title: Prediction of an unfavourable course of low back pain in general practice: comparison of four instruments. A Cluster-Randomised Trial Evaluating an Intervention for Patients with Stress-Related Mental Disorders and Sick Leave in Primary Care Mini-Intervention for Subacute Low Back Pain: A Randomized Controlled Trial Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Medically unexplained symptoms--GPs' attitudes towards their cause and management. Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice Characterizing the course of low back pain: a latent class analysis. The LBP patient perception scale: a new predictor of LBP episode outcomes among primary care patients. A Population‐Based, Randomized Clinical Trial on Back Pain Management Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. The 'difficult patient' as perceived by family physicians. The significance of health anxiety and somatization in care-seeking for back and upper extremity pain. Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care. Biomechanical constraints remain major risk factors for low back pain. Results from a prospective cohort study in French male employees. Occupational, Personal and Psychosocial Resources for Preventing Persistent Low Back Pain Why is a treatment aimed at psychosocial factors not effective in patients with (sub)acute low back pain? Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Early Intervention Options for Acute Low Back Pain Patients: A Randomized Clinical Trial with One-Year Follow-Up Outcomes In a controlled trial training general practitioners and occupational physicians to collaborate did not influence sickleave of patients with low back pain. Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society NICE guidance on long-term sickness and incapacity. Economic Evaluation of an Intensive Group Training Protocol Compared With Usual Care Physiotherapy in Patients With Chronic Low Back Pain
abstract: BACKGROUND Several instruments can be used to identify patients with an unfavourable course of low back pain in general practice . However , it is unclear which instrument is the predictor of outcome . AIM To compare the predictive performance ( that is , calibration and discrimination ) of risk estimation by GPs with assessment s using the Orebro Musculoskeletal Pain Screening Question naire , the Low Back Pain Perception Scale ( LBPPS ) , and a prediction rule developed for this purpose . DESIGN OF STUDY A prospect i ve cohort study with 1-year follow-up . SETTING General practice in The Netherl and s. METHOD The outcome ' unfavourable course of low back pain ' was defined as having no clinical ly important improvement at minimally 50 % of the measurements at 6 , 13 , 26 , and 52 weeks . Logistic regression analyses were used to study associations between potential predictors and outcome . RESULTS In total , 60 GPs recruited 314 patients to the study ( 16 patients were excluded from analysis due to missing data on the course of low back pain ) . Over a third of patients ( 112/298 ) showed an unfavourable course of low back pain on follow-up . Risk estimation by GPs , the Orebro question naire , the LBPPS , and the prediction rule had discriminative ability ( area under the curve ) of 0.59 ( 95 % CI [ confidence intervals ] = 0.52 to 0.66 ) ; 0.61 ( 95 % CI = 0.54 to 0.67 ) ; 0.59 ( 95 % CI = 0.52 to 0.66 ) ; and 0.75 ( 95 % CI = 0.69 to 0.81 ) respectively . The prediction rule included history of low back pain , self-perceived risk to develop chronic low back pain , no solicitous responses of the patient 's partner ( as reported by the patient ) , frequent walking at work , and ' pain catastrophising ' . CONCLUSION Although the prediction rule performed best with regard to calibration and discrimination , it needs to be externally vali date d. Risk estimation by GPs performs as well as other instruments and , at present , seems to be the best available option Objective : Mental health problems often affect functioning to such an extent that they result in sick leave . The worldwide reported prevalence of mental health problems in the working population is 10%–18 % . In developed countries , mental health problems are one of the main grounds for receiving disability benefits . In up to 90 % of cases the cause is stress-related , and health-care utilisation is mainly restricted to primary care . The aim of this study was to assess the effectiveness of our Minimal Intervention for Stress-related mental disorders with Sick leave ( MISS ) in primary care , which is intended to reduce sick leave and prevent chronicity of symptoms . Design : Cluster-r and omised controlled educational trial . Setting : Primary health-care practice s in the Amsterdam area , The Netherl and s. Participants : A total of 433 patients ( MISS n = 227 , usual care [ UC ] n = 206 ) with sick leave and self-reported elevated level of distress . Interventions : Forty-six primary care physicians were r and omised to either receive  training in the MISS or to provide UC . Eligible patients were screened by mail . Outcome Measures : The primary outcome measure was duration of sick leave until lasting full return to work . The secondary outcomes were levels of self-reported distress , depression , anxiety , and somatisation . Results : No superior effect of the MISS was found on duration of sick leave ( hazard ratio 1.06 , 95 % confidence interval 0.87–1.29 ) nor on severity of self-reported symptoms . Conclusions : We found no evidence that the MISS is more effective than UC in our study sample of distressed patients . Continuing research should focus on the potential beneficial effects of the MISS ; we need to investigate which elements of the intervention might be useful and which elements should be adjusted to make the MISS effective Study Design . R and omized controlled trial . Objectives . To investigate the effectiveness and costs of a mini-intervention , provided in addition to the usual care , and the incremental effect of a work site visit for patients with subacute disabling low back pain . Summary of Background Data . There is lack of data on cost-effectiveness of brief interventions for patients with prolonged low back pain . Methods . A total of 164 patients with subacute low back pain were r and omized to a  mini-intervention group ( A ) , a work site visit group ( B ) , or a usual care group ( C ) . Groups A ( n = 56 ) and B ( n = 51 ) underwent one assessment by a physician plus a physiotherapist . Group B received a work site visit in addition . Group C served as controls ( n = 57 ) and was treated in municipal primary health care . All patients received a leaflet on back pain . Pain , disability , specific and generic health-related quality of life , satisfaction with care , days on sick leave , and use and costs of health care consumption were measured at 3- , 6- , and 12-month follow-ups . Results . During follow-up , fewer subjects had daily pain in Groups A and B than in Group C ( Group A vs. Group C , P = 0.002 ; Group B vs. Group C , P = 0.030 ) . In Group A , pain was less bothersome ( Group A vs. Group C , P = 0.032 ) and interfered less with daily life ( Group A vs. Group C , P = 0.040 ) than among controls . Average days on sick leave were 19 in Group A , 28 in Group B , and 41 in Group C ( Group A vs. Group C , P = 0.019 ) . Treatment satisfaction was better in the intervention groups than among the controls , and costs were lowest in the mini-intervention group . Conclusions . Mini-intervention reduced daily back pain symptoms and sickness absence , improved adaptation to pain and patient satisfaction among patients with subacute low back pain , without increasing health care costs . A work site visit did not increase effectiveness Background . The IMPaCT Back study ( IMplementation to improve Patient Care through Targeted treatment for Back pain ) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain ( LBP ) in primary care . This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aim ed at equipping clinicians to deliver it . The subgrouping and targeted treatment system . This system differs from ‘ one-size fits all ’ usual practice as it suggests that first contact health care practitioners should systematic ally allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity . Patients in each subgroup ( those at low , medium or high risk of chronicity ) are then managed according to a targeted treatment system of increasing complexity . The subgrouping tools . Subgrouping tools help guide clinical decision-making about treatment and onward referral . Two subgrouping tools have been used in the IMPaCT Back study , a 9-item version used by participating physiotherapists and a 6-item version used by GPs . The targeted treatments . The targeted treatments include a minimal intervention delivered by GPs ( for those patients at low risk of poor outcome ) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability  ( for those at medium risk ) and additional cognitive-behavioural approaches to help address  psychological and social obstacles to recovery  ( for those at high risk ) . The training packages . Building on previous interventions for other pilot studies and r and omized trials , we have developed and delivered clinical training and support programmes for GPs and physiotherapists . Discussion . This paper describes in detail the IMPaCT Back study ’s subgrouping for targeted treatment system and the training and mentoring packages aim ed at equipping clinicians to deliver it , within the IMPaCT Back study . Study registration . IS RCT N55174281 BACKGROUND Medically unexplained physical symptoms present one of the most common problems in modern medical practice but often prove difficult to manage . The central position of the GP in the care of patients with medically unexplained symptoms has been emphasized repeatedly , but little is known about the attitudes of GPs to this role . Underst and ing how GPs view these patients may inform the development of effective strategies for management . OBJECTIVE Our aim was to survey the attitudes of UK GPs towards medically unexplained symptoms  ( MUS ) and somatization . METHODS A r and om sample of 400 GPs in the South Thames ( West ) region were surveyed using a postal question naire . Respondents ' attitudes toward the cause and management of MUS were recorded . RESULTS A total of 284 completed question naires were returned ( 22 returned incomplete ) , giving an adjusted response rate of 75 % . Although it was broadly felt that patients with MUS are difficult to manage , most GPs felt that patients with MUS should be managed in primary care . Providing reassurance , counselling and acting as a ' gatekeeper ' to prevent inappropriate investigations were considered important roles for GP management . A majority felt that patients with MUS have personality problems or psychiatric illness . Fewer than half of the respondents felt that there are effective treatments available for somatization . CONCLUSION GPs consider the management of patients with MUS to be an important part of their workload , but there is a perception that effective management strategies are lacking . Psychiatrists need to offer greater support and training for GPs in this area of health care Abstract Objective To compare the effects of a minimal intervention strategy aim ed at assessment and modification of psychosocial prognostic factors and usual care for treatment of (sub)acute low back pain in general practice . Design Cluster r and omised clinical trial . Setting 60 general practitioners in 41 general practice s. Participants 314 patients with non-specific low back pain of less than 12 weeks ' duration , recruited by their general practitioner . Interventions In the minimal intervention strategy group the general practitioner explored the presence of psychosocial prognostic factors , discussed these factors , set specific goals for reactivation , and provided an educational booklet . The consultation took about 20 minutes . Usual care was not st and ardised . Main outcome measures Functional disability ( Rol and -Morris disability question naire ) , perceived recovery , and sick leave because of low back pain assessed at baseline and after 6 , 13 , 26 , and 52 weeks . Results The dropout rate was 8 % in the minimal intervention strategy group and 9 % in the usual care group . Multilevel analyses showed no significant differences between the groups on any outcome measure during 12 months of follow-up in the whole group or in relevant subgroups ( patients with high scores on psychosocial measures at baseline or a history of frequent or prolonged low back pain ) . Conclusion This study provides no evidence that ( Dutch ) general practitioners should adopt our new treatment strategy aim ed at psychosocial prognostic factors in patients with (sub)acute low back pain . Further research should examine why our new strategy was not more effective than usual care Underst and ing the course of back pain is important for clinicians and research ers , but analyses of longitudinal data from multiple time points are lacking . A prospect i ve cohort study of consecutive back pain consulters from five general practice s in the United Kingdom was carried out between 2001 and 2003 to identify groups defined by their pain pathways . Patients were sent monthly question naires for a year . Longitudinal latent class analysis was performed by using pain intensity scores for 342 consulters . Analysis yielded four clusters representing different pathways of back pain . Cluster 1 ( " persistent mild " ; n = 122 ) patients had stable , low levels of pain . Patients in cluster 2 ( " recovering " ; n = 104 ) started with mild pain , progressing quickly to no pain . Cluster 3 ( " severe chronic " ; n = 71 ) patients had permanently high pain . For patients in cluster 4 ( " fluctuating " ; n = 45 ) , pain varied between mild and high levels . Distinctive patterns for each cluster were maintained throughout follow-up . Clusters showed statistically significant differences in disability , psychological status , and work absence ( p < 0.001 ) . This is the first time , to the authors ' knowledge , that latent class analysis has been applied to longitudinal data on back pain patients . Identification of four distinct groups of patients improves underst and ing of the course of back pain and may provide a basis of classification for intervention OBJECTIVE To describe a new tool design ed to capture patients ' perception of their low back pain ( LBP ) episodes-the  patient perception scale ( PPS ) and test its ability to predict episode outcomes . METHODS Thirty-two family physicians recruited 526 low back pain patients during an office visit . Physicians completed a short question naire at the index visit , which included both their assessment s of patients ' patient perception scale ( PPS-doc ) and contact information . Patients were then interviewed by telephone within 2 weeks after the index visit , with follow-up telephone contacts at 2 , 4 , 8 and 12 months . The  patient perception scale as reported by the physician ( PPS-doc ) and patient ( PPS-pt ) , each constituent question , and different combinations were analyzed for their ability to predict patient outcomes . RESULTS Patients ' responses ( PPS-pt ) proved predictive for all outcome items . PPS-doc was much less predictive . Measures of patient centeredness did not perform well in this study . CONCLUSION By using a short scale based on the patient 's perception of pain ( PPS-pt ) , it is possible to predict adverse outcomes of a low back pain episode . The patient perception scale should be evaluated further and perhaps combined with other instruments for targeting care and chronicity prevention efforts in low back pain . PRACTICE IMPLICATION S The PPS-pt could potentially be used as part of the st and ard initial patient evaluation of new LBP patients , as a proxy for " yellow flags " ( markers of psychosocial risk ) where a positive score might be the equivalent to high-risk identification . The apparent advantage of this scale is its brevity and simplicity of administration . The separation , through this scale of pain episodes into simple and complex LBP might be a useful tool for helping direct re sources and avoiding chronicity Study Design . Population ‐based r and omized clinical trial . Objectives . To develop and test a model of management of subacute back pain , to prevent prolonged disability . Summary of Background Data . The present management of back pain seems inadequate , and development of innovative models has been urged . Methods . A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population ‐based r and omized clinical trial . Workers ( n = 130 ) from eligible workplaces in the Sherbrooke area ( N = 31 ) , who had been absent from work for more than 4 weeks for back pain , were r and omized , based on their workplace , in one of four treatment groups : usual care , clinical intervention , occupational intervention , and full intervention ( a combination of the last two ) . The duration of absence from regular work and from any work was evaluated using survival analysis . Functional status and pain were compared at study entry and after 1 year of follow‐up . Results . The full intervention group returned to regular work 2.41 times faster than the usual care intervention group ( 95 % confidence interval 1.19‐4.89 ; P = 0.01 ) . The specific effect of the occupational intervention accounted for the most important part of this result , with a rate ratio of return to regular work of 1.91 ( 95 % confidence interval = 1.18‐3.10 ; P < 0.01 ) . Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups , compared with the trend in the usual care intervention group . Conclusions . Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain RATIONALE Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease ( COPD ) , but their effects on exacerbations are not clear . OBJECTIVES To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations . METHODS A multicenter prospect i ve cohort study in 491 patients with stable COPD in China . Multivariate Poisson and linear regression analyses were used , respectively , to estimate adjusted incidence rate ratios ( IRRs ) and adjusted effects on duration of events . MEASUREMENTS AND MAIN RESULTS  Depression and anxiety  were measured using the  Hospital Anxiety and Depression Scale ( HADS ) at baseline . Other measurements included sociodemographic , clinical , psychosocial , and treatment characteristics . Patients were then monitored monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations . Exacerbation was determined using both symptom-based ( worsening of > or = 1 key symptom ) and event-based definitions ( > or = 1 symptom worsening plus > or = 1 change in regular medications ) . A total of 876 symptom-based and 450 event-based exacerbations were recorded , among which 183 led to hospitalization . Probable depression ( HADS depression score > or = 11 ) was associated with an increased risk of symptom-based exacerbations ( adjusted IRR , 1.51 ; 95 % confidence interval [ CI ] , 1.01 - 2.24 ) , event-based exacerbations ( adjusted IRR , 1.56 ; 95 % CI , 1.02 - 2.40 ) , and hospitalization ( adjusted IRR , 1.72 ; 95 % CI , 1.04 - 2.85 ) compared with nondepression ( score < or = 7 ) . The duration of event-based exacerbations was 1.92 ( 1.04 - 3.54 ) times longer for patients with probable anxiety ( HADS anxiety score > or = 11 ) than those with no anxiety ( score < or = 7 ) . CONCLUSIONS This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations . Further studies are warranted to confirm this finding and to test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improving health re source utilizations OBJECTIVES The aim of this study is to underst and in depth the experience of the family physician faced with the patient that he perceives as ' difficult ' . This was done by means of the ' long interview ' as a method of qualitative research . METHOD We interviewed 15 r and omly selected Board-certified family physicians , with five or more years experience as specialists , employed in the northern district of the ' Clalit Health Services ' , the major sick fund in Israel . RESULTS The participants stated that the ' difficult ' patients are not those with difficult medical problems but rather those who are violent , dem and ing , aggressive , rude and who seek secondary gain . Patients with multiple non-specific complaints and those with psychosomatic problems are also difficult for the family physician . Appropriate use of patient-doctor communication skills and an effort to improve relations with the patient through empathy , tolerance and non-judgmental listening were suggested by the physicians as ways of making the difficult encounter easier . CONCLUSIONS Family physicians acknowledge their responsibility for the ' difficult ' patient , and seek innovative and creative ways to cope with the difficult medical encounter . The more experienced the doctor is , the less he perceives patients as ' difficult ' , as he learns to accept greater diversity of behaviours in his patients BACKGROUND Patients with musculoskeletal pain account for a large number of consultations in primary care . Improving our underst and ing of factors that make patients seek care could be of interest in decision making and prevention in the health care system . OBJECTIVES Our objectives were to examine if health anxiety , somatization and fear-avoidance beliefs were of importance for care-seeking with either back pain or upper extremity pain and to look at possible differences between the two groups . METHODS This is a prospect i ve study with a baseline question naire and 18 months follow-up . Using the International Classification for Primary Care ( ICPC ) , we identified care-seekers with either back pain or upper extremity pain among the potential patients of eight GPs . For analysis , we used Cox proportional hazards regression analysis . Analysis was stratified by gender . RESULTS We found that previous regional pain was a strong predictor of care-seeking . Somatization was associated with seeking care for back pain . Health anxiety was a predictor among women suffering from back pain . Only previous pain was a predictor of care-seeking for upper extremity pain . CONCLUSION The study implies that prevention of back pain and upper extremity pain requires different strategies and that gender and health anxieties should be taken into account Background Medically unexplained physical symptoms ( MUPS ) are common in general practice ( GP ) , and are even more problematic as they become persistent . The present study examines the relationship between persistent MUPS in general practice on the one h and and quality of life , social conditions , and coping on the other h and . Additionally , it is examined how patients with persistent MUPS  evaluate the quality of GP-care . Methods Data were used from a representative survey of morbidity in Dutch general practice , in which data from the electronic medical records were extracted . A r and om sample of patients participated in an extensive health interview and completed self-reported measures on social isolation , coping and the quality of GP-care .  Patients with persistent MUPS ( N = 192 ) were compared with general practice patients not meeting the criteria for persistent MUPS ( N = 7.314 ) , and with a group of patients that visited the GP in comparable rates for medical diagnoses ( N = 2.265 ) . Multiple logistic regression analyses were used to control for relevant socio-demographic variables and chronic diseases . Results After adjustment for demographics and chronic diseases , patients with persistent MUPS reported more psychological distress , more functional impairment , more social isolation , and they evaluated the quality of GP-care less positive than the other two patient groups . Although the majority of MUPS patients were positive about the quality of GP-care , they more often felt that they were not taken seriously or not involved in treatment decisions , and more often reported that the GP did not take sufficient time . The three groups did not differ with respect to the statement that the GP unnecessarily explains physical problems as psychological ones . ConclusionS trengthening MUPS patients ' social network and encouraging social activities may be a meaningful intervention in which the GP may play a stimulating role . To further improve MUPS patients ' satisfaction with GP-care , GPs may pay extra attention to taking sufficient time when treating MUPS patients , taking the problems seriously , and involving them in treatment decisions Guidelines portray low back pain ( LBP ) as a benign self‐limiting disease which should be managed mainly by primary care physicians . For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment . This is a longitudinal prospect i ve cohort study . General practitioners recruited consecutive adult patients presenting with LBP .  Data on physical function , on depression , and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months .  Logistic regression models  were calculated to investigate predictors for specialist consultations and use of specific health care services . Large proportions ( 57 % ) of the 1342 patients were seeking additional specialist care . Although patients receiving specialist care had more often chronic LBP and a positive depression score , the association was weak . A total of 623 ( 46 % ) patients received some form of imaging  , 654 ( 49 % ) physiotherapy and 417 ( 31 % ) massage . Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions  while disease‐related and socio‐demographic factors were less important . Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection . The high dependence of health care service utilization on providers rather than clinical factors indicates an un systematic and probably inadequate management of LBP The aim of this paper is to assess whether patient-centred consultations are more effective than the usual style of consultations used by general practitioners with patients suffering from benign chronic musculoskeletal pain and fibromyalgia . It also seeks to evaluate the differential characteristics of these two clinical groups of symptoms . The study was design ed as a cluster r and omised and simple blind trial . Twenty general practitioners took part and 110 patients were recruited . Compared with patients who received the usual treatment from their family physician , those who received a patient-centred approach showed greater improvement after 1 year in terms of psychological distress ( anxiety ) and number of tender points , as well as showing positive trends in some important outcomes such as pain intensity . Significantly better results were observed in those patients suffering chronic pain than in those with fibromyalgia , particularly as regards associated symptoms , self-rated pain and physical mobility as measured by the Nottingham health profile BACKGROUND CONTEXT Low back pain ( LBP ) is a major public health problem , with a considerable impact on workers . PURPOSE To model the risk of LBP in the male general working population . STUDY DESIGN / SETTING Repeated cross-sectional surveys in a wide occupational setting . PATIENT SAMPLE A r and om sample of 2,161 men working in various occupations in a French region participated in a first survey in 2002 , and 1,313 of these ( 60.8 % ) participated in a second survey in 2007 . OUTCOME MEASURE The self-reported prevalence of LBP during the previous week in the second survey . METHODS Twenty-one biomechanical , organizational , psychosocial , and individual factors were assessed in the first survey . The association between these potential risk factors and the prevalence of later LBP ( in the second survey ) was studied , using multistep logistic regression models . RESULTS Three hundred ninety-four men reported LBP in the second survey ( prevalence 30.0 % ) . The final multivariate model highlighted four risk factors : frequent bending ( odds ratio [ OR ] , 1.45 , 95 % confidence interval [ CI ] , 1.07 - 1.97 for bending forward only ; and OR , 2.13 , 95 % CI , 1.52 - 3.00 for bending both forward and sideways ) , driving industrial vehicles ( OR , 1.35 ; 95 % CI , 1.00 - 1.81 ) , working more hours than officially planned ( OR , 1.38 ; 95 % CI , 1.05 - 1.81 ) , and reported low support from supervisors ( OR , 1.35 ; 95 % CI , 1.02 - 1.79 ) . CONCLUSIONS These results emphasize that biomechanical factors remain worth considering , even when psychosocial factors are taken into account , and provide a significant contribution to preventive strategies The aim of this prospect i ve cohort study was to identify modifiable protective factors of the progression of acute/subacute low back pain ( LBP ) to the persistent state at an early stage to reduce the socioeconomic burden of persistent LBP .  Patients attending a health practitioner for acute/subacute LBP were assessed at baseline addressing occupational , personal and psychosocial factors , and followed up over 12 weeks . Pearson correlations were calculated between these baseline factors and the presence of nonpersistent LBP at 12-week follow-up . For those factors found to be significant , multivariate logistic regression analyses were performed . The final 3-predictor model included job satisfaction , mental health and social support . The accuracy of the model was 72 % , with 81 % of nonpersistent and 60 % of persistent LBP patients correctly identified . Further research is necessary to confirm the role of different types of social support regarding their prognostic influence on the development of persistent LBP & NA ; Psychosocial factors have been shown to play an important role in the development of chronic low back pain ( LBP ) . In our recently completed cluster‐r and omized trial we found , however , no evidence of an effect of our minimal intervention strategy ( MIS ) aim ed at psychosocial factors , over usual care ( UC ) in patients with (sub)acute LBP . To explore the reasons why , this paper presents an evaluation of the processes presumably underlying the effectiveness of MIS . General practitioner ( GP ) attitude was evaluated by the Pain Attitudes and Beliefs Scale and two additional questions . GP behaviour was evaluated by analysing treatment registration forms and patients ' responses to items regarding treatment content . Patients also scored items on satisfaction and compliance . Modification of psychosocial measures was evaluated by analysing changes after 6 and 52 weeks on the Fear Avoidance and Beliefs Question naire , the Coping Strategies Question naire and the 4‐Dimensional Symptom Question naire . A total of 60 GPs and 314 patients participated in the study . GPs in the MIS‐group adopted a less biomedical orientated attitude than in the UC‐group , but were only moderately successful in identification of psychosocial factors . Treatment contents as perceived by the patient and patient satisfaction differed significantly between both groups . Changes on psychosocial measures , however , did not differ between groups . The suboptimal identification of psychosocial factors in the MIS‐group and the absence of a relevant impact on psychosocial factors may explain why MIS was not more effective than UC Context Exercise and advice are common treatments for patients with subacute low back pain  , but their effectiveness is unclear . Contribution In this trial , 259 adults with subacute low back pain received 12 real or sham physiotherapist-directed exercise sessions and 3 real or sham advice sessions over 6 weeks . Compared with sham exercise and sham advice , patients who received real exercise and real advice had the most benefit at 6 weeks . However , only a small benefit on patient-reported function persisted at 12 months . Implication Compared with no exercise or advice , a combination of physiotherapist-directed exercise and advice seems to improve pain and function in the short term for patients with subacute low back pain . The Editors Back pain is 1 of the most frequent reasons for consultation with a general practitioner ( 1 , 2 ) . Most treatment guidelines provide advice for patients on managing acute or recent-onset low back pain but not chronic pain ( 3 ) . This reflects the view that acute low back pain is typically self-limited and that only a small proportion of persons develop chronic pain . However , a recent systematic review of the prognosis of acute low back pain ( 4 ) showed that this view is inaccurate : Pain and disability are typically ongoing , and recurrences are common . Thus , effective treatments for patients whose pain and disability persist beyond the acute phase are needed . We are interested in the subacute phase , which is the transition period from acute ( duration < 6 weeks ) to chronic ( duration > 3 months ) low back pain . All treatment guidelines ( 3 ) endorse advice as a treatment for subacute low back pain , and advice is the most frequently administered treatment in general practice ( 1 ) . Exercise is the most common treatment for low back pain ( 2 , 5 , 6 ) , and some guidelines recommend it for subacute low back pain ( 3 ) . However , a systematic review of treatment for subacute low back pain ( 7 ) concluded that no high- quality evidence exists for the efficacy of any intervention . To address this knowledge gap , we conducted a factorial r and omized , placebo-controlled trial of the effect of exercise , advice , or both on pain , function , and global perceived effect . Methods Setting The trial was conducted at 7 physiotherapy clinics in Australia and New Zeal and , of which 6 were in university teaching hospitals and 1 was in a primary care clinic . There were 16 physiotherapists . Each clinic had 1 to 5 therapists providing treatment . We enrolled participants from January 2001 to June 2003 . The study protocol was approved by the institutional review boards of the University of Sydney , Sydney , Australia , and of each clinic . Participants We sought persons between 18 and 80 years of age with nonspecific low back pain lasting for at least 6 weeks but no longer than 12 weeks . Participants were recruited by direct referral to the trial by a health care professional ( n= 1 ) , invitations to patients on hospital waiting lists for physiotherapy treatment of low back pain ( n= 73 ) , and advertisements in newspapers ( n= 185 ) . Exclusion criteria were spinal surgery in the past 12 months , pregnancy , nerve root compromise , confirmed or suspected serious spinal abnormality ( for example , infection , fracture , or the cauda equina syndrome ) , contraindications to exercise , and poor comprehension of the English language . We did not exclude participants who were receiving low back pain treatment other than spinal surgery . Potential participants who reported osteoarthritis ; spondylitis ; spondylolysis ; spondylolisthesis ; disc protrusion , herniation , or prolapse ; or spinal stenosis were eligible . We asked participants not to take other treatments for low back pain during the 6-week treatment phase . Written informed consent was obtained from all participants before they enrolled in the trial . R and omization and Interventions After completing the baseline assessment , we r and omly allocated participants to 1 of 4 intervention groups : exercise and advice , exercise and sham advice , sham exercise and advice , or sham exercise and sham advice . The allocation schedule was generated by using the r and om-number function in Microsoft Excel ( Microsoft , Inc. , Redmond , Washington ) , and the allocation codes were placed in sequentially numbered , sealed , opaque envelopes . At each site , the trial coordinator or the physiotherapist allocated participants to groups by opening the next numbered envelope . This process ensured that allocation was concealed from participants , referring medical practitioners , trial staff who determined eligibility , and the assessor of outcomes . The 12 exercise or sham exercise sessions were delivered over 6 weeks : 3 sessions per week in weeks 1 and 2 , 2 sessions per week in weeks 3 and 4 , and 1 session per week in weeks 5 and 6 . In weeks 1 , 2 , and 4 , participants also received advice or sham advice . Sham treatments were design ed to provide similar contact time with the treating clinician . The clinicians who provided the sham treatments were the same ones who provided the real treatments . Registered physiotherapists who received training from an experienced clinical psychologist delivered treatment . Treatment consistency was promoted at the initial staff meeting and at regular trial treatment meetings , and by providing a treatment manual to all treatment providers . To assess treatment validity , an investigator recorded and assessed sample treatment sessions . In addition , 1 investigator regularly visited each treatment site to monitor delivery of treatment . The comprehensive treatment manual is in the Appendix . Appendix . Treatment Manual Exercise The exercise program was based on the program described by Lindstrm and colleagues ( 8) . It included an individualized , progressive , submaximal program design ed to improve the abilities of participants to complete functional activities that they specified as being difficult to perform because of low back pain . Each participant undertook aerobic exercise ( for example , a walking or cycling program ) ; stretches ; functional activities ; activities to build speed , endurance , and coordination ; and trunk- and limb-strengthening exercises . Physiotherapists used principles of cognitive-behavioral therapy , including setting goals of progressively increasing difficulty , encouraging self-monitoring of progress , and promoting self-reinforcement ( 9 ) . Physiotherapists provided individualized home exercise programs , which they regularly review ed , and they encouraged continuation of the home program after the intervention finished . Sham Exercise The control for the exercise intervention consisted of sham pulsed ultrasonography ( 5 minutes ) and sham pulsed short-wave diathermy ( 20 minutes ) . The sham units were identical to active units ( for example , the on and off lights illuminated and the output dial moved ) except that they did not provide output . To optimize treatment credibility , physiotherapists followed the usual clinical routine for delivering these treatments . The active forms of these treatments delivered in pulsed mode do not produce heat ; thus , previous experience with the treatments would not unblind participants . Participants allocated to exercise did not receive the active forms of these treatments . Advice Advice sessions were based on the program by Indahl and colleagues ( 10 ) and aim ed to encourage a grade d return to normal activities . The physiotherapist explained the benign nature of low back pain , addressed any unhelpful beliefs about back pain , and emphasized that being overly careful and avoiding light activity would delay recovery . Sham Advice During sham advice sessions , participants were given the opportunity to talk about their low back pain and any other problems . The physiotherapist responded in a warm and empathic manner , displaying genuine interest in the participant , but did not give advice about the low back pain ( 11 ) . Participants were told that the trial included active and placebo physiotherapy treatments and that they would receive 2 treatments , but they were not told whether the interventions they received were active or sham . Outcomes and Measurements We determined participants ' perceptions of the effectiveness of treatment at the beginning of the trial and at 12 months . We assessed treatment adherence by the number of  appointments attended  ,  session  duration , and amount of time the physiotherapist spent with each participant . Participants were asked not to seek other treatments during the 6-week treatment period . Participants who discontinued treatment were encouraged to return for follow-up . Immediately before r and omization , we obtained baseline measurements . We collected additional data on work status , medication use , side effects , adverse events , and number and type of co- interventions  at 6 weeks , 3 months , and 12 months after r and omization . We chose primary and secondary outcomes a priori . The primary outcomes were pain , global perceived effect , and functional ability at 6 weeks and 12 months . Secondary outcomes were pain , global perceived effect , and functional ability at 3 months ; number of health care contacts during the past 6 weeks ( determined at 12 months ) ; and disability and depression at 6 weeks , 3 months , and 12 months . We rated pain as average pain over the past week on a scale of 0 ( no pain ) to 10 ( worst pain possible ) ( 12 ) . We measured functional ability by using the Patient-Specific Functional Scale ( score range , 0 [ can not perform activity ] to 10 [ can perform activity at preinjury level ] ) ( 13 ) . We measured global perceived effect of treatment on an 11-point scale , ranging from 5 ( vastly worse ) to 5 ( completely recovered ) , with 0 being no change . We measured disability with the Rol and Morris Disability Question naire ( score range , 0 to 24 ) ( 14 ) . We measured depression , anxiety , and stress by using the 21-item Depression Anxiety Stress Scales ( DASS-21 ) ( score range for each subscale , 0 to 42 ) ( 15 ) . These measures have acceptable psychometric properties and are widely used in OBJECTIVE To determine the prevalence of serious pathology in patients presenting to primary care setting s with acute low back pain , and to evaluate the diagnostic accuracy of recommended " red flag " screening questions . METHODS An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain was recruited from primary care clinics in Sydney , Australia . At the initial consultation , clinicians recorded responses to 25 red flag questions and then provided an initial diagnosis . The reference st and ard was a 12-month followup supplemented with a specialist review of a r and om sub sample of participants . RESULTS There were 11 cases ( 0.9 % ) of serious pathology , including 8 cases of fracture . Despite the low prevalence of serious pathology , most patients ( 80.4 % ) had at least 1 red flag ( median 2 , interquartile range 1 - 3 ) . Only 3 of the red flags for fracture recommended for use in clinical guidelines were informative : prolonged use of corticosteroids , age > 70 years , and significant trauma . Clinicians identified 5 of the 11 cases of serious pathology at the initial consultation and made 6 false-positive diagnoses . The status of a diagnostic prediction rule containing 4 features ( female sex , age > 70 years , significant trauma , and prolonged use of corticosteroids ) was moderately associated with the presence of fracture ( the area under the curve for the rule score was 0.834 [ 95 % confidence interval 0.654 - 1.014 ] ; P = 0.001 ) . CONCLUSION In patients presenting to a primary care provider with back pain , previously undiagnosed serious pathology is rare . The most common serious pathology observed was vertebral fracture . Approximately half of the cases of serious pathology were identified at the initial consultation . Some red flags have very high false-positive rates , indicating that , when used in isolation , they have little diagnostic value in the primary care setting OBJECTIVES Because musculoskeletal pain is the second most frequent reason for seeking health care , the aims of this study were to determine the value of psychosocial variables in evaluating risk for developing chronic back pain problems and to develop a screening methodology to identify patients likely to have a poor prognosis . STUDY DESIGN A prospect i ve study was conducted on consecutive patients with acute or subacute back pain , in which patients completed a screening question naire and were then followed up for 6 months to determine outcome . The primary outcome variable was accumulated sick leave . METHODS One hundred forty-two consecutive patients were asked to complete a question naire design ed for this study . This question naire contained 24 items concerning psychosocial aspects of the problem . Six months later , patients were contacted to complete outcome questions about accumulated sick leave .  RESULTS A total of 97 % of the patients completed both question naires . Although patients , on average , improved greatly , 18 % had 1 - 30 days and 20 % had fewer than 30 days of sick leave during the follow-up period . Five variables were found to be the strongest predictors of sick leave outcome ( fear-avoidance work beliefs , perceived improvement , problems with work function , stress , and previous sick leave ) , correctly classifying 73 % of the patients as opposed to a chance rate of 33 % . A total score was evaluated as a means of judging risk and found to be strongly related to outcome . CONCLUSION Potent psychosocial risk factors associated with future sick absenteeism were identified . Because the total score was related to outcome , the instrument may have use in screening patients with acute or subacute spinal pain in clinical situations Introduction In an earlier study , Gatchel et al. ( J Occup Rehabil 13:1–9 , 2003 ) demonstrated that participants at high risk for developing chronic low back pain disability ( CLBPD ) , who received a biopsychosocial early intervention treatment program , displayed significantly more symptom improvement , as well as cost savings , relative to participants receiving st and ard care . The purpose of the present study was to exp and on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment . Methods Using an existing algorithm , participants were identified as being high-risk ( HR ) or low-risk ( LR ) for developing CLBPD . HR participants were then r and omly assigned to one of three groups : early intervention ( EI ) ; early intervention with work transition ( EI/WT ) ; or st and ard care ( SC ) . Participants provided information regarding pain , disability , work status , and psychosocial functioning at baseline , periodically during treatment , and again 1 year following completion of treatment . Results At 1-year follow-up , no significant differences were found between the EI and EI/WT groups in terms of occupational status , self-reports of pain and disability , coping ability or psychosocial functioning . However , significant differences in all these outcomes were found comparing these groups to st and ard care . Conclusion The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes . However , results further support the effectiveness of early intervention for high-risk ALBP patients OBJECTIVE The objective of this study was to determine the effectiveness of a training to increase collaboration between general practitioners and occupational health physicians in the treatment of patients with low back pain ( LBP ) because more collaboration might improve a patient 's recovery and shorten sick leave . METHODS In a controlled trial , the intervention in one region was compared with usual care in a control region . Participating physicians enrolled patients with LBP on sick leave for 3 - 12 weeks . Patients filled out three question naires : at inclusion , at 3 months , and at 6 months . Information on sick leave was gathered from occupational health services . All analyses were performed on an intention-to-treat basis . RESULTS Fifty-six patients with LBP were enrolled in each region . There was little collaboration between physicians during the project . Patients in the intervention region returned to work significantly later ( P=.005 ) but were significantly more satisfied with their occupational health physician ( P=.01 ) . No differences were found between the intervention and control patients for pain , disability , quality of life , and medical consumption . CONCLUSION Our study does not show a positive effect of the training to increase collaboration between general practitioners and occupational health physicians . The training may not have improved collaboration enough to influence the prognosis of LBP BACKGROUND Better insight into frequent comorbidities in patients with chronic ( ≥ 3 months ) low back pain ( LBP ) may help general practitioners when planning comprehensive care for these patients . OBJECTIVE To prospect ively study the prevalence of psychological , social , musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners , in comparison to a contrast group of patients consulting in the same setting . METHODS This case-control study is embedded in a historical cohort , based on a primary care practice -based research network . All the health problems presented by the patients were prospect ively coded according to the international classification of primary care between 1996 and 2013 . The prevalence of psychological , social , musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP , using conditional logistic regressions . RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it , with odds ratios ( 95%confidence intervals ) of 1.39 ( 1.20 - 1.61 ) and 1.56 ( 1.35 - 1.81 ) , respectively . They did not more often present psychological , social or non-musculoskeletal somatoform disorders . CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP . Rather than systematic ally screening for specific psychological , social or somatoform disorders , they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied Long-term  sickness absence and incapacity benefits ( disability pension ) rates have increased across industrialised countries . Effective measures are needed to support return to work . The recommendations of this guidance were informed by the most appropriate available evidence of effectiveness and cost-effectiveness . Public health evidence was provided by research using a variety of study design s that attempted to determine the outcome of a particular intervention by evaluating status before and after the intervention had been effected , and was not limited to r and omised control trials . Where the evidence base was depleted or underdeveloped , expert witnesses were called to give their opinion on the best available evidence and emerging interventions . The process enabled challenge and contestability from stakeholder groups at different points as the guidance was developed . Forty-five heterogeneous studies were included in the review of interventions to reduce long-term sickness absence and transitions from short-term to long-term absence ( mainly covering the former and also mainly examining musculoskeletal conditions ) . The analysis of evidence was restricted to descriptive synthesis . Three general themes emerged from an analysis of the studies that were more likely to report positive results : early interventions ; multidisciplinary approaches ; and interventions with a workplace component . Two further review s were undertaken , one on interventions to reduce the re-occurrence of sickness absence , which identified seven studies on lower back pain , and concluded that early intervention and direct workplace input are important factors . The final evidence review focused on six studies of interventions for those in receipt of incapacity benefit . The evidence was that work-focused interviews coupled with access to tailored support are effective and cost-effective interventions . Practitioners should consider the impact of interventions and management options on work ability for patients of working age . Work ability should be considered a key outcome for future intervention studies Study Design . Economic evaluation from a societal perspective conducted alongside a r and omized controlled trial with a follow-up of 52 weeks . Objective . To evaluate the cost effectiveness and cost utility of an intensive group training protocol compared with usual care physiotherapy in patients with nonspecific chronic low back pain . The intensive group training protocol combines exercise therapy , back school , and behavioral principles . Summary of Background Data . Two studies found a significant reduction in absenteeism for a grade d activity program in occupational health care . This program has not yet been evaluated in a primary care physiotherapy setting . Methods . Participating physical therapists in primary care recruited 114 patients with chronic nonspecific low back pain . Eligible patients were r and omized to either the protocol group or the guideline group . Outcome measures included functional status ( Rol and Morris Disability Question naire ) , pain intensity ( 11-point numerical rating scale ) , general perceived effect and quality of life ( EuroQol-5D ) . Cost data were measured with cost diaries and included direct and indirect costs related to low back pain . Results . After 52 weeks , the direct health care costs were significantly higher for patients in the protocol group , largely due to the costs of the intervention . The mean difference in total costs amounted to & OV0556 ; 233 ( 95 % confidence interval : & OV0556 ; −2.185 ; & OV0556 ; 2.764 ) . The cost-effectiveness planes indicated no significant differences in cost effectiveness between the 2 groups . Conclusion . The results of this economic evaluation showed no difference in total costs between the protocol group and the guideline group . The differences in effects were small and not statistically significant . At present , national implementation of the protocol is not recommended
target: In the first systematic review , the patients ' or HCPs ' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome , with predictive validity similar to that of multidimensional scales .
  This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view .
  It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients ; interventions targeting determinants from several fields ( mainly psychosocial , biomechanical , and occupational ) may be more relevant .
  Finally , in the third study , the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care .
  Rather than specifically screening for psychosocial conditions , this suggests taking into account any potential comorbidity in patients with chronic LBP , as in other patients .
  As this condition is illustrative of many situations encountered in primary care , the strategies proposed here may benefit most patients consulting in this setting
background: Non-specific low back pain ( LBP ) affects many people and has major socio-economic consequences .
  Traditional therapeutic strategies , mainly focused on biomechanical factors , have had moderate and short-term impact .
  Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP .
  Primary health care providers ( HCPs ) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care , including consideration of psychosocial dimensions .
  This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care .