Bruce Walker

The need to transition students from an academic mindset towards an evidence based approach to the clinical work-up of their client/patient is an important component of the training of chiropractic students. Within the broad spectrum of diagnostic procedures students must become familiar with, imaging is an important tool in their decision making armament. With increasing awareness of the need to apply evidence based practice to this decision making process, the concept of "just do as you were taught" is slowly disappearing from the chiropractic practice ethos. Consequently, as teachers of clinical practice we must begin to place more onus on the students to find and use the best evidence before they "leave the educational nest". To move towards this outcome, we have implemented a unit in the first trimester of our Year 5 chiropractic course in which the students engage in their own, and each others, learning by becoming the principle teachers. Small groups of 4-5 students actively work-up all aspects of a clinical case from its initial presentation, learning how to grapple with clinical uncertainty and seek out the best evidence to support their next step in the diagnostic work-up. Students then present a full case to the class and ultimately develop the notes for the unit and their future clinical practice. This presentation will focus on the thought process underpinning the development of the unit, its basic design and operation, and the role of technology. A brief overview of the outcomes of a post unit survey will be offered. Overall, the students found the concepts and activities of the unit to be of great value in helping them understand how to find and apply new evidence to clinical practice. They felt that having the responsibility of developing the lectures and learning materials for the unit improved their learning experience.

Introduction Two commonly used labels for low back pain (LBP) are that of “mechanical” (1) or “inflammatory” (2). These labels have no universally accepted definitions. However, there are two distinct types of treatment for low back pain that seem to follow this definitional separation. That is, mechanical treatments (mobilisation, manipulation, traction and exercise) contrasted with anti-inflammatory treatments (medication and injections). The objective of this study was to obtain the opinion of five groups of experts about symptoms/signs that may identify inflammatory and mechanical LBP. Methods A convenience sample of 125 practitioners including spine surgeons, rheumatologists, musculoskeletal physicians, chiropractors and physiotherapists was asked to complete a questionnaire. Participants were asked to use a Likert (0-10) scale to indicate the strength of agreement or disagreement with respect to potential signs/symptoms identifying inflammatory or mechanical LBP. Ethics approval was obtained. Results One hundred and five practitioners responded (81% response). No signs/symptoms were found to clearly distinguish between inflammatory and mechanical LBP. Nevertheless, seven signs/ symptoms did show a higher score for either inflammatory or mechanical LBP, and a lower score for the other. Morning pain on waking, pain that wakes the person up, constant pain, and stiffness after resting (including sitting) were more likely to suggest inflammatory LBP, while intermittent pain during the day, pain when lifting and pain on repetitive bending were more likely to suggest mechanical LBP. There was however some disagreement between professions about the extent to which these signs/symptoms indicated mechanical or inflammatory LBP. Discussion There was no clear agreement either within or between professions regarding the signs and symptoms that suggest mechanical or inflammatory low back pain. There was however weak agreement on seven signs/symptoms. Further research should be aimed at testing these for their ability to predict the outcome of mechanical and anti-inflammatory treatments of LBP. References 1. Dawson WJ Jr. Minn Med 1984; 67:191-2. 2. Saal JS. Spine 1995; 20:1821-7.

Introduction Two commonly used labels for low back pain (LBP) are that of 1Cmechanical 1D (1) or 1C inflammatory 1D (2). These labels have no universally accepted definitions. However, there are two distinct types of treatment for low back pain that seem to follow this definitional separation. That is, mechanical treatments (mobilisation, manipulation, traction and exercise) contrasted with anti-inflammatory treatments (medication and injections). The objective of this study was to obtain the opinion of five groups of experts about symptoms/ signs that may identify inflammatory and mechanical LBP. Methods A convenience sample of 125 practitioners including spine surgeons, rheumatologists, musculoskeletal physicians, chiropractors and physiotherapists was asked to complete a questionnaire. Participants were asked to use a Likert (0 1310) scale to indicate the strength of agreement or disagreement with respect to potential signs/symptoms identifying inflammatory or mechanical LBP. Ethics approval was obtained. Results One hundred and five practitioners responded (81% response). No signs/symptoms were found to clearly distinguish between inflammatory and mechanical LBP. Nevertheless, seven signs/symptoms did show a higher score for either inflammatory or mechanical LBP, and a lower score for the other. Morning pain on waking, pain that wakes the person up, constant pain, and stiffness after resting (including sitting) were more likely to suggest inflammatory LBP, while intermittent pain during the day, pain when lifting and pain on repetitive bending were more likely to suggest mechanical LBP. There was however some disagreement between professions about the extent to which these signs/symptoms indicated mechanical or inflammatory LBP. Discussion There was no clear agreement either within or between professions regarding the signs and symptoms that suggest mechanical or inflammatory low back pain. There was however weak agreement on seven signs/symptoms. Further research should be aimed at testing these for their ability to predict the outcome of mechanical and anti-inflammatory treatments of LBP.

INTRODUCTION: There is no shortage of treatments for low back pain (LBP), including medication, injections, bed rest, physiotherapy, chiropractic, osteopathy, acupuncture, massage therapy, and surgery. In addition to this are a plethora of home and folk remedies. However, there is still doubt about the efficacy or effectiveness of even the most common forms of therapy1 • Also, little is known about the proportion of persons who seek care for LBP, why they sought care, the type of care sought and indeed what differentiates them from those who do not seek care at all. The objective of this study was to determine the characteristics of Australian adults who seek care for LBP, including the type of care they choose and any factors associated with making those choices. METHODS: An age, gender and State stratified random sample of2768 Australian adults was selected from the Electoral Roll. This sample were mailed a fully structured questionnaire that included a series of questions relating to care-seeking for LBP, choice of provider and types of treatment received. In addition a series of questions were asked relating to demographic characteristics, socioeconomic variables, and severity of LBP. Also asked was cigarette smoking status, anthropometric variables, perceived cause oflow back pain, emotional distress, job satisfaction, physical fitness, past five year health status, and whether the subject feared LBP could impair their . work capacity or life in the future. RESULTS: The survey response rate was 69.1 %. The sample proved to be similar to the Australian adult population. The majority of respondents with LBP in the past six months did not seek care for it (55.5%). Factors that increased care seeking were higher grades of pain and disability, fear of the impact of pain on future work and life and female sex. Factors decreasing the likelihood for seeking care were identified as the cause of pain being an accident at home and also never being married. General medical practitioners and chiropractors are the most popular providers of care. DISCUSSION: High levels of pain and disability equating with higher levels of care-seeking would not surprise, however fear as a motivator for care-seeking has implications for clinical practice. Another important issue is the type of care selected for LBP. Using the best evidence available for the management ofLBP is now seen as a responsibility for all practitioners. It would be useful to compare care-seeking with the evidence of the efficacy and effectiveness of the various therapies utilised. REFERENCES: 1. Cochrane Back Review Group. The Cochrane Library. Available at: http://www.cochrane.org/cochrane/revabstr/g05hindex.htm

INTRODUCTION: Low back pain (LBP) is a common symptom in Australian adults. In any six months period approximately 10% of Australian adults suffer some significant disability from low back pain1 • One way of assessing the impact ofLBP on a population is to estimate the economic costs associated with the disorder. This method is usually known as a "Cost-of-Illness" or an "Economic Burden" studl. The economic burden of disease is often divided into direct and indirect costs and is most often calculated using the Human Capital Method2 • According to this method the direct costs are represented by the dollar value of the interventions required for diagnosis, treatment and rehabilitation of the disease and the indirect costs by valuing the loss of productivity due to morbidity and mortality2 • 3 • We estimated the economic burden ofLBP in Australian adults. METHODS: Data sources used in this study were the 2001 Australian adult low back pain prevalence survey1 and a multiplicity of Commonwealth, State and Private Health instrumentalities. Using the Human Capital Method direct costs were estimated on the basis of market prices (charges) and the indirect costs by valuing the loss of productivity due to morbidity. The conservative Friction Cost Method for calculating indirect costs was also used as a comparison4 • A sensitivity analysis was undertaken where unit prices and volume for a range of services were varied over a feasible range (10%) to review the consequent change in overall costs. RESULTS: We estimated the direct cost oflow back pain in 2001 to be AUD$1.02 Billion. Approximately 71% of this amount is for treatment by chiropractors, general practitioners, massage therapists, physiotherapists and acupuncture. However, the direct costs are minor compared to the indirect costs of AUD$8.15 Billion giving a total cost of A UD$9 .17 Billion. The sensitivity analysis showed very little change in results. DISCUSSION: The economic burden oflow back pain in Australian adults represents a massive health problem. This burden is so great that it has compelling and urgent ramifications for health policy, planning and research. This study identifies that research should concentrate on the reduction of indirect costs. This is not to suggest excluding direct cost research, as it is likely that early, efficient and evidence-based management oflow back pain in the first instance may lessen the indirect costs that often follow. These startling results advocate urgent Government attention to LBP as a disorder. REFERENCES: 1. Walker, B.F. The prevalence of low back pain and related disability in Australian adults. Data from a population survey of3000 Australians selected at random in 2001. Paper under review. 2. Hodgson, T.A. and Meiners, M.R. Cost-of-Illness methodology: a guide to current practices and procedures, Milbank Memorial Fund Quarterly/Health and Society, 1982;60:429-462. 3. Rice,DP (1966): Estimating the Cost ofllness. Health Economics Series, Number 6. DREW, Public Health Service, Division of Medical Care Administration, Health Economics Branch, Washington, DC, 20201 USA. 4. Koopmanschap,MA; Rutten,FFH. A practical guide for calculating indirect costs of disease. Pharmaco-Economics 1996,1 0:460-466.