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Mixed-Methods Research in a Complex Multisite Veterans Affairs’ Health Services Study

Mixed-Methods Research in a Complex Multisite Veterans Affairs’ Health Services Study

The Chiro.Org Blog


SOURCE:   Evid Based Complement Alternat Med. 2013: 701280

Raheleh Khorsan, Angela B. Cohen, Anthony J. Lisi,
Monica M. Smith, Deborah Delevan, Courtney Armstrong,
and Brian S. Mittman

VA Center for Implementation Practice and Research Support,
VA Greater Los Angeles Healthcare System,
16111 Plummer Street,
Sepulveda, Los Angeles, CA 91343, USA


Maximizing the quality and benefits of newly established chiropractic services represents an important policy and practice goal for the US Department of Veterans Affairs’ healthcare system. Understanding the implementation process and characteristics of new chiropractic clinics and the determinants and consequences of these processes and characteristics is a critical first step in guiding quality improvement. This paper reports insights and lessons learned regarding the successful application of mixed methods research approaches-insights derived from a study of chiropractic clinic implementation and characteristics, Variations in the Implementation and Characteristics of Chiropractic Services in VA (VICCS). Challenges and solutions are presented in areas ranging from selection and recruitment of sites and participants to the collection and analysis of varied data sources. The VICCS study illustrates the importance of several factors in successful mixed-methods approaches, including (1) the importance of a formal, fully developed logic model to identify and link data sources, variables, and outcomes of interest to the study’s analysis plan and its data collection instruments and codebook and (2) ensuring that data collection methods, including mixed-methods, match study aims. Overall, successful application of a mixed-methods approach requires careful planning, frequent trade-offs, and complex coding and analysis.


The Full-Text Article:

Introduction

There is growing consumer interest in complementary and alternative medicine (CAM) in the USA and internationally. [1-3] Healthcare systems have responded to this demand by offering a range of CAM services in outpatient and inpatient settings. [4, 5] Patients enrolled in the US Department of Veterans Affairs (VA) healthcare delivery system often use CAM services outside of VA but have a strong interest in receiving these services within the VA system. [6-11] In response, VA began providing selected in-house CAM services in about 2001. [12] VA’s most substantial undertaking in delivering any CAM-related service has been its introduction of chiropractic services.

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Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs

Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs

The Chiro.Org Blog


SOURCE:   J Manipulative Physiol Ther. 2016 (Jun); 39 (5): 381-6

Anthony J. Lisi, DC, Cynthia A. Brandt, MD, MPH

Chiropractic Section Chief,
VA Connecticut Healthcare System,
West Haven, CT;
Assistant Clinical Professor,
Yale Center for Medical Informatics,
Yale University School of Medicine,
New Haven, CT.


OBJECTIVES:   The purpose of this study was to analyze national trends and key features of the Department of Veterans Affairs’ (VA’s) chiropractic service delivery and chiropractic provider workforce since their initial inception

METHODS:   This was a serial cross-sectional analysis of the VA administrative data sampled from the first record of chiropractic services in VA through September 30, 2015. Data were obtained from VA’s Corporate Data Warehouse and analyzed with descriptive statistics.

RESULTS:   From October 1, 2004, through September 30, 2015, the annual number of patients seen in VA chiropractic clinics increased from 4052 to 37349 (821.7%), and the annual number of chiropractic visits increased from 20072 to 159366 (693.9%). The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services. The total number of VA chiropractic clinics grew from 27 to 65 (9.4% annually), and the number of chiropractor employees grew from 13 to 86 (21.3% annually). The typical VA chiropractor employee is a 45.9-year-old man, has worked in VA for 4.5 years, and receives annual compensation of $97860. VA also purchased care from private sector chiropractors starting in 2000, growing to 159533 chiropractic visits for 19435 patients at a cost of $11155654 annually.

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National Medicare Equality Petition

National Medicare Equality Petition

The Chiro.Org Blog


SOURCE:   American Chiropractic Association (ACA)


The Time for Change is NOW

The American Chiropractic Association (ACA) has launched a major grassroots campaign to enact federal legislation that would allow doctors of chiropractic (DC) to perform to the fullest scope of their license in Medicare. This initiative would significantly improve the health and wellness of our nation’s aging population — and your support is urgently needed.

The National Medicare Equality Petition will raise awareness of how the current Medicare system shortchanges seniors who want and need the essential services provided by doctors of chiropractic (DCs) to stay healthy, pain free and mobile, and how DCs can be a part of the solution for what ails the U.S. health care system.


Petition to White House and Members of Congress

Give Seniors the Medicare Coverage They Need and Deserve: Full Access to and Reimbursement for Services Provided by Doctors of Chiropractic


Studies have shown that essential services provided by doctors of chiropractic (DCs) can help aging Americans live healthier and happier lives, yet every day our nation’s seniors are being unjustly denied full access to Medicare covered services by doctors of chiropractic that could improve their quality of life.

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Does Cervical Spine Manipulation Reduce Pain in People With Degenerative Cervical Radiculopathy?

Does Cervical Spine Manipulation Reduce Pain in People With Degenerative Cervical Radiculopathy? A Systematic Review of the Evidence, and a Meta-analysis

The Chiro.Org Blog


SOURCE:   Clinical Rehabilitation 2016 (Feb); 30 (2): 145-155

Liguo Zhu, Xu Wei, Shangquan Wang

Department of Spine,
Wangjing Hospital, Beijing,
People’s Republic of China


OBJECTIVE:   To access the effectiveness and safety of cervical spine manipulation for cervical radiculopathy.

DATA SOURCES:   PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health.

REVIEW METHODS:   Randomized controlled trials that investigated the effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy were searched. Two authors independently evaluated the quality of the trials according to the risk of bias assessment provided by the PEDro (physiotherapy evidence database) scale. RevMan V.5.2.0 software was employed for data analysis. The GRADE approach was used to evaluate the overall quality of the evidence.

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Aging Baby Boomers and the Rising Cost of Chronic Back Pain

Aging Baby Boomers and the Rising Cost of Chronic Back Pain: Secular Trend Analysis of Longitudinal Medical Expenditures Panel Survey Data for Years 2000 to 2007

The Chiro.Org Blog


SOURCE:   J Manipulative Physiol Ther. 2013 (Jan); 36 (1): 2–11

Monica Smith, DC, PhD, Matthew A. Davis, DC, MPH,
Miron Stano, PhD, James M. Whedon, DC, MS

Adjunct Faculty (Off-Site),
National University Health Sciences,
Lombard, IL, USA.


OBJECTIVES:   The purposes of this study were to analyze data from the longitudinal Medical Expenditures Panel Survey (MEPS) to evaluate the impact of an aging population on secular trends in back pain and chronicity and to provide estimates of treatment costs for patients who used only ambulatory services.

METHODS:   Using the MEPS 2-year longitudinal data for years 2000 to 2007, we analyzed data from all adult respondents. Of the total number of MEPS respondent records analyzed (N = 71,838), we identified 12,104 respondents with back pain and further categorized 3842 as chronic cases and 8262 as nonchronic cases.

RESULTS:   Secular trends from the MEPS data indicate that the prevalence of back pain has increased by 29%, whereas chronic back pain increased by 64%. The average age among all adults with back pain increased from 45.9 to 48.2 years; the average age among adults with chronic back pain increased from 48.5 to 52.2 years. Inflation-adjusted (to 2010 dollars) biennial expenditures on ambulatory services for chronic back pain increased by 129% over the same period, from $15.6 billion in 2000 to 2001 to $35.7 billion in 2006 to 2007.

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Long-term Trajectories of Back Pain:
Cohort Study With 7-year Follow-up

Long-term Trajectories of Back Pain:
Cohort Study With 7-year Follow-up

The Chiro.Org Blog


SOURCE:   BMJ Open. 2013 (Dec 11); 3 (12): e003838

Kate M Dunn, Paul Campbell, and Kelvin P Jordan

Arthritis Research UK Primary Care Centre,
Institute of Primary Care and Health Sciences,
Keele University,
Newcastle, Staffordshire, UK.


OBJECTIVE:   To describe long-term trajectories of back pain.

DESIGN:   Monthly data collection for 6 months at 7-year follow-up of participants in a prospective cohort study.

SETTING:   Primary care practices in Staffordshire, UK.

PARTICIPANTS:   228 people consulting their general practitioners with back pain, on whom information on 6-month back pain trajectories had been collected during 2001-2003, and who had valid consent and contact details in 2009-2010, were contacted. 155 participants (68% of those contacted) responded and provided sufficient data for primary analyses.

OUTCOME MEASURES:   Trajectories based on patients’ self-reports of back pain were identified using longitudinal latent class analysis. Trajectories were characterised using information on disability, psychological status and presence of other symptoms.

RESULTS:   Four clusters with different back pain trajectories at follow-up were identified:

(1)   no or occasional pain
(2)   persistent mild pain
(3)   fluctuating pain and
(4)   persistent severe pain.

Trajectory clusters differed significantly from each other in terms of disability, psychological status and other symptoms. Most participants remained in a similar trajectory as 7 years previously (weighted κ 0.54; 95% CI 0.42 to 0.65).

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Cohort Study With 7-year Follow-up

Memorial Day (2016)
In Memory of Those Who Have Fallen

Memorial Day (2016)
In Memory of Those Who Have Fallen

The Chiro.Org Blog


The Bivouac of the Dead

The muffled drum’s sad roll has beat
The soldier’s last tattoo’
No more on life’s parade shall meet
That brave and fallen few;

On Fame’s eternal camping ground
Their silent tents are spread;
But Glory guards with solemn round
The bivouac of the dead.

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In Memory of Those Who Have Fallen

Trajectories of Low Back Pain

Trajectories of Low Back Pain

The Chiro.Org Blog


SOURCE:   Best Pract Res Clin Rheumatol. 2013 (Oct); 27 (5): 601–612

Iben Axén, Charlotte Leboeuf-Yde

Unit of Intervention & Implementation Research,
Institute of Environmental Medicine,
Karolinska Institutet,
Nobels väg 13, S-171 77 Stockholm, Sweden


Low back pain is not a self-limiting problem, but rather a recurrent and sometimes persistent disorder. To understand the course over time, detailed investigation, preferably using repeated measurements over extended periods of time, is needed. New knowledge concerning short-term trajectories indicates that the low back pain ‘episode’ is short lived, at least in the primary care setting, with most patients improving. Nevertheless, in the long term, low back pain often runs a persistent course with around two-thirds of patients estimated to be in pain after 12 months. Some individuals never have low back pain, but most have it on and off or persistently. Thus, the low back pain ‘condition’ is usually a lifelong experience. However, subgroups of patients with different back pain trajectories have been identified and linked to clinical parameters. Further investigation is warranted to understand causality, treatment effect and prognostic factors and to study the possible association of trajectories with pathologies.



From the FULL TEXT Article:

Introduction

Until recently, low back pain (LBP) was believed to be a self-limiting condition, much like the common cold. The European guidelines for the management of acute LBP state that 90% of patients will recover within 6 weeks. [1]

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What Have We Learned From Ten Years of Trajectory Research in Low Back Pain?

What Have We Learned From Ten Years of Trajectory Research in Low Back Pain?

The Chiro.Org Blog


SOURCE:   BMC Musculoskelet Disord. 2016 (May 21); 17 (1): 220

Alice Kongsted, Peter Kent, Iben Axen,
Aron S. Downie, and Kate M. Dunn

The Nordic Institute of Chiropractic and Clinical Biomechanics,
Odense, Denmark.
a.kongsted@nikkb.dk


BACKGROUND:   Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals’ course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.

DISCUSSION:   LBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients.

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Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims’ Data Analysis

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims’ Data Analysis

The Chiro.Org Blog


SOURCE:   J Manip Physiol Ther. 2016 (May); 39 (4): 229–239

Eric L. Hurwitz, DC, PhD, Maria Vassilaki, MD, MPH, PhD,
Dongmei Li, PhD, Michael J. Schneider, DC, PhD,
Joel M. Stevans, DC, Reed B. Phillips, DC, PhD,
Shawn P. Phelan, DC, Eugene A. Lewis, DC, MPH,
Richard C. Armstrong, MS, DC

Office of Public Health Studies,
University of Hawai`i at M?noa,
Honolulu, HI.


OBJECTIVES:   The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina.

METHODS:   Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns.

RESULTS:   The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care.

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Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis

The Chiro.Org Blog


SOURCE:   J Manipulative Physiol Ther. 2016 (May); 39 (4): 240–251

Eric L. Hurwitz, DC, PhD, Dongmei Li, PhD, Jenni Guillen, MS,
Michael J. Schneider, DC, PhD, Joel M. Stevans, DC,
Reed B. Phillips, DC, PhD, Shawn P. Phelan, DC,
Eugene A. Lewis, DC, MPH, Richard C. Armstrong, MS, DC,
Maria Vassilaki, MD, MPH, PhD

Office of Public Health Studies,
University of Hawaii at Manoa,
Honolulu, HI.


OBJECTIVES:   The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina.

METHODS:   This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP).

RESULTS:   Care patterns with single-provider types and no referrals incurred the least average charges for both uncomplicated neck pain (UNP) and complicated neck pain (CNP). When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers.

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The Effect of Chiropractic Techniques on the Cobb Angle in Idiopathic Scoliosis Arising in Adolescence

The Effect of Chiropractic Techniques on the Cobb Angle in Idiopathic Scoliosis Arising in Adolescence

The Chiro.Org Blog


SOURCE:   J Phys Ther Sci. 2016 (Apr); 28 (4): 1106–1110

Sunghak Byun, PhD and Dongwook Han, PhD, PT

Department of Physical Therapy,
College of Health and Welfare,
Silla University, Republic of Korea.


Purpose   The purpose of this study was to examine whether chiropractic techniques would reduce the curvature of idiopathic scoliosis, which commonly occurs in elementary school children.

Subjects   The subjects of this study were 5 healthy elementary students who listened to an explanation of the study methods and purpose of the study and agreed to participate in the experiment.

Methods   The Cobb angle was measured by taking an X-ray (FCT-1, Dongmun, Goyangsi, Republic of Korea) taken from the rear, using X-ray film. The method of intervention this study used was application of chiropractic techniques. Spinal correction was carried out for 30 minutes per session, which included soft tissue massage, 3 times a week for 8 weeks.

Results   It was established that the Cobb angle was noticeably decreased after 4 weeks of the intervention. Post Hoc analysis revealed that the Cobb angle noticeably decreased after 4 weeks compared with the Cobb angle before the chiropractic techniques were applied. However, no significant difference in Cobb angle was evident after the fourth week.

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Vertical Posture and Head Stability in Patients With Chronic Neck Pain

Vertical Posture and Head Stability in Patients With Chronic Neck Pain

The Chiro.Org Blog


SOURCE:   J Rehabil Med. 2003 (Sep); 35 (5): 229–235

P. Michaelson, M. Michaelson, S. Jaric,
M .L. Latash, P. Sjölander, M. Djupsjöbacka

Southern Lapland Research Department
Vilhelmina, Sweden.


OBJECTIVE:   To evaluate postural performance and head stabilization of patients with chronic neck pain.

DESIGN:   A single-blind comparative group study.

SUBJECTS:   Patients with work-related chronic neck pain (n = 9), with chronic whiplash associated disorders (n = 9) and healthy subjects (n = 16).

METHODS:   During quiet standing in different conditions (e.g. 1 and 2 feet standing, tandem standing, and open and closed eyes) the sway areas and the ability to maintain the postures were measured. The maximal peak-to-peak displacement of the centre of pressure and the head translation were analysed during predictable and unpredictable postural perturbations.

RESULTS:   Patients with chronic neck pain, in particular those with whiplash-associated disorders, showed larger sway areas and reduced ability to successfully execute more challenging balance tasks. They also displayed larger sway areas and reduced head stability during perturbations.

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Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis

Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis

The Chiro.Org Blog


SOURCE:   J Manip Physiol Ther. 2016 (May); 39 (4): 252–262

Eric L. Hurwitz, DC, PhD, Dongmei Li, PhD,
Jenni Guillen, MS, Michael J. Schneider, DC, PhD,
Joel M. Stevans, DC, Reed B. Phillips, DC, PhD,
Shawn P. Phelan, DC, Eugene A. Lewis, DC, MPH,
Richard C. Armstrong, MS, DC,
Maria Vassilaki, MD, MPH, PhD

Office of Public Health Studies,
University of Hawai`i at M?noa,
Honolulu, HI.


OBJECTIVES:   The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by patterns of care for the treatment of low back pain in North Carolina.

METHODS:   This was an analysis of low-back-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, 9th Revision diagnostic codes for:

uncomplicated low back pain   (ULBP) and
complicated low back pain   (CLBP).

RESULTS:   Care patterns with single-provider types and no referrals incurred the least charges on average for both ULBP and CLBP. When care did not include referral providers or services, for ULBP, MD and DC care was on average $465 less than MD and PT care. For CLBP, MD and DC care averaged $965 more than MD and PT care. However, when care involved referral providers or services, MD and DC care was on average $1600 less when compared to MD and PT care for ULBP and $1885 less for CLBP. Risk-adjusted charges (available 2006-2009) for patients in the middle quintile of risk were significantly less for DC care patterns.

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Prevalence and Tracking of Back Pain
From Childhood to Adolescence

Prevalence and Tracking of Back Pain
From Childhood to Adolescence

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SOURCE:  

Per Kjaer, Niels Wedderkopp, Lars Korsholm
and Charlotte Leboeuf-Yde

Institute of Sports Science and Clinical Biomechanics,
Part of Clinical Locomotion Network,
University of Southern Denmark,
Campusvej 55, DK-5230, Odense, Denmark.


BACKGROUND:   It is generally acknowledged that back pain (BP) is a common condition already in childhood. However, the development until early adulthood is not well understood and, in particular, not the individual tracking pattern. The objectives of this paper are to show the prevalence estimates of BP, low back pain (LBP), mid back pain (MBP), neck pain (NP), and care-seeking because of BP at three different ages (9, 13 and 15 years) and how the BP reporting tracks over these age groups over three consecutive surveys.

METHODS:   A longitudinal cohort study was carried out from the years of 1997 till 2005, collecting interview data from children who were sampled to be representative of Danish schoolchildren. BP was defined overall and specifically in the three spinal regions as having reported pain within the past month. The prevalence estimates and the various patterns of BP reporting over time are presented as percentages.

RESULTS:   Of the 771 children sampled, 62%, 57%, and 58% participated in the three back surveys and 34% participated in all three. The prevalence estimates for children at the ages of 9, 13, and 15, respectively, were for BP 33%, 28%, and 48%; for LBP 4%, 22%, and 36%; for MBP 20%, 13%, and 35%; and for NP 10%, 7%, and 15%. Seeking care for BP increased from 6% and 8% at the two youngest ages to 34% at the oldest. Only 7% of the children who participated in all three surveys reported BP each time and 30% of these always reported no pain. The patterns of development differed for the three spinal regions and between genders. Status at the previous survey predicted status at the next survey, so that those who had pain before were more likely to report pain again and vice versa. This was most pronounced for care-seeking.

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From Childhood to Adolescence