Shoulder pain is common in the general population. Reports on specific diagnoses in general populations are scarce and only from primary care. The diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the clinical research in the shoulder field is done in hospital settings. The aim of this study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies.A diagnostic routine was conducted among patients referred to our physical medicine outpatient clinic at Oslo University Hospital. Diagnostic criteria were derived from the literature and supplemented with research criteria.Of 766 patients diagnosed, 55% were women and the mean age was 49 years . The most common diagnoses were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Subacromial pain and adhesive capsulitis were most frequent in persons aged 40–60 years. Shoulder myalgia was most frequent in age groups under 40. Labral tears and instability problems (8%) were most frequent in young patients and not present after age 50. Full-thickness rotator cuff tears (8%) and glenohumeral osteoarthritis (4%) were more prevalent after the age of 60. Few differences were observed between sexes. We identified three studies reporting shoulder diagnoses in primary care.Subacromial pain syndrome, myalgia and adhesive capsulitis were the most prevalent diagnoses in our study. However, large differences in prevalence between different studies were found, most likely arising from different use of diagnostic criteria and a difference in populations between primary and secondary care. Of the diagnoses in our cohort, 20% were not reported by the studies from primary care . Van der Windt et al.[Shoulder pain is common in the general population with a reported 1-month prevalence of 18–31% and a 1-year prevalence of 5–47%[et al. were alsdt et al..To our knowledge, the diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the research in the shoulder field is done in hospital settings. If the majority of diagnoses are the same in general practice as in a specialist outpatient clinic, the generalisability of results from research done in specialist practices will tend to increase. The same might be true for diagnostic measures. Therefore, we considered it would be interesting to compare the diagnostic distribution in primary care with diagnoses given in a specialist practice.The aim of this prospective study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies.The data in this article were collected routinely from an outpatient clinic at the Department of Physical Medicine and Rehabilitation in Oslo University Hospital, Ullevål, Norway. Referrals to the clinic come mainly from primary care physicians.All referrals regarding shoulder pain were marked with the World Health Organization International Classification of Diseases (ICD)-10 diagnosis m25.51 “Shoulder joint pain” in the hospital’s administrative system . All patients were examined by a medical doctor who took a history and performed a systematic clinical examination. When considered helpful, diagnostic ultrasound, X-rays, MRI, blood samples or neurophysiological investigations were conducted in addition before the final ICD-10 diagnosis was decided and recorded. The registration period started on 1 April 2008 and ended on 31 March 2009, giving a 1-year cohort.The data were extracted from DoculivePasDoc through a report of all referrals marked m25.51. This report contained the patient’s ID, date of visits, the final ICD-10 diagnosis given, as well as gender and duration of pain. The data were de-identified after review of the records. As the study was part of regular clinical activity and patient privacy was routinely taken into account, informed consent and permission from the Regional Ethics committee was not considered necessary.Five medical doctors worked in the clinic during the registration period: four were specialists in physical medicine and rehabilitation and one was undergoing speciality training. Diagnostic criteria for the various diagnoses were established in accordance with the literature,10-17 asThe criteria were implemented prior to the data registration period. Training sessions in performing the clinical tests needed for diagnostic purposes were conducted to increase inter rater reliability which is reported to be varying from slight to substantial for the tests used, see Table The data were analysed using the statistical package SPSS v. 15.0 . Descriptive statistics  were calculated. The relative proportion of one diagnosis  in an age group was calculated by dividing the number of patients with this diagnosis in that age group (nd-ag) with all patients in the same age group (n-ag) times 100; nd-ag/n-ag*100.During the 1-year registration period, 766 patients were referred to the clinic with a shoulder problem. Fifty-five per cent of the patients were women (419/766) and overall mean age in both sexes were 49 years . The mean duration (± SD) of shoulder pain was 29 ± 42 weeks for men and 26 ± 38 weeks in women. 471 (61%) of the patients supplied a compact disc with a magnetic resonance imaging (MRI) scan or had a description of the scan attached to their referral letter.The most common diagnoses were subacromial pain syndrome (36%), followed by myalgia 17%), adhesive capsulitis (11%), full thickness rotator cuff tears (8%), acromioclavicular (AC) joint osteoarthritis (4%) and glenohumeral (GH) joint osteoarthritis (4%). The relative proportions of these diagnoses are shown in Figure 7%, adhesSubacromial pain was most frequent in patients aged between 40 and 60 years. For men, this diagnosis increased with age, but in women it was reduced after age 70. For myalgia, most affected individuals were also aged 40–60. The relative proportion of this diagnosis was highest in the lowest age group, 44% in women and 29% in men, decreasing almost linearly with age to less than 5% in both women and men aged over 70. Adhesive capsulitis was most frequent between 40 and 70 years of age for both men and women, as was the case for the proportion of this diagnosis. For full-thickness rotator cuff tears and glenohumeral osteoarthritis, almost all affected individuals were aged over 50 years. The proportion of both full-thickness rotator cuff tears and glenohumeral osteoarthritis increased dramatically from less than 5% before 50 years, up to 30% of all patients over 70 except for men with osteoarthritis (17%). Acromioclavicular osteoarthritis was most frequent for patients aged 40–70.The remaining diagnoses were grouped into labral tears (6%), neurological conditions (4%), other shoulder diagnoses (5%) and non-shoulder diagnoses 1%). Of the study cohort, 26 patients (3%) did not get a specific diagnosis and were labelled “shoulder pain NUD”. Of the 49 patients with labral tears, 19 had anterior tears and five had posterior tears. Sixteen had superior labrum anterior to posterior (SLAP) lesions and nine were diagnosed with multidirectional instability. There were 31 patients with neurological conditions. Of these, 17 had cervicobrachialgia without radiculopathy, five had radiculopathy and nine suffered from mononeuritis in the shoulder girdle. Among other shoulder diagnoses, we found 10 sequelae after fracture, seven with AC-joint rupture and seven with biceps tendinopathy only. There were one to three patients with the following diagnoses: sternoclavicular joint pathology, avascular necrosis of the caput humeri, snapping scapulae, postoperative pain, neuropathic pain, septic bursitis and generalised hypermobility syndrome. The eight non-shoulder diagnoses included pulmonary tumour, polymyalgia rheumatica, thoracic back pain, psoriatic cervical osteochondritis, myopathy and monoarthritis in the elbow. The relative proportions of the less frequent diagnoses labral tears, neurological conditions, other shoulder diagnoses and non-shoulder diagnoses are shown in Figure %. Of theSubacromial pain syndrome was the most common shoulder diagnosis (36%) and it increased with age for both men and women. Then myalgia in the shoulder girdle (17%) and adhesive capsulitis (11%) followed. Myalgia was the most frequent diagnosis in persons under 40 years for both genders, decreasing linearly with age. Adhesive capsulitis was found almost entirely in patients aged 40–70 with an even sex distribution except for a peak in women between 50 and 59 years. The degenerative diseases full thickness rotator cuff tear (8%) and glenohumeral osteoarthritis (4%) represented fewer patients, but accounted together for almost 60% of the patients over 70 years of age. In men between 50 and 69 years, glenohumeral osteoarthritis was six times more frequent than in women, among whom the diagnosis was present almost entirely after the age of 70 years.The results in this study were collected from routine diagnostic practice in an outpatient clinic. The practice was based on a literature-based written diagnostic consensus reinforced by regular supervision, meetings on a regular basis and discussions regarding difficult cases. The diagnostic criteria listed in Table For 17 patients, the pre-set diagnosis was not changed to a more specific diagnosis after the consultation due to lacking registration from the consultants. To include these patients the senior consultant (NGJ) corrected these diagnoses by going through these medical records after the registration period, and retrospectively set a diagnosis according to the methods used in this study.The most common diagnoses of shoulder ailments are based on sets of criteria in the absence of tissue specific characteristics. There is no conclusive gold standard and the pain generator is not known for conditions such as subacromial pain syndrome and myalgia. This is even true in the degenerative diseases where studies have shown both full thickness rotator cuff tears and osteWe report only one main diagnosis per person although some patients had more than one diagnosis. This have probably affected the results, particularly in the myalgia and AC joint osteoarthritis groups. AC joint osteoarthritis is reported as increasingly present with age in persons without shoulder pain and was et al.[et al.[et al.[A search of the literature did not reveal any studies reporting the prevalence of shoulder diagnoses in secondary care. Three studies reporting shoulder diagnoses from population studies or primary care were identified. Walker-Bone et al.  and accounted for 17% of the diagnoses in men of this age group. This large difference in results between the four studies might occur because these degenerative diagnoses are rare in primary care. On the other hand, one would expect scattered cases in a 1-year cohort with ages up to 87 years. In our cohort, all diagnoses of glenohumeral osteoarthritis and full thickness rotator cuff tears were supported by MRI scans, which have very high sensitivity for these diagnoses. This miet al. found a high percentage of AC joint osteoarthritis compared with the other studies. This might be because their diagnostic criteria included either tenderness in the AC joint region or pain on adduction of the arm only. Adduction is often painful in patients with subacromial pain syndrome and always in cases of adhesive capsulitis and this may have led to an overestimation of AC joint osteoarthritis in their study.In the present study, AC joint osteoarthritis had to fulfil the clinical criteria in Table et al. did not find any age or gender-related difference in diagnoses, and the other reports did not detail such differences. In our study, the most striking difference was the approximately 10% higher proportion of myalgia in women aged up to 60 years, a higher proportion of subacromial pain syndrome in women under 50 years of age and a higher proportion of full thickness tears after the age of 60 for both sexes.Walker-Bone et al. reported the median duration of pain to be 10 weeks. The participants in our cohort had suffered from shoulder pain for 26 weeks on average at the consultation. This might imply a more chronic group in secondary care, which is also to be expected. The rather large difference in the frequencies of the diagnose myalgia might be explained by the different diagnostic criteria used in the studies but it could also partly reflect the longer duration of pain in secondary care.In terms of the duration of pain, there were only one comparable study from primary care. Östör eThe generalisability of this study is limited because of differences in the spectre of diagnoses used compared to other studies, and also the methodological limitations with the lack of inter rater reliability testing, the missing secondary and tertiary diagnoses and the pragmatic use of clinical tests and imaging as diagnostic tools.However, our data is the first description of the shoulder diagnoses in a secondary care setting, and we found that the most frequent diagnoses were subacromial pain, myalgia and adhesive capsulitis. Our results from secondary care are partly in line with studies from primary care settings. In all these studies subacromial pain and adhesive capsulitis represented 50% or more of the cases for both men and women. Consequently, these two diagnoses should always be considered in patients presenting with shoulder pain in all levels of health care.This is the first report on the prevalence and age and gender related prevalence of specific shoulder diagnoses in secondary care. The most frequent diagnoses set in our clinic were subacromial pain syndrome, myalgia in the shoulder girdle and adhesive capsulitis. Subacromial pain syndrome and adhesive capsulitis were most frequent in the middle age and the degenerative diseases were almost only present after the age of 60 and represented 60% of all diagnoses in persons over 70. In people under 40 myalgia and instabilities were most frequent.The authors declare that they have no competing interests.NGJ planned and designed the study, took part in all phases of the study and are responsible for the work as a whole. BN contributed in analysis and interpretation of data, drafting and revising the manuscript and approved the final submitted version. Both authors read and approved the final manuscript.NGJ is head of the outpatient clinic for musculoskeletal diseases and responsible for the quality of diagnostic procedures in his department and also for specialist education in the field in Norway. BN is professor in general practice and do research on the epidemiology of musculoskeletal pain.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/89/prepub


Patients are often given the option of undergoing future painful treatments in one or multiple sessions . In a randomized controlled field experiment, we investigated the impact of transient pain on patients’ decision to combine or separate future periodontal treatments. The main results show that most patients preferred to have the future treatments take place in one session when they made their choice after a painless examination . However, the patients’ preference for combining the future treatments did not differ from chance when the choice was made immediately following a painful examination . The impact of pain on decision making is observed within and between participants. Current pain seems to lead patients to question their ability to endure future painful treatments in one session. All participants were informed about the general objectives and methods of the study. Written consent was obtained from each participant prior to data collection.The experiment was conducted at a public dental clinic with sixty-two patients pre-diagnosed with periodontal disease in two quadrants of the mouth. The clinic is affiliated with a national university and offers free dental care to the community. Dental patients at this clinic first undergo a pre-examination to identify the type of oral disease, if any, and the recommended treatment. During this screening, the dentist performs a broad clinical exam of the mouth followed by an X-ray. Those pre-diagnosed with periodontal disease  are directed to the periodontal disease waitlist. These patients then wait for a second round of more detailed examinations  and the scheduling of the periodontal treatment. Our study was conducted with pre-diagnosed patients.The study adopted a 2 [order: painless-painful vs. painful-painless (between subjects)] ×2 [choice: first time vs. second time (within subjects)] mixed design. Each participant indicated his/her preference for future treatment at two points in time: immediately following a painless examination and immediately following a painful examination. The order of the dental examinations was counter-balanced so that participants were randomly exposed to either the painless-painful order or the painful-painless order.general clinical exam , the dentist used a mirror as the main instrument to obtain a diagnosis of the patient’s mouth. The dentist assessed the number of teeth, spontaneous bleeding in gingival tissues, presence of intense biofilm and calculus, gingival recession, and halitosis. This exam was expected to produce minimal, if any, pain and discomfort. The other standard examination was the pocketing and bleeding on probing exam . During this examination, a periodontal probe  was used to measure the sulcus (pocket) between the tooth and the gums as well as to assess any bleeding. In contrast to the general clinical exam, the probe exam was expected to cause some pain and discomfort. Each exam lasted approximately 15 minutes.Upon arrival at the clinic, general information about the study was provided, and patients were informed that they were free to decline the invitation or to drop from the study at any point. All patients agreed to participate in the study. They signed an informed consent form, answered a few socio-demographic questions, and underwent two detailed dental examinations meant to assess the level of their periodontal disease. In the each dental examination, the patients were asked if they preferred to schedule future periodontal treatments  for a single day or over two days, one week apart. In other words, the patients reported their choice twice and were allowed to change their preference. At the time the patients made their first choice, they were not aware that they would have the opportunity to change their mind after undergoing the second dental examination. Because the future treatments would involve both sides of the mouth, they were informed that (a) two identical local anesthetic procedures would be required, and (b) the post-treatment recovery would make it more painful to chew for a few days near the treated regions. They were further told that the actual treatment would take place in a few months.Immediately following The dentist explained that the options were identical in terms of clinical outcome, financial costs , and duration of the surgery. The dentist also stated that the end of the periodontal treatment would be the same independent of the choice of one or two sessions. Therefore, if the participant decided to separate the treatments, the first treatment would occur at Time 1, and the second treatment (or the single treatment option) would occur one week later at Time 2. Additionally, to avoid schedule conflicts, the patients were told that the treatments could be performed after the patients’ working hours.Following the choice of single or multiple session treatments, the patients reported their current level of pain and discomfort on two numeric rating scales . After reliability checks, these two items were collapsed to form a pain index–i.e., the manipulation check.The following is a summary of the experiment protocol: while seated in the dental chair, the patient (a) underwent the first dental examination (painless vs. painful), (b) indicated their preference about the scheduling of the future periodontal treatment and reported their current level of pain and discomfort, (c) underwent the second dental examination (painful vs. painless), and (d) confirmed or revised their preference about the scheduling of the future periodontal treatment and again reported their current level of pain and discomfort. At the completion of all treatments, the patients were asked how much time it took to get to the clinic on average. This variable was used to assess the potential impact of commuting.Approximately six months later, the patients underwent the periodontal treatment. One day and seven days after the completion of the treatment, a short telephone survey was conducted. The patients were asked to report their current level of pain and discomfort as well as to indicate if they would choose a single or multiple sessions if they had to repeat the treatment .Cronbach’s alpha was used to check the reliability of the pain and discomfort items. Analyses of variance and t tests were used to test the impact of the type of exam (painful vs. painless) and the order of examination on the pain index. When the homogeneity of variance assumption was violated, a non-parametric test was used (Mann-Whitney’s U test). Z-tests were used to assess whether the proportion of patients who chose to combine the treatments differed from chance or between conditions. Logistic regressions were used to assess the impact of the pain index and the impact of commuting on the decision to combine or separate future treatments. Within each condition, chi-squared tests were used to compare proportions between subjects and McNemar tests were used to compare proportions within subjects.after choice 1 = .90, α after choice 2 = .91]. Thus, both items were collapsed to create a single pain index. The pain index showed that the dental examinations produced the expected effects on the patients’ current level of pain. As expected, on the numeric rating scale (10 = extreme), the patients experienced significantly higher levels of pain after the probing exam  than after the clinical exam , t(61) = 12.99, p<.001). The levels of pain within a given pain condition were the same independent of the order of the dental examinations, F<1.The patients’ reported levels of pain and discomfort were strongly correlated [α Z = 3.05, p<.005). A logistic regression indicated that the commute time to the clinic did not predict patients’ choice  after the first or after the second dental examination  = .01, p>.10 and χ2  = 1.39, p>.10), respectively.On average, the patients were more likely to combine the future painful treatments  = 6.50, p = .01; β = −.42, SE = .17, p = .01). A model with both the commuting time and the pain index as independent variables showed that pain remained a significant predictor , whereas commuting time did not . The omnibus test of the model was significant  = 6.76, p<.05).Current pain influenced patients’ preference. After the painless examination, 72.6% of the patients preferred to undergo the future painful treatment in a single session. This proportion was significantly greater than 50%, χ2  = 4.72, p<.05). The patients who were exposed to the painless exam first were also significantly more likely to choose to undergo the future painful treatment in a single intervention relative to their own preference at time 2 –i.e., when they then experienced a painful exam. In other words, pain reduced patients’ willingness to undergo the future treatment in one session in both the within subjects comparison and the between subjects comparison. The patients who were exposed to the painful examination first did not change their choice of single or multiple sessions .An analysis by order of examination see  showed tduring the actual treatment. Further, in the two after-treatment follow-up surveys, the majority of remaining 57 patients reported that they would have made the same choice again. This preference is observed regardless of whether they were asked one day (77%) or seven days (82.5%) after the treatment. Both proportions are significantly greater than chance . The high level of consistency with the temporal choice may have been in part due to the relatively low levels of post-treatment pain  = 62.3, p<.0001).Only five (out of the 62) patients explicitly asked the dentist to change their choice In a randomized controlled field experiment, this experiment demonstrated that people prefer to combine future painful dental treatments. It is reasonable to suggest that the patients’ choice was directly related to their intrinsic desire to endure the future pain in a single session because the financial costs , duration of the surgery, and date of completion were the same for the one or two session options; the treatments could be performed after the patients’ working hours; and the commute did not influence the patients’ choice.recent pain may impact patients’ preferences.This preference, however, was moderated by the patients’ current level of pain. As the current level of pain increased due to the dental examination, the preference for the combination of future painful treatments decreased. Our findings are consistent with the idea that pain leads patients to question their ability to endure the future treatment in one session, which increases their willingness to separate the treatments into two sessions. It is worth noting that the patients who were exposed to the painful examination first did not change their minds after the painless examination, which suggests that not only current pain but also beginning of the negative experience but not an earlier end of the experience. In other words, any feelings of dread would still be present in the interval between the first and the second treatment. However, the impact of pain on feelings of dread and subsequent choices represents an interesting research avenue, which, to the best of our knowledge, is yet to be investigated.Although our research provides direct causal evidence for the impact of current pain on the decision to combine or separate future pain, it does not provide direct evidence for the underlying psychological mechanism(s). For example, the dentist stated that the date of completion of the periodontal treatment would be the same independent of choice. Therefore, if the participant decided to separate the treatments, the first treatment would happen one week in advance of the second treatment. It is possible that patients in the painful (vs. painless) treatment chose to separate the treatments to reduce the dread associated with the waiting In addition, we suggest three other avenues for future research. First, it was not clear from this study whether higher levels of pain at the time of the decision led people to overestimate the future pain, to question their coping skills, or a combination of both. Second, research on the relationship between pain and treatment schedules in other medical contexts  is necessary, as is an exploration of the theoretical ramifications of similarities or differences across contexts. Finally, our research was limited to the impact of transient and exogenously generated pain. In the painless condition , the patients reported no pain at all, which indicates that the patients were not experiencing chronic pain. Because chronic pain may add a new motivational component , it is not clear how this might interact with patients’ tendency to separate future treatment sessions.In conclusion, this paper focused on a class of visceral experiences (transient and exogenously generated pain) and a particular medical context  in order to provide insight on how visceral experiences influence a patient’s temporal decision making. Due to the amount of shared decision making in medical settings and the fact that patients may be experiencing different emotional and visceral states at the time of such decisions, there is a wide array of opportunities for further research.


In many countries, general practitioner (GP) care of acute low back pain often does not adhere to evidence-based clinical guidelines. There has been little exploration of this deviation from evidence-based care from the patients’ perspective, particularly in relation to patients’ care expectations. The aim of this study was to explore the care expectations in patients who present to their GP with acute low back pain, influences on expectation development, and congruence of these expectations with clinical guideline recommendations.Qualitative study in an inner urban general practice in Brisbane, Australia. Semi-structured interviews were conducted with 11 patients who presented to their GP with acute low back pain.Patients had a biomechanical understanding of back pain, how it should be tested and treated, and a poor understanding of its natural history. Most expected x-rays, believing they were necessary to identify the “cause of the pain” without belief of any downsides to x-rays. Patients’ expectations were primarily influenced by the experiences of family and friends, their own previous experiences of low back pain care, and comments from other health professionals they were consulting. The GP-patient relationship was important in influencing patient satisfaction of care provided. Most patient expectations, and some of the care that they reported receiving, were incongruent with guideline recommendations.A biomechanical approach to management rather than an awareness of empirical evidence was evident in patients’ expectations. Communication and education by the GP that includes specifically enquiring about patients’ expectations, provides an opportunity to correct misperceptions, explain acute low back pain natural history, and the rationale for test and treatment recommendations. Low back pain consultations are among one of the most common reasons for general practice appointments in many developed countries ,2. Key rtheir perceptions of patients’ expectations [Various reasons for non-adherence to guidelines have been reported. -8 In addThe problem of GPs’ deviation from evidence-based care from the patient perspective in relation to patients’ actual expectations has been insufficiently explored. We aimed to explore the expectations of the management of patients presenting to primary care with acute low back pain, influences on the development of these expectations, and their congruence with guideline recommendations.This study received ethical approval from the Behavioural and Social Sciences Ethical Review Committee of The University of Queensland.We chose a qualitative design using a descriptive phenomenological approach ,11 and pPatients were eligible for inclusion if they: were 18 years or older; presented to their GP with an episode of acute low back pain (defined as an episode of pain present for less than three months ); and haA convenience sample of patients was recruited from an inner urban general practice in Brisbane, Australia, between April and July 2011. The medical centre is located in a suburb with a bimodal socio-economic profile, with large proportions of both high income and low income individuals . PatientOne of the authors (JM) completed a semi-structured telephone interview with each patient. Interviews were audio-recorded, with an average duration of interviews of 20 minutes. An interview guide was used, based on research on barriers to evidence-based practice from the patient perspective, including barriers to guideline implementation. The guide focused on topics such as patients’ expectations of testing and treatment procedures for low back pain and how these expectations were conceived. The interview guide (available from the corresponding author on request) was used flexibly so that the interviewer could explore patients’ comments further if needed. Data saturation was reached when no new ideas or constructs arose in two consecutive interviews ,13.Each interview was transcribed verbatim, using pseudonyms, prior to inductive thematic content analysis . Two of Data saturation was reached when no new themes were identified in two consecutive interviews at interview 11, completing the recruitment phase. Of three additional patients invited to participate in the study, two declined (one too busy to participate and one not interested in being interviewed), and one was excluded because the primary reason for her consultation was not acute low back pain. Ten women and one man, with an average age of 52 years  were interviewed. Three of the participants had work-related acute low back pain. Table The themes which emerged could be framed around three areas: patient expectations about the testing and treatment arising during their consultation; influences on patients’ expectations; and the importance of the relationship between the patient and the GP. Table Most patients expected their GP to refer them for an x-ray, particularly patients who felt that their pain was severe Table , quote ASome patients reported receiving the testing procedures they had anticipated , while some stated their GP provided procedures they had not expected to receive . Patients reported satisfaction with their GP’s care, apart from one who wanted to have an MRI and was given an x-ray referral instead.Most patients, including both those that did and did not have an expectation of an x-ray, believed that there were no downsides associated with x-rays (quote H). A few expressed minor concerns about radiation and time inconveniences. However, these patients reported that the usefulness of an x-ray outweighed these potential negatives , assuming that their GP had already balanced these benefits and harms.There was variation among patients regarding the treatments they were expecting from their GP. Many did not know what to expect (quote K); some expected a referral to another health professional (e.g. physiotherapist) (quote L); others expected analgesics . When asked about the option of ‘no treatment’ for low back pain with the exception of analgesics, most believed in a biomechanical approach of needing to find the problem and fix it in a timely manner (quotes O-Q). A few patients felt that no treatment may be suitable for some people, but not for them (quote R).Patients were advised to use, or prescribed, anti-inflammatory drugs and analgesics. Some patients reported being told to avoid vigorous activities; others were told to stay active, including specific muscle strengthening exercises. Other treatments that patients reported receiving from their GP were referrals to allied health professionals, and recommendations for orthotics. There was no expressed dissatisfaction with GP treatment.Patients’ expectations about diagnostic investigations had been influenced by family, friends and/or other health professionals (particularly osteopaths and chiropractors) . Prior experiences of care for low back pain were an influence for those who had experienced it before (quote U). However many patients could identify no specific influences on their expectations, instead reiterating their biomechanical model. Those who expected an x-ray assumed it was part of standard procedure (quote V) and those experiencing no improvement expected a change in management (quote W). Of the patients who had articulated particular treatment expectations, these were predominantly influenced by prior experiences of family and friends (quote X). When patients held a biomechanical model, the assumed cause of their low back pain determined their treatment expectations .When asked how their GP knew what management to adopt, most patients identified their experience (quote AA). Some thought care was guided by the GP’s knowledge of the patient and his/her medical history (quote BB). One patient mentioned a guide, although it is not clear whether this referred to a research-based guide (quote CC). Patients’ level of trust and confidence in their GP, particularly in patients who had seen their usual GP, influenced their overall satisfaction about the consultation, and confidence in their GP’s management (quotes DD-EE). Those reporting discrepancies between their expectations of care and that actually provided by the GP, described satisfaction with the consultation if they had a strong, and previously successful, relationship with the GP (quotes FF).Key findings were that patient expectations included: almost universally that x-rays were standard; a wide variety of treatments; a biomechanical understanding was necessary to dictate management; and a naivety about contemporary empirical clinical evidence on best practice for acute low back pain.Patients in this study expressed a number of misperceptions including that severity of the pain is an important indicator and that the cause of the pain needs to be identified and is necessary for guiding treatment. Any  findings on x-ray were thought to indicate the cause of the pain. Patients were referred for x-ray, despite guideline recommendations that this is unnecessary for most in primary care. In Australia, 25% of acute low back pain primary care patients are referred for imaging [Patients felt that their back pain needed to receive active treatment, particularly to prevent it from getting worse. They demonstrated little understanding of its natural prognosis. A key guideline recommendation is that patients should receive education and reassurance , yet patOur study approached a well-known problem from a perspective that has been rarely studied. It provides insights into patients’ management expectations when consulting a GP for acute low back pain. These insights can be used to guide the interaction that GPs have with patients with acute low back pain. We did not recruit a random sample of participants as is appropriate for qualitative research, but our sample was a convenience sample, relatively small, with an unequal gender distribution, and participants from only one medical centre. However, our study is strengthened by including patients from a range of ages, occupations, and education levels, and consulting either their usual GP or another. Self-reported patient recall imposes some concerns about the accuracy of patients’ recall of events from the consultation and patients’ expectations may have been influenced as a result of the consultation.Patients were satisfied with their GP consultation, even when their management expectations were not met - possibly because of a strong doctor-patient relationship. This is fundamentally important in promoting patients’ trust , perhapsIn facilitating patient-centred care and shared decision making, a fundamental step is for clinicians to elicit patients’ expectations; discuss, and correct any of their misperceptions, expectations or fears . HoweverNot unexpectedly, patients’ expectations were predominately influenced by their previous experiences of low back pain care and advice received from family, friends, colleagues and health professionals. But the messages from other health professionals were alarmingly inconsistent, as noted previously  and furtFuture enhancements to this area of research could include interviewing patients prior to the consultation, and recording the consultation so that the actual care received is captured to further explore the doctor-patient encounter.Patients’ biomechanical understanding of back pain, their subsequent test and treatment expectations, poor understanding of the natural history of low back pain, and message inconsistency from health professionals suggest a need for public education about the appropriate management of acute low back pain. A public education campaign that ran in the mass media in Victoria, Australia for 22 months improved back pain beliefs in both the general public and GPs , with thThe authors declared that they have no competing interest.TH, JS, and CDM conceptualised the study. JM was responsible for data collection. JM, JS, and TH were responsible for most of the data analysis, with some input from CDM. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/7/prepub


Occipital nerve block (ONB) has been used in several primary headache syndromes with good results. Information on its effects in facial pain is sparse. In this chart review, the efficacy of ONB using lidocaine and dexamethasone was evaluated in 20 patients with craniofacial pain syndromes comprising 8 patients with trigeminal neuralgia, 6 with trigeminal neuropathic pain, 5 with persistent idiopathic facial pain and 1 with occipital neuralgia. Response was defined as an at least 50% reduction of original pain. Mean response rate was 55% with greatest efficacy in trigeminal (75%) and occipital neuralgia (100%) and less efficacy in trigeminal neuropathic pain (50%) and persistent idiopathic facial pain (20%). The effects lasted for an average of 27 days with sustained benefits for 69, 77 and 107 days in three patients. Side effects were reported in 50%, albeit transient and mild in nature. ONBs are effective in trigeminal pain involving the second and third branch and seem to be most effective in craniofacial neuralgias. They should be considered in facial pain before more invasive approaches, such as thermocoagulation or vascular decompression, are performed, given that side effects are mild and the procedure is minimally invasive. The use of occipital nerve block (ONB) has been propagated in occipital and cervical pain syndromes and dates back into the 1970s –5. SubseDespite the effective application in headaches involving the first trigeminal branch, little is known regarding efficacy of ONB in craniofacial neuralgias , trigeminal neuropathic pain and persistent idiopathic facial pain. More precisely, little is known whether ONB is effective in painful conditions involving the second and third maxillary branch. One report dating back to the 1960s reported complete pain relief in postherpetic neuralgia after alcohol blocks of the greater occipital nerve in all six patients . Three oONB effects were principally confined to the first trigeminal branch or would also extend to the second and third branch.ONB would be clinically meaningful effective in craniofacial neuralgias, neuropathies and persistent idiopathic facial painDifferences in efficacy were syndromal, i.e. more or less efficacious in neuralgias than in persistent facial pain.Consequently, patients attending our outpatient department were identified who had medically intractable facial pain and received uni- or bilateral occipital nerve blocks. We wanted to elucidate whether:Medical records of patients with facial pain or cranial neuralgias who presented to the facial pain clinic of the University Medical Centre Hamburg-Eppendorf between December 2009 and July 2010 were reviewed. Only patients who received an ONB in these conditions with appropriate clinical documentation were included in this retrospective chart review. Further inclusion criteria were: diagnosis of craniofacial neuralgia, trigeminal neuropathic pain or persistent idiopathic facial pain according to the criteria given below, stable preventative medication during follow-up period and at least 18 years of age. Patients were treated with an ONB due to impairment by acute exacerbations of pain.All patients had been seen by headache specialists  who established a diagnosis of craniofacial neuralgia including classical trigeminal neuralgia (IHS 13.1.1), symptomatic trigeminal neuralgia (IHS 13.1.2) and occipital neuralgia (IHS 13.8) and persistent idiopathic facial pain (IHS 13.18.4) according to the current ICDH-II criteria . In trigAs no diagnostic criteria for trigeminal neuropathic pain are given in the ICHD-II, the criteria by Zakrzewska  had to bPatients had been routinely contacted (by either OF or PM) every 3–7 days after ONB and pain intensity and relevant changes had been noted as part of the outpatient clinics internal standard protocol in the medical files. These outcomes were assessed during telephone contact verbally as indicated by the patient. This routine was implemented to ensure that patients without clinical effects or exacerbation after transient improvement were rapidly seen again to initiate alternative therapy. A total of 20 patients  were identified who had received a total of 25 ONBs with appropriate documentation. Detailed information on demographical data is given in Table As this was a chart review, no experimental design was predefined. Due to standard operating procedures and a standardized documentation in our clinic, patients were treated in a uniform manner. However, composition of the local anesthetic and steroid mixture varied in some patients and some received only unilateral blocks . Data had been collected immediately after the ONB and every 3–7 days thereafter. If the benefit had been less than 50% for more than 2 telephone visits, the subject had been asked to visit the outpatient department again on short notice or advised to take an alternative therapy. Apart from improvement measured in percent of baseline pain, pain intensity on a verbal rating scale (VRS) from 0 (no pain) to 10 (worst imaginable pain) and susceptibility to triggers on a scale from 0 (unsusceptible to triggers) to 10 (highly susceptible to triggers) had been noted. Before ONB, the presence of local tenderness over the greater occipital nerve had been tested bilaterally. After ONB, the patient had been screened for the presence of occipital hypoesthesia and asked whether the procedure was painful. At follow-up, the patients had been routinely asked about the degree of improvement, current pain intensity, susceptibility to triggers, and side effects as part of standard medical care. Additionally, they were asked about any change in medication. As patients were contacted on a regular basis with narrow intervals of 3–7 days, outcome measures were determined solely by personal contact and not by means of a diary.All occipital nerve blocks were administered by TPJ to minimize variation. Injections were placed halfway on the nuchal line between the occipital protuberance and the mastoid process and above the occipital ridge , 13. Aftt tests  were used, categorical data were analyzed using 2 × 2 or 2 × 3 tables for Fisher’s Exact test (SPSS 18.0) with p < 0.05 regarded significant. Graphs were plotted with SigmaPlot2000 .Patient data were entered into an Excel 2007  spreadsheet for descriptive statistics. For pairwise comparisons of metric data A total of 25 ONBs were given to 20 patients with craniofacial neuralgias, trigeminal neuropathic pain and persistent idiopathic facial pain. Among them, 8 patients suffered from trigeminal neuralgia (40%), 6 patients from trigeminal neuropathic pain (30%), 5 patients from persistent idiopathic facial pain (25%) and 1 patient from occipital neuralgia (5%). The male:female ratio was 1:1.9. The affected nerve branches are given in Table A positive response with a global improvement of at least 50% pain from baseline according to the patient’s statement was found in 11 out of 20 patients .Fisher’s Exact test using a 2 × 3 table with response (yes/no) versus type of facial pain  yielded no significant result . Notably, the comparison between improvement in patients with trigeminal neuralgia and persistent idiopathic facial pain missed significance by a narrow margin.Improvement of baseline pain 3 days after ONB compared between the different subtypes of facial pain yielded no significant results in pairwise comparisons . Results of unpaired Evaluation of the number of effective nerve blocks yielded similar results. The total response rate was 13 out 25 blocks (52%). In trigeminal neuralgia 6 out of 8 blocks (75%) were considered effective, in occipital neuralgia 1 out of 1 block (100%). In trigeminal neuropathic pain, 4 out of 7 blocks were beneficial (57%), in persistent idiopathic facial pain 2 out of 9 blocks were effective (22%).p = 0.095).Seven responders were females and 4 males , which is comparable to the entire sample (1:1.9). Hypoesthesia ipsilateral to the pain was present in 10 successful ONBs and 3 unsuccessful ONBs (data on hypoesthesia were missing in TN1), no relevant hypoesthesia was noted in 4 successful and 7 unsuccessful ONBs . In trigeminal neuropathic pain, a reduction of only 37% was observed . Reduction of pain intensity was lowest in patients with persistent idiopathic facial pain with only 22% .Mean pain ratings for all patients (responders and non-responders) were reduced by 50% .A comparison of net ONB effects on pain ratings (difference of pain ratings before and after ONB) between the subgroups yielded no significant results in unpaired Mean duration of clinical improvement (considering only patients with at least 50% improvement on day 3) was 27 days . A sustained benefit (defined as continuous improvement of at least 50%) was obtained in 3 patients who were followed-up for 69, 77 and 107 days  and not tested in one patient (i.e. present in 83%). Contralateral tenderness was present in eight patients and not tested in one (i.e. present in 44%). A combination of the absent tenderness over the greater occipital nerve and missing hypoesthesia after ONB was found in only 2 unsuccessful blocks.In three patients, repetitive ONBs were performed. However, only one patient (TNP5) reported recurrent benefit after both blocks, while another patient (FP1) experienced beneficial effects after two of four ONBs. In another patient (FP4), a second ONB was performed despite failure of the initial block again without success.In patients with trigeminal neuralgia, three patients reported shorter attacks, two patients an unchanged duration of attacks and another slightly longer attacks. Due to missing data, effects of ONB on attack duration could not be evaluated in 2 out of 8 patients.The susceptibility to known triggers was lower in 3 out of 8 (38%) patients with trigeminal neuralgia and in 3 out of 6 patients with trigeminal neuropathic pain (50%) on the third day post-ONB. It was unchanged in two patients with trigeminal neuralgia and two with trigeminal neuropathic pain and increased in 2 patients with trigeminal neuralgia and 1 with trigeminal neuropathic pain. The only patient with occipital neuralgia reported a persistent and complete reduction of trigger factors after ONB with decline from 10/10 to 0/10. Trigger factors were not evaluated in patients with persistent idiopathic facial pain.Two patients who received unilateral ONBs did not respond.The amount of lidocaine and thus the applied volume varied over the observed period. Initially, 30 mg lidocaine was given routinely. Later, most patients received 40–50 mg. Distribution of response rates among various lidocaine amounts was not dose specific: a positive response was observed in 0 out of 1 ONB with 20 mg (0%), 10 out of 15 ONBs with 30 mg (67%), 3 out of 5 ONBs with 40 mg (60%) and 0 out of 4 ONBs with 50 mg (0%).In addition, no relation between the lidocaine dose and the absence of hypoesthesia could be found. In 8 of 15 blocks (53%) with 30 mg lidocaine no hypoesthesia could be found and in 2 of 4 blocks (50%) with 50 mg and missing data in 1 patient. Hypoesthesia could always be found in ONBs with 20 mg (1 block) and 40 mg (5 blocks) lidocaine.1+2 (100%), in 2 out of 3 with involvement of V1–3 and V2+3 (67%), 3 out of 9 with V2 (33%) and 2 out of 3 with V3 (66%), respectively. The only patient with involvement of the greater occipital nerve (C1–3) responded (100%).Positive response rates were reported in the only patient with involvement of VThe injection procedure was rated painful by 2 out of 8 patients with trigeminal neuralgia (13%) and by one patient each with trigeminal neuropathic pain (17%) and persistent idiopathic facial pain (20%) resulting in a total of 4 out of 20 patients (20%). Transient and only mild ONB-related side effects were observed in 10 of the 20 patients  had second and/or third division trigeminal pain. The mean response rate was 55%  and was most effective in patients with trigeminal neuralgia (75%), although results did not reach statistical significance. ONB was less effective in trigeminal neuropathic pain (50%) and persistent idiopathic facial pain (20%).Occipital nerve block reduced mean pain ratings significantly in the entire sample by 50% . These effects lasted for an average of 27 days with a sustained benefit for up to 107 days in three patients .Our data have to be seen with caution as our study was retrospective and open labeled. Groups were small and composition of the lidocaine/dexamethasone mixture varied. As such, these data mirror clinical routine and not a controlled study; consequently we decided to report descriptive statistics for most variables only. Despite these limitations, we show striking differences in efficacy of ONB between different entities of facial pain. Patients with idiopathic facial pain responded barely, while those with craniofacial neuralgia showed highest response rates.It has been shown in anatomical studies that A-delta and C-fiber afferents from trigeminal and occipital (C1-3) nerve branches terminate in the trigemino-cervical complex (TCC) –24 and t2 and V3) trigeminal branch and could explain ONB efficacy in these conditions.The phenomenon of referred pain in the occipital region upon nociceptive trigeminal activation has been described in patients with primary headaches such as migraine and cluster headache , 28. TheHowever, recent studies imply that ONB effects could be mediated by an additional mechanism. In rodents and human cadavers nociceptive collaterals of the nervus spinosus  were found to innervate both the dura mater and occipital periost and neck muscles . Based oThe observation that effects are most pronounced in craniofacial neuralgia and trigeminal neuropathic pain rather than in persistent idiopathic facial pain would argue in favor of different pathophysiological models. While craniofacial neuralgia  and trigResponse was defined as an at least a 50% decrease in pain after ONB as judged by the patients in percent of baseline pain. Evaluation of interventional procedures based on subjective assessment by the patient is certainly controversial. Facial pain syndromes differ substantially in their temporal profiles (constant versus intermittent pain), pain characteristics (burning versus stabbing or lancinating pain) and other factors like reduced susceptibility to triggers. The above criterion had thus been chosen as standard in a clinical setting to increase comparability between groups and simplify evaluation for the patient. Moreover, reports of pain intensity yielded similar results.Occipital hypoesthesia after ONB was present in 76% of the patients. Hypoesthesia was absent in 8 out of 12 unsuccessful ONBs and present in 9 of 13 successful ONBs . One potential explanation for missing hypoesthesia could be that ONBs were misplaced (as ONBs induce conduction blocks with consecutive sensory loss of the innervated area) or due to the varying amount of lidocaine/cortisone. However, there was no obvious correlation between the degree of hypoesthesia and the amount of lidocaine used.Our data do at present not support a predictive role of hypoesthesia for ONB efficacy. This is in line with a previous study on cluster headache, migraine and new daily persistent headache  which foLidocaine has been used frequently in ONB studies , 10, 12.Regarding the ideal composition of the injection it is not known whether a local anesthetic or corticosteroid alone or a combination of both is more effective. While some studies used either local anesthetics or corticosteroids alone . However, as placebo effects are known to be high in chronic pain, results have to be interpreted with caution and randomized controlled studies are mandatory to confirm these preliminary results.


Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique. A conventional multiport laparoscopic adrenalectomy (MPLA) using three or four ports is the gold standard operative treatment for benign adrenal tumors -3. The aData were prospectively entered in an LESS adrenalectomy database and retrospectively reviewed. Between January 2010 and July 2012, 14 consecutive patients (7 men and 7 women) with benign adrenal tumors underwent LESS adrenalectomies at the Iwate Medical University Hospital. All procedures were performed by a single surgeon. Informed consent was received from all the patients for the procedure, and the difference between the LESS and the conventional multiport approaches were explained. This study was approved by the institutional review board at Iwate Medical University Hospital and conducted in accordance with Declaration of Helsinki.As a general principle, indications for LESS adrenalectomy were hormonally active tumors ranging in size up to 5 cm, and non-functioning tumors greater than 3 cm, or with proven growth Table . ExclusiA visual analog scale (VAS) was used as an objective assessment of incisional pain on postoperative days 1, 3, and 14, and for incisional cosmesis on postoperative days 3 and 14. The VAS was used to score incisional pain on a 10-point scale with a range from 0 (no pain) to 10 (worst possible pain). The VAS was also used to score cosmesis on a 10-point scale with a range from 0 (worst) to 10 (best). Data are expressed as mean ± standard deviations (SD).The patient was placed in the semilateral position. All procedures were performed through a single multichannel port. A 2.5 cm incision was made through the umbilical skin and fascia. The wound protector/sleeve of the GelPOINT  was placed. Three 5-mm cannulas were placed through the GelPOINT and then attached to the wound protector. A 5-mm flexible laparoscope , a SILS dissector , and a tissue sealing device  were the primary tools used in the operation. An anterior approach, with no mobilization of the right lobe, was used for the right-sided tumors, while a lateral approach was used for left-sided tumors. Only the central adrenal vein was clipped and the small adrenal vessels were divided using an EnSeal device. For the right-sided adrenal tumor, the right liver lobe was evaluated using a 2.3 mm percutaneous instrument  and a small gauze, which provided good visualization of the operative field surrounding the right adrenal gland. Although MiniLap insertion appears to be scar-less, a needle instrument can be traumatic for the liver. To avoid a traumatic procedure, we used small gauze as cushioning to evaluate the liver. The overall procedure was similar to the procedure performed in a conventional anterior approach using a four-port technique Figure . The adr2. Mean operating time was 128.1 ± 31.5 min and mean blood loss was 10.5 ± 12.1 ml. There was no difference between the initial 7 cases and the last 7 cases in mean operating time . There were also no other significant differences between the preoperative characteristics of the patients. No blood transfusions were required. Mean tumor size was 21.2 ± 7.0 mm. No patients demonstrated a delay in initiating oral intake or a regular diet. Mean hospital stay after surgery was 3.9 ± 1.0 days, and convalescence was complete at two weeks. The postoperative course was uneventful with no morbidity within one month of follow-up.Patient demographics are summarized in Table Mean scores for postoperative incisional pain on postoperative days 1, 3, and 14 were 2.3 ± 1.6, 1.0 ± 1.1, and 0.3 ± 0.7 points, respectively. The rate of analgesic use  was also lower within 12 hours after surgery (14%). According to their self-assessments, mean cosmesis scores on postoperative days 3 and 14 were 9.4 ± 0.7 and 9.8 ± 0.3 points, respectively. The rates of best cosmetic satisfaction (VAS score of 10) at 3 and 14 days were 57% and 79%, respectively. The patient has had an excellent cosmetic result on postoperative follow-up .Conventional multiport laparoscopic surgery is the gold standard operative treatment for a variety of diseases. Generally, the goal has been to minimize the invasiveness of this procedure by reducing the number or size of the operating ports. Recently, LESS surgery was developed as an extension of standard laparoscopic minimally invasive procedures. The potential for decreased pain, faster recovery, and improved cosmesis has surgeons, their patients, and the industry interested in pushing the technique forward. In 2008, Castellucci et al.  reported2. Good laparoscopic skills and careful patient selection are essential; additional ports should be considered to help with liver retraction.Since March 2009, we have been using LESS cholecystectomies in selected patients with benign gallbladder diseases. Additionally, our team has recently performed successful advanced LESS procedures, such as gastrectomy, colectomy, splenectomy, Heller-Dor procedure, and Nissen fundoplication . At our Two matched-control studies have reported that patients undergoing LESS adrenalectomy had significantly lower pain scores or required significantly less analgesia ,14. JeonLESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique. Further studies are necessary to clearly identify the risks and benefits of this new approach to the adrenalectomy.Written informed consent was obtained from the patient for publication of this report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.LESS: Laparoendoscopic single site; MPLA: Multiport laparoscopic adrenalectomy; VAS: Visual analog scale; SD: Standard deviations.The authors declare that they have no competing interests.AS conceived the experimental plan, analyzed the data, and drafted the manuscript. NH, OK, SN, KK, MM, and GW helped to draft the manuscript. SB and AU cared for the patients. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/13/21/prepub


Clinical characteristics and patterns of healthcare utilization in patients with painful neuropathic disorders (PNDs) who are under the care of general practitioners (GPs) in the UK are not well understood.Using a large electronic UK database, we identified all adults (age ≥ 18 years) with any GP encounters between 1 January 2006 - 31 December 2006 at which a diagnosis of PND was noted ("PND patients"). An age-and gender-matched comparison group also was constituted consisting of randomly selected patients with one or more GP encounters-but no mention of PNDs-during this period. Characteristics and patterns of healthcare utilization of patients in the two groups were then examined over the one-year study period.p < 0.01). Receipt of prescriptions for pain-related pharmacotherapy also was higher among PND patients, including nonsteroidal anti-inflammatory drugs (56% of PND patients had one or more such prescriptions vs. only 22% in the comparison group), opioids (49% vs. 12%), tricyclic antidepressants (20% vs. 1%), and antiepileptics (12% vs. 1%) . PND patients also averaged significantly more GP visits (22.8 vs. 14.2) and referrals to specialists (2.8 vs. 1.4) over one year (both comparisons p < 0.01).The study sample consisted of 31,688 patients with mention of PNDs and an equal number of matched comparators; mean age was 56 years, and 62% were women. The prevalence of various comorbidities was higher among patients in the PND group, including digestive disorders (31% vs. 17% for comparison group), circulatory disorders (29% vs. 22%), and depression (4% vs. 3%) (all Patients with PNDs under the care of GPs in the UK have relatively high levels of use of healthcare services and pain-related pharmacotherapy. Neuropathic pain results from dysfunction of either the peripheral nerves or, less commonly, the central nervous system ,2. NeuroIn contrast to the growing body of literature on the etiology, pathophysiology, and treatment of neuropathic pain, relatively little has been reported about the clinical characteristics and costs of patients with painful neuropathic disorders (PNDs) in clinical practice, including their levels of use of pain-related pharmacotherapy and healthcare services. These issues were examined by the authors in two prior studies in which patients with PNDs were compared with an equal number of age-and sex-matched comparators ,8. In thThere is some evidence that patients with PNDs in the UK are similarly treated. In their study of approximately 25,000 patients with post-herpetic neuralgia, trigeminal neuralgia, phantom limb pain, or painful diabetic neuropathy newly diagnosed by a GP in the UK between CY1992 and CY2002, Hall et al. reported that the medications most commonly prescribed were amitriptyline, carbamazepine, coproxamol, codydramadol, and codeine + paracetamol . In a seWhile providing important insights into the treatment of PNDs in the UK, these studies are not without their limitations. The two studies by Hall and colleagues were limited to the four above-noted PNDs; the degree to which their findings are generalizeable to the overall population of patients with PNDs is unknown. Moreover, none of these studies compared healthcare utilization and pharmacotherapy between patients with PNDs versus those without these disorders. We address this issue in the study described below, focusing attention on patients under the care of GPs in the UK.Data were obtained from The Health Improvement Network (THIN) database, which consists of patient-level information on GP encounters from approximately 300 computerized GP practices throughout the UK. All practices registered with THIN use a clinical management system provided by In Practice Systems Ltd. (INPS). Many practices have contributed over 15 years of data to THIN, and more than 5 million patients are represented in the database. The database documents all patient care by GPs, and includes extensive information on diagnoses and treatments; it is designed to be representative of GP practices throughout the UK. All patient identifiers in the database are fully encrypted to protect patient confidentiality.Available information in the THIN database includes date of service, diagnoses (in READ format), actions taken , and medications prescribed--including the prescribing date and the quantity prescribed. Selected demographic information is also available, including patient age and gender. All patient-level data can be arrayed chronologically to provide a detailed, longitudinal profile of all medical and pharmacy services rendered by participating GPs.The study protocol was submitted for review to--and subsequently approved by--the UK National Health Service (NHS) Multi-Centre Research Ethics Committee (MREC).The study sample consisted of all patients, aged ≥ 18 years, with one or more visits to GPs between 1 January 2006 and 31 December 2006 ("study period") (the most recent one-year period for which data were available at the time of study) at which a diagnosis of PND was noted (Appendix). A comparison group also was constituted, consisting of patients who did not have any GP encounters with noted diagnoses of PNDs during the same period; they were randomly selected and matched to PND patients based on age (within 1 year) and sex.  All GP encounters were compiled for PND patients and patients in the comparison group over the 12-month study period.any encounters during the study period with a corresponding diagnosis code, or a prescription for a drug specific to that condition .The prevalence of selected clinically recognized comorbidities  was examined in both groups. Patients were deemed to have any of the conditions of interest if they had The number of patients receiving prescriptions for pain-related and non-pain-related medications during the study period was examined. Medications were designated as "painrelated" based on their classification as analgesics or adjuvant medications in the World Health Organization's (WHO) "analgesic ladder" . AlthougUse of healthcare services during the 12-month study period was examined in terms of the numbers of GP visits, referrals from GPs to other healthcare providers , and hospitalizations; "sick notes" (physician-excused absences from work) also was examined. We did not attempt to attribute care specifically to the treatment of PNDs, because of inherent difficulties in attribution using electronic healthcare databases. We also did not attempt to examine nonpharmacologic treatments for PNDs, such as spinal cord stimulation and psychological support.® v.8.4 [The statistical significance of differences in continuous measures between the PND and comparison groups was ascertained using paired t-tests or Wilcoxon signed-rank tests, as appropriate. McNemar's and Bowker's tests, as appropriate, were used to ascertain the statistical significance of differences in categorical measures. All analyses were conducted using PC-SAS® v.8.4 .We identified a total of 31,688 patients with one or more encounters at which PNDs were recorded between 1 December 2006 and 31 January 2006; a comparison group of the same size also was constituted, matched on age and gender. The most frequently noted PNDs were neuropathic back pain , nerve impingement syndromes  (14.1%), and unspecified neuropathic pain  (9.7%) (Table p < 0.01). Approximately one in five PND patients  had at least one encounter during the study period with a diagnosis of "symptoms, signs, and ill-defined conditions", compared with only 11.1% of patients in the comparison group (p < 0.01). Eighty-eight percent of patients with PNDs had two or more comorbidities noted by their GPs during the study period, versus 56.9% for the comparison group.Mean (SD) age of patients in both groups was 56.1 (16.6) years, and 61.6% were women Table . Nearly p < 0.01), including "traditional" analgesics, such as NSAIDs and opioids, as well as "adjuvant" medications, such as AEDs, benzodiazepine, and tricyclic antidepressants (Table p < 0.01).The number of patients who received prescriptions from their GPs for pain-related pharmacotherapy was approximately twice as high in the PND group than in the comparison group  , ACE inhibitors (26.6% vs. 16.8%), antiulcerants  (23.7% vs. 12.1%), dermatologicals (23.6% vs. 17.1%), and cough and cold preparations (21.1% vs. 16.4%)  (Table p < 0.01). A total of 16.5% of PND patients had one or more "sick notes"  during the year, versus 7.0%, of the comparison group.Patients with PNDs averaged significantly more GP visits during the 12-month study -most commonly, NSAIDs and opioids. Despite the proven efficacy of antidepressants  in treating neuropathic pain, which has led to recommendations regarding their use as first-line therapy ,36,37, oPatients with PNDs also had more GP encounters with diagnoses of other medical problems  compared with their age-and sex-matched peers without evidence of PND; they also had higher levels of use of non-pain-related medications, such as anti-ulcerants, systemic anti-infectives, and dermatologicals. Patients with PNDs averaged 10 additional GP office visits over 1 year, and twice as many specialist referrals and hospitalizations; 17% had at least one physician-excused absence from work versus as opposed to only 7.0% in the comparison group. Other studies of US and German patients have reported similar findings .While the precise reasons for these associations are unclear, a number of possible explanations come to mind. For one, some comorbid conditions may be etiologically related to PNDs-for example, diabetes, vascular complications thereof, and diabetic peripheral neuropathy-and such associations therefore are not unexpected. More generally, since neuropathic disorders are often chronic and difficult to treat, patients with PNDs may present more frequently to their GPs than patients without these disorders. More frequent visits may lead to more opportunistic case findings, and hence a higher rate of clinical recognition of many complaints and diseases that otherwise might have gone undiagnosed and/or untreated. Difficulties in diagnosing neuropathic disorders also may have yielded spuriously high rates of comorbid conditions among PND patients. On the other hand, since THIN does not have a direct link to hospital data and/or sick notes, our findings may actually underestimate the prevalence of various comorbidities. Further study is needed to better understand how common these comorbidities are in patients with PNDs, as well as the relationship between these conditions and PNDs.In their study utilizing another electronic database containing information from GP encounters in the UK, Gore and colleagues reported that NSAIDs were the most commonly dispensed medication among patients with "pure" PNDs   ; 17% recPatterns of prescribing of pain-related pharmacotherapy among our study subjects also differed substantially from those reported by Hall and colleagues, who used the same database to examine patterns of pharmacotherapy among patients with post-herpetic neuralgia (N = 1923), trigeminal neuralgia (N = 1862), phantom limb pain (N = 57), and painful diabetic neuropathy (N = 1444) between May 2002 and July 2005 . SpecifiOur study has several limitations. Perhaps most important, our findings are based on information from CY2006. Treatment guidelines changed after CY2006 and now recommend a number of different medications as first-line therapy for PNDs  ,6; the dSecond, information on medication use was limited to drugs prescribed by GPs. Thus, to the extent that patients with PNDs  used medications available for direct retail purchase  and/or received "private prescriptions" , we may have underestimated total medication use.Third, we do not know the reason(s) why particular medications were prescribed . Since some medications designated as "pain-related" also may be used to treat conditions that are not typically associated with pain , it would be incorrect to infer that these agents were used exclusively for the treatment of neuropathic pain. However, only 4% of PND patients-and 3% of those in the comparison group-had any encounters at which a diagnosis of depression was recorded; corresponding values for epilepsy were 0.2% and 0.1%, respectively (data not shown). Similarly, given the widespread prevalence of comorbid pain-related conditions among patients with PNDs, as well as the possibility of "mixed" pain  among those with back pain with neuropathic involvement, it is possible that NSAIDs (and other pain-related medications for that matter) may have been prescribed for the treatment of pain that was not neuropathic in origin . Since we did not have access to medical records, the degree to which this actually occurred must remain conjectural.Fourth, the study database is limited to information from GP encounters. Given the large numbers of PND patients with medical and psychiatric comorbidities-as well as the difficulty of treating PNDs-it is reasonable to expect that some patients in the study sample also had encounters with healthcare providers other than GPs.Fifth, the GP-centric records of referrals, sick notes, and hospitalizations that are available in the study database are complete only to the extent that GPs actually record such information; to the extent that this information is not recorded by GPs, our findings may represent underestimates of healthcare utilization and prescribing patterns in this population.Sixth, study subjects were selected based on evidence of at least one GP encounter during which a diagnosis of a PND was recorded during the one-year study period. Thus, patients who were exclusively under the care of specialists  for their neuropathic pain, but who saw GPs for other reasons, would not necessarily have had GP encounters at which PNDs were noted. Not only would these patients not have been designated as having PNDs, but they also could have been selected for inclusion in the comparison group. On the other hand, the database does not contain information on how physicians rendered their diagnoses. Given that some types of PNDs are more difficult to diagnosis than others -44, and Patients with PNDs under the care of GPs in the UK have relatively high levels of use of healthcare services and pain-related (and other) pharmacotherapy. Because treatment guidelines evolved while our study was underway, it is unknown whether patterns of pharmacotherapy that we observed are representative of clinical practice in the UK today.Funding for this research was provided by Pfizer Inc., New York, NY. Two of the study authors--Dr. Sadosky, an employee of Pfizer Inc., and Dr. Dukes, an employee of Pfizer at the time this research was conducted--were involved with the design of the study, data analysis and interpretation, manuscript preparation, and publication decisions. Mr. Berger, Dr. Edelsberg, and Dr. Oster, who are employed by Policy Analysis Inc., were involved with the design of the study, data analysis and interpretation, manuscript preparation and publication decisions. Policy Analysis Inc. received funding to support manuscript development.All authors  helped with all aspects of this study . All authors read and approved the final manuscript.This research was funded by Pfizer Inc., New York, NY. Mr. Berger, Dr. Edelsberg, and Dr. Oster are employed by Policy Analysis Inc., an independent contract research organization. Dr. Dukes is a former employee of Pfizer Inc. Dr. Sadosky is currently employed by Pfizer Inc.Table The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/12/8/prepub


Given the costs associated with the management of musculoskeletal pain in primary care, predicting the course of these conditions remains a research priority. Much of the research into prognostic indicators however considers musculoskeletal conditions in terms of single pain sites whereas in reality, many patients present with pain in more than one site. The aim of this study was to identify prognostic factors for early improvement in primary care consulters with acute and persistent musculoskeletal conditions across a range of pain sites.th treatment visit, and if they were still consulting, at the 10th visit. The outcome was defined as patient self-report improvement sufficient to make a meaningful difference. Independent predictors of outcome were identified using multivariate regression analyses.Consecutive patients with a new episode of musculoskeletal pain completed self-report questionnaires at baseline, and then again at the 4/5th visit. Several variables at baseline were associated with improvement at the 4/5th visit, but the predictive models were weak and unable to discriminate between patients who were improved and those who were not. In contrast, it was possible to elicit a predictive model for improvement later on at the 10th visit, but only in patients with persistent pain. Being employed, reporting a decline in work fear-avoidance behaviour at the 4/5th visit, and being better by the 4/5th visit, were all independently associated with improvement. This model accounted for 34.3% (p < 0.001) of the variation in observed improvement, and had good discriminative ability (the area under receiver operating characteristic (ROC) curve was 0.80 (95%CI 0.73 to 0.86)) and approximate balance in correctly identifying improved and non-improved cases (79.0% and 68% respectively).Acute (<7 weeks) patients, on average, had more severe conditions in terms of pain, disability, anxiety and work fear-avoidance behaviour than patients with persistent (≥7 weeks) pain, but were more likely to be better by the 4/5We were unable to identify baseline characteristics that predicted early outcome in musculoskeletal pain patients. However, early self-reported improvement and decline in work fear-avoidance behaviour as predictors of later improvement highlighted the importance of speedy recovery in persistent musculoskeletal pain consulters. Our findings reinforce the elusive nature of baseline predictors, and the need for more emphasis on early changes as prognostic predictors in musculoskeletal conditions. Musculoskeletal disorders, including back, leg, neck, shoulder and arm pain, are costly and prevalent conditions most of which are managed in primary care . The impIt is apparent that musculoskeletal disorders are highly individualised and multidimensional, and that patients differ both in their response to treatment and in their recovery patterns. This presents enormous challenges to researchers using methodologies in the quantitative paradigm. For example, the modest average treatment effects may mask individual differences with some patients responding a great deal, and others hardly at all. This led, almost a decade ago, to calls for the identification of subgroups of patients either with more favourable prognoses or more likely to respond to particular treatments ,6.Unfortunately what was described then as the 'holy grail' of back pain research  has yet Nevertheless, given the potential of clinical prediction research in improving patient care in musculoskeletal disorders, the pursuit of prognostic factors continues apace, predominantly in low back and neck and/or shoulder pain. Most recently, investigators in this field have distinguished between acute and chronic patients, arguing that predictors may differ given the different prognostic characteristics of these two groups ,9,10. MoThe aim of this study therefore was to identify prognostic factors for short-term improvement in a large cohort of patients with acute and persistent musculoskeletal conditions across different pain sites, typical of those managed in primary care by GPs, physiotherapists, osteopaths and chiropractors.th or 5th treatment session and, if they were still consulting, after their 10th visit. The data from these questionnaires were primarily used to inform the clinician and guide his/her decision-making during the course of treatment. However, patients were informed that the information would also be used anonymously for research purposes and that completion of the questionnaires was indicative of their consent. Ethics approval was given by the local ethics committee. Over the period of data collection, there were a number of chiropractors employed in the practice, and patients were treated pragmatically according to individual needs, including advice, spinal manipulation and mobilisation, dry needling and exercise in keeping with current guidelines [Data from new or new episode patients consulting for a range of musculoskeletal conditions at a chiropractic practice in Bristol, UK from November 2001 to December 2009 were collected prospectively. The only exclusion criteria were patients below the age of 17, and those not able to read and understand the questionnaires either because of limited fluency in the English language or being considered too elderly and frail to do so. Patients were asked to complete questionnaires in the reception area prior to their first consultation (baseline), then again in the reception area after their 4idelines .th and 10th visits, patients completed the BQ as well as the Patient Global Impression of Change (PGIC) scale [The baseline questionnaire collected patient information relating to demographics, work status, lifestyle behaviours and attitudes, and clinical characteristics of the presenting complaint. Areas that the patient felt 'most pain' were categorised as: 'low back'; 'leg(s)'; 'neck'; 'shoulder(s)/arm(s)'; 'head' and 'other'. Patients were allowed to mark more than one area. The questionnaire also included the Bournemouth Questionnaire (BQ), a validated outcome measure for use in routine practice settings in back  and neckC) scale .A priori discussion between clinicians and researchers identified sociodemographic, biopsychosocial and clinical variables likely to be associated with prognosis in musculoskeletal conditions. Potential predictors were defined either as baseline variables, or as change (between visit) variables. Age, total area of body pain marked on the anterior and posterior pain drawings, and BQ scores and change scores were analysed as continuous variables. All other potential predictors recorded at baseline were dichotomised for ease of interpretation and clinical utility. Area of pain was dichotomised using the mean score for the sample (<8/≥8 units); injury/trauma as a perceived cause of the pain (yes/no/don't know) was collapsed by 'don't know' responses recoded to 'no', expectation of change in condition over the next few weeks (recover or improve/stay about the same/get worse) by recoding to recovery (yes/no), and employment status (employed/working in the home/retired/seeking work) by recoding to paid employment (yes/no). All other variables, which did not require recoding, included pain all over (yes/no), a similar complaint in the past (yes/no), medication use , satisfaction with current work status (yes/no), expectation of working normally in six months' time (yes/no), smoker (yes/no), alcohol consumption (regularly/never or hardly ever), level of physical activity compared to people of a similar age (more or about the same/less) and general health and well-being (excellent or good/fair or poor).Outcomes were monitored using BQ total and sub-scale raw change (i.e. baseline minus treatment visit) scores. The outcome (improvement) for the prediction analysis was defined as those patients scoring either 6  or 7  on the PGIC. All other patients  were categorised as reporting no (meaningful) improvement.2 test and unpaired t test for categorical and continuous variables respectively. Within-patient differences in continuous variables were analysed using the paired t test.Baseline characteristics were compared between acute (current episode <7 weeks) and persistent (current episode ≥7 weeks) pain patients using the chith visit and at the 10th visit. The significance level was set at p ≤ 0.10 to avoid excluding potential predictor variables. Significant variables (p ≤ 0.05) independently associated with the outcome were subsequently entered into a forward stepwise multivariate logistic regression model. Variables were checked for redundancy by noting the correlation coefficients (r≥0.8) between variables in the presence of the other variables in the model. The independence of the variables was also assessed by noting the condition index (<20) of each variable calculated by re-running the final model using linear regression. The ability of the final model to discriminate between improvers and non-improvers was calculated from the area under the receiver operating characteristic curve (AUC) using patient self-report improvement as the external criterion. An AUC of 0.5 indicates no discrimination, 0.7 to 0.8 acceptable discrimination, and 0.9 excellent discrimination [2 was used as the index of the percentage of the variance in the outcome explained by the model. All analyses were conducted using SPSS v17.For the prediction analysis, univariate logistic regression was carried out to determine those variables that were significantly associated with improvement at the 4/5mination . The adjThe baseline questionnaire was completed by 2,422 patients with musculoskeletal complaints amenable to chiropractic treatment. Patients reported pain in the following region(s), which were not mutually exclusive: 1,691 (70.0%) back pain, 973 (40.3%) neck pain, 686 (28.4%) shoulder and/or arm pain, 472 (19.6%) leg pain and 210 (8.7%) headache. Of 1,706 back pain patients, 420 (24.6%) reported accompanying leg pain, and 504 (29.6%) also had neck and/or shoulder/arm pain. Of 1,216 patients presenting with neck and/or shoulder/arm pain, 522 (42.9%) had only neck pain and 231 (19.0%) had only shoulder/arm pain. Almost half  of patients with neck and/or upper extremity pain also reported pain in the back and/or leg.th visit, and between baseline and the 10th visit, were 16.8 (± 10.49) and 51.6 (± 15.36) days respectively.The mean age of the sample was 40.8 (SD ± 14.21) years and the gender split was approximately equal . The majority of the sample was in paid employment  with 221 (9.2%) retired, 146 (6.1%) working in the home, 63 (2.6%) seeking work and 62 (2.6%) students. The mean times between baseline and the 4/5The characteristics of acute n = 1,335, 56%) and persistent  musculoskeletal pain patients are shown in table ,335, 56%th/5th visit. There was a significant (p < 0.001) decline in all seven BQ sub-scales from baseline to follow up in both groups of patients  in the persistent pain group.All patients completed a follow-up questionnaire at the 4ts table . The magth and at the 10th visits were investigated.Thirty potential predictor variables for improvement at the 4/5th visitImprovement at 4/5th visit. In contrast, having a high area marked on the pain drawing and having upper extremity pain reduced the odds of improvement.In acute patients, being male, taking medication for the pain complaint, being in paid employment, being a smoker and expecting to make a good recovery were all positively associated with improvement table . SimilarIn the subsequent multivariate analysis table  being math visit  of the variance in observed improvement, and poor discriminative ability (AUC 0.60).In the multivariate analysis table , having th visitImprovement at 10th visit, the number of patients still consulting was significantly reduced. Of the 1,335 acute patients, improvement data at the 10th visit were available on 168 (11.4%) patients, of whom only 25 (14.9%) reported they were not improved. As a result, there was insufficient data for multivariate regression analysis in this group.At the 10th visit. Table th visit, and improvement at the 10th visit. Reporting a similar condition in the past at baseline was negatively associated with improvement. Being in paid employment, being a smoker and higher baseline BQ scores in disability in ADL and social activities, and in work fear-avoidance behaviour, were all associated with increased odds of improvement at the 10th visit. Considering the change variables, the BQ total and sub-scale change scores, and being better at the 4/5th visit, were all associated with improvement at the 10th visit.For patients with persistent pain, of the original group of 1,059, data were available on 185 (17.5%), of whom 76 (41.1%) were not improved at the 10th visit  improving at the 10th visit. The predictive model accounted for 34.3% of the variation in observed improvement, had good discriminative ability (AUC 0.80) and an approximate balance of correctly identifying improved and non-improved cases (79.0% and 68% respectively).To avoid over-fitting the model given the relatively small number of patients (109 outcome events (improvement)), only those predictor variables significant at the 5% level were entered in the multivariate model. The change in total BQ was excluded to avoid colinearity between this and the BQ sub-scale scores. From the 12 variables entered, three variables were independently associated with improvement at the 10th visit (approximately 2 weeks on average) a greater proportion reported that they were better.This study identified prognostic variables in patients consulting for acute and persistent musculoskeletal pain conditions. We chose to use patient self-report improvement as the outcome, and used a rigorous cut-off for improvement that was meaningful to the patient. It has been shown that patients' perception of improvement is multi-factorial and more complex than either alleviation of symptoms or improvement in function alone ,17. We mA significant proportion of patients in this study reported pain in more than one site, illustrating the difficulty of investigating musculoskeletal disorders on the basis of regional pain. In spite of this, most musculoskeletal research in primary care confines itself to single pain sites, for example low back pain, even though inevitably a proportion of participants will have musculoskeletal pain elsewhere. In spite of this, in a systematic review of prognostic factors in musculoskeletal pain, only 4 out of 45 included studies investigated patients with general musculoskeletal pain .th visit in both acute and persistent pain patients, but apart from this no other predictors were the same in these two groups. This contrasts with the study by Grotle et al. [th visit, suggesting that other factors, not measured in this study, are important. For example, longer pain duration has been identified as one of the few consistent predictive factors in back and neck pain [th visit, which in another prognostic study in chiropractic patients, being better at the 2nd visit was identified as a strong predictor of improvement at the 4th [Expecting to make a good recovery was strongly associated with early improvement by the 4/5e et al.  that suge et al.  low backeck pain . However the 4th . It may th visit in acute patients because most of these patients had ceased to consult. Although this might be presumed to be because they were no longer in pain, this may not be the case [th visit, while having a similar condition in the past was negatively associated. Declines in all the BQ sub-scales between baseline and the 4/5th visit, and reporting improvement on the PGIC scale at the 4/5th visit, were also positively associated with improvement at the 10th visit. In the final predictive model, being better at the 4/5th visit was by far the strongest predictor, together with being in paid employment and reporting a decline in work fear-avoidance behaviour at the 4/5th visit. This result echoes that shown by others [We were unable to investigate prognostic factors for improvement at the 10the case . In conty others ,19 that y others  reportedThis study has several limitations, not least because it was a pragmatic study conducted in real time everyday clinical practice. First, it is restricted to relatively early outcomes (up to seven weeks on average) and in the relatively small proportion of patients that were still consulting. We therefore do not know if the predictive model presented here holds true either in the longer term or in those patients who had stopped consulting. Second, there was no control group, and therefore we are only able to present prognostic factors for the clinical course of these conditions, and not for treatment effects. Third, all variables were self-reported by patients in the chiropractic practice, which may have been subject to reporting bias. Fourth, all patients attended one chiropractic practice, and as such may not be representative either of musculoskeletal patients in general seeking chiropractic care, or of those seeking care from other primary care practitioners. Finally, while it may be considered a strength of the study to include patients with musculoskeletal complaints in general, there still remains the question of why should prognostic factors be common across musculoskeletal pain sites. Many of these conditions share similar characteristics, such as co-morbidities, non-specific aetiologies, recurrent and episodic courses, and prognostic factors such as duration of pain and previous episodes. Nevertheless, clumping these conditions together may be a step too far, or alternatively beg the question as to why not more musculoskeletal research is conducted on this basis.th visit, the predictive models were weak and we were unsuccessful in identifying baseline variables as predictors of early recovery. In contrast, the model constructed to predict self-reported improvement later on in persistent musculoskeletal pain patients showed good discriminative ability. In this model, reporting improvement at the 4/5th visit, a decline in work fear-avoidance behaviour at the 4/5th visit and being in paid employment at baseline were all independently associated with improvement at the 10th visit. These results highlight the importance of early recovery in persistent musculoskeletal pain consulters, and the need to include change variables in addition to baseline variables in future prognostic research.Patients with acute musculoskeletal pain consulting a chiropractor were more severe, on average, than those with persistent pain, but more likely to get better quicker. Although a number of variables were associated with a favourable outcome in acute and persistent pain patients by the 4/5The authors declare that they have no competing interests.JB and HH conceived and designed the study; HH collected the data; JB and HH analysed and interpreted the data. JB was responsible for the first draft of the manuscript; JB and HH were responsible for revisions and approval of the final manuscript.