Acute low-back pain : a randomised controlled trial of sick-listed patients, with emphasis on co-morbidity, clinical outcome, predictors and costs

Sammanfattning: The general aim of this thesis was to evaluate three treatment options, i.e. a manual treatment programme, an intensive training programme and a general practitioner programme, in patients sick-listed for acute low-back pain with or without sciatica regarding impairment, pain, functional disability, socio-economic disability and satisfaction with treatment and explanations of their low-back pain. Additional aims were: 1. to comprehensively characterise patients sick-listed for acute low-back pain with or without sciatica and compare them with referents matched for age, sex and geographic area regarding demographic data, previous sick history, working conditions and psychosocial work environment, 2. to identify factors that might predict outcome at one year, in order to identify patients at risk of significant long-term unfavourable outcome, and (3) to analyse the cost to society of the three different treatment regimes. The thesis is based on study of two materials: 180 patients sick-listed for acute low-back pain with or without sciatica and 608 referents matched for age and sex. The two materials were compared in the first study. In the second study the patients were randomised to one of three conservative treatment programmes and followed at 1, 3 and 12 months. The other two studies deal with outcome prediction and cost analysis. The results demonstrate that the patient sick-listed for acute low-back pain does not differ from referents in personality characteristics, he/she smokes more, and is more commonly divorced. He/she estimates high work load. When he/she stays home from work due to low-back pain the perceived pain intensity and disability are moderate. No differences were revealed between the three treatment programmes except for satisfaction variables. The manual treatment programme and intensive training programme groups were more satisfied with treatment, and manual treatment programme patients were more satisfied with explanations of the low-back pain episode. The patients who did not complete a conservative treatment programme were those with less symptoms at the initial visit. Acute low-back pain patients consume a large amount of health care resources. This is because low-back pain is a recurrent problem and low-back pain patients have a considerably increased in co-morbidity compared to referents. The total cost per patient was 47 501 SEK, the most expensive part being indirect costs due to sick-leave: about 90% of the total costs. We identified some factors which predicted functional disability, recurrences or chronicity by the end of the follow-up year. These were: sick-listings for low-back pain past two years; high Oswestry score at onset of acute low-back pain episode; lack of stimulating work tasks; increased pain on coughing at first visit and long "duration of pain of the current episode". We suggest that initial examination should focus on these. A patient sick-listed for low-back pain, with a moderate/severe disability at the initial visit and previous sciatica is at high risk of surgery for disc herniation during the following year. A positive Laségue sign at the initial visit does not predict operation during the following year.