , 1.80 to 4.10 ) . There were no differences in use of any other services , medication use or sickness absence at 3 or 9 months . No serious spinal pathology was identified in either group . The commonest X-ray reports were of discovertebral degeneration and normal findings . Many patients did not perceive their information needs were met within the consultation . Satisfaction with care was greater in the group receiving radiography at 9 months . Participants randomised to receive an X-ray were not less worried , or more reassured about serious disease causing their low back pain . Satisfaction was associated with meeting participants ' information needs and reduced belief in the necessity for investigations for low back pain , including X-rays and blood tests . In both groups , at 3 and 9 months 80 % of participants would choose to have an X-ray if the choice was available . Participants in the patient preference group achieved marginally better outcomes than those randomised to a treatment group , but the clinical significance of these differences is unclear . Lumbar spine radiography was associated with a net economic loss at 3 and 9 months . CONCLUSIONS Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning , severity of pain or overall health status , and is associated with an increase in GP workload . Participants receiving X-rays are more satisfied with their care , but are not less worried or more reassured about serious disease causing their low back pain . CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH : Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients , and the needs of patients and GPs to be reassured about missing serious disease . Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology , even if the pain has persisted for at least 6 weeks .
7404
Intervention_Physical
radiography
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Intervention_Physical
Lumbar spine radiography
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Intervention_Physical
radiography
7407
Intervention_Physical
no radiography
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Intervention_Control
)
7409
Intervention_Physical
Lumbar spine radiography and usual care versus usual care without radiography
7410
Intervention_Other
X-ray
7411
Intervention_Other
lumbar spine radiography
7412
Outcome_Pain
pain
7413
Outcome_Physical
disability , health status , sickness absence , reassurance
7414
Outcome_Other
satisfaction
7415
Outcome_Physical
belief
7416
Outcome_Physical
Roland adaptation of the Sickness Impact Profile
7417
Outcome_Pain
visual analogue pain scale
7418
Outcome_Physical
health status scale , EuroQol
7419
Outcome_Other
use of primary and secondary care services
7420
Outcome_Other
physical and complementary therapies
7421
Outcome_Other
sickness absence
7422
Outcome_Other
medication use
7423
Outcome_Other
patient satisfaction
7424
Outcome_Other
reassurance and belief in value of radiography
7425
Outcome_Pain
low back pain
7426
Outcome_Physical
health status
7427
Outcome_Physical
health
7428
Outcome_Physical
functional status
7429
Outcome_Physical
consulted the general practitioner ( GP )
7430
Outcome_Other
any other services , medication use
7431
Outcome_Other
sickness absence
7432
Outcome_Physical
serious spinal pathology
7433
Outcome_Physical
discovertebral degeneration
7434
Outcome_Physical
normal findings
7435
Outcome_Mental
Satisfaction
7436
Outcome_Mental
worried
7437
Outcome_Mental
reassured
7438
Outcome_Physical
outcomes
7439
Outcome_Other
economic loss
7440
Outcome_Physical
functioning
7441
Outcome_Pain
severity of pain
7442
Outcome_Physical
overall health status
7443
Outcome_Physical
GP workload
7444
Participant_Condition
primary care patients with low back pain of at least 6 weeks duration
7445
Participant_Sample-size
Seventy-three
7446
Participant_Sample-size
Fifty-two
7447
Participant_Sample-size
421
7448
Participant_Condition
low back pain , with median duration of 10 weeks
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Participant_Sample-size
55