Prediction of outcome in patients with low back pain--A prospective cohort study comparing clinicians' predictions with those of the Start Back Tool

Rehabilitation Management of Neck Pain-Development of a Diagnostic Framework Based on the Pain and Disability Drivers Management Model

RATIONALE

Neck pain is a major cause of disability worldwide, and current rehabilitation strategies show limited effectiveness. Subgrouping patients by their primary pain and disability drivers can help tailor treatments. At this end, the Pain and Disability Drivers Management (PDDM) was developed and has demonstrated preliminary effectiveness in the management of low back pain. Nevertheless, the PDDM model was only validated for this population. Adapting this framework to patients with neck pain would provide a more global view of the patient's experience of pain and support a genuine biopsychosocial intervention.

AIMS AND OBJECTIVES

The aim of this study was to develop and validate the content of the PDDM model for patients living with neck pain.

METHODS

Through a modified DELPHI study design, participants with clinical and research expertize in rehabilitation of neck pain were invited to participate. A questionnaire was developed using literature reviews and endorsed by a steering committee. The relevance of each element of the newly adapted model was evaluated on a 4-point Likert scale. An item reached consensus if it obtained the predefined threshold of > 78% "relevant" and "very relevant." Participants left comments on terminology and recommended items to add in early rounds. Quantitative and qualitative analyses were performed.

RESULTS

An invitation was sent to 1650 potential participants, from which 155 accessed the survey, 64 completed the first round and 55 the second round. A total of 70 elements met consensus and were distributed across six domains: "Nociceptive pain drivers", "nociplastic pain drivers," "drivers associated with neuropathic pain", "comorbidity drivers", "cognitive-emotional drivers" and "environmental or lifestyle drivers, and social determinants of health."

CONCLUSION

Through a modified DELPHI study, the PDDM model was updated and adapted to people with neck pain. Subsequent steps include clinical integration and measures of efficacy when used for assessment/treatment.

Association between chronic low back pain and regular exercise, sedentary behaviour and mental health before and during COVID-19 pandemic: insights from a large-scale cross-sectional study in Germany

Background

Nonspecific chronic low back pain (CLBP) is a complex symptom with numerous possible causes and influencing factors. Understanding how modifiable factors affect the course of CLBP is important for preventing progression. As the COVID-19 pandemic has changed the lifestyle of many people, this study paper assessed whether it also changed the influence of modifiable lifestyle factors (regular exercise and sedentary behaviour) and mental health factors (anxiety and depression) on CLBP pain intensity and disability by comparing the strength of these associations before and during the pandemic. We hypothesised that the importance of regular physical activity and good mental health for CLBP patients would increase during the pandemic.

Methods

These questions were investigated in a cross-sectional study of insurance claims data and self-reported data from various questionnaires from 3,478 participants in a German CLBP health intervention (2014–2021) by calculating pre- and intra-pandemic odds ratios (OR) and 95% confidence intervals (CI) for each variable of interest and outcome. Potential confounders were also considered. Pandemic status was treated as an effect modifier. Based on the date of enrolment, participants were classified as “pre-pandemic” or “pandemic”.

Results

Regularly exercising ≥ 4 h/week significantly reduced the odds of high disability for men (OR 0.49, 95% CI 0.31 – 0.79, p = 0.003) and women (OR 0.30, 95% CI 0.14 – 0.563, p = 0.002) and reduced the probability of severe pain in women (OR 0.37, 95% CI 0.21 – 0.65, p < 0.001). Each one-point increase in PHQ-4 score for anxiety and depression increased the OR of high pain intensity by 1.25 points (95% CI 1.18 – 1.34, p < 0.001). A clear impact of COVID-19 lockdowns was observed. In individuals who exercised ≥ 4 h/week the OR of high disability was 0.57 (95% CI 0.36 – 0.92, p = 0.021) in the pre-pandemic group compared to 0.29 (95% CI 0.12 – 0.56, p = 0.002) in the pandemic group. The probability of high disability increased from an OR of 1.42 (95% CI 1.33 – 1.52, p < 0.001) per marginal increase in the PHQ-4 scale before the pandemic, to an OR of 1.73 (95% CI 1.58 – 1.89, p < 0.001) during the pandemic.

Conclusions

The magnitude of association of the factors that influenced high pain intensity and disability increased during the pandemic. On the one hand, the protective effect of regular exercising was greater in participants surveyed during lockdown. On the other hand, a higher risk through anxiety or depression during the lockdown was identified. An additional study with objective measures of sedentary behaviour and physical activity is needed to validate these results. More in-depth investigation of lockdown-induced associations between reduced daily physical activity, increased levels of anxiety and depression, and their effects on CLPB could also be worthwhile.

Trial registration

This study used routinely collected data from a CLBP intervention that was previously evaluated and registered in the German Registry of Clinical Trials under DRKS00015463 (04/09/2018). The original ethics approval, informed consent and self-reported questionnaire have remained unchanged and are still valid.

Development and internal validation of a machine learning prediction model for low back pain non-recovery in patients with an acute episode consulting a physiotherapist in primary care

Background

While low back pain occurs in nearly everybody and is the leading cause of disability worldwide, we lack instruments to accurately predict persistence of acute low back pain. We aimed to develop and internally validate a machine learning model predicting non-recovery in acute low back pain and to compare this with current practice and ‘traditional’ prediction modeling.

Methods

Prognostic cohort-study in primary care physiotherapy. Patients (n = 247) with acute low back pain (≤ one month) consulting physiotherapists were included. Candidate predictors were assessed by questionnaire at baseline and (to capture early recovery) after one and two weeks. Primary outcome was non-recovery after three months, defined as at least mild pain (Numeric Rating Scale > 2/10). Machine learning models to predict non-recovery were developed and internally validated, and compared with two current practices in physiotherapy (STarT Back tool and physiotherapists’ expectation) and ‘traditional’ logistic regression analysis.

Results

Forty-seven percent of the participants did not recover at three months. The best performing machine learning model showed acceptable predictive performance (area under the curve: 0.66). Although this was no better than a’traditional’ logistic regression model, it outperformed current practice.

Conclusions

We developed two prognostic models containing partially different predictors, with acceptable performance for predicting (non-)recovery in patients with acute LBP, which was better than current practice. Our prognostic models have the potential of integration in a clinical decision support system to facilitate data-driven, personalized treatment of acute low back pain, but needs external validation first.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05718-7.

Limited prognostic value of pain duration in non-specific neck pain patients seeking chiropractic care

BACKGROUND

Pain chronicity is considered an important prognostic factor for outcome. Here, it was investigated whether pain duration influences outcome when only chronic patients (pain > three months) are considered. Secondary aims were to determine, in patients of any pain duration, how much variance in outcome is explained by pain duration and whether pain duration truly predicts outcomes, i.e. out-of-sample prediction in independent data.

METHODS

Secondary analysis of a cohort study of neck pain patients. Patients were assessed before start of treatment and at one week, one, three, six- and 12-months follow-up. Outcomes were Patient Global Impression of Change (PGIC) and percent change of patients' perceived pain intensity, rated on a numerical rating scale (NRS). Regression analyses (linear and logistic) and supervised machine learning were used to test the influence of pain duration on PGIC and percent NRS change at one week, one, three, six- and 12-months follow-up within sample and out-of-sample. Separate analyses were performed for the full sample (n=720) and for chronic patients (n=238) only.

RESULTS

No relationship between pain duration and outcome was found for chronic patients only. For the full sample, statistical relationships between pain duration and outcomes were observed at all tested follow-up time points. However, the amount of variance in outcome explained by pain duration was low and no out-of-sample prediction was possible.

CONCLUSIONS

Pain duration did not emerge as an important predictor of outcome in this database of 720 neck pain patients receiving chiropractic treatment.

No prognostic model for people with recent-onset low back pain has yet been demonstrated to be suitable for use in clinical practice: a systematic review

OBJECTIVE

What model development and external validation studies exist that focus on the prognosis of patients with recent-onset low back pain (LBP)? What is the performance (in terms of discrimination and calibration) of these clinical prediction models?

METHODS

Systematic searches on MEDLINE, Embase and CINAHL were conducted. Model development and/or external validation studies of patients with recent-onset LBP were selected. Models predicting outcomes of pain, disability, sick leave, work absence and self-reported recovery, with at least 12 weeks of follow-up, were included. Risk of bias was assessed using the PROBAST instrument.

RESULTS

We identified 17 prognostic models developed to predict outcomes in people with recent-onset LBP: six models were in the development phase and 11 were in the validation phase. The most assessed prediction model was the Original Örebro Musculoskeletal Pain Questionnaire. The Da Silva Clinical Prediction Model was the only model, from a study with low risk of bias, that presented acceptable discrimination, demonstrating 'good' performance in predicting recovery from pain (C-statistic 0.71, 95% CI 0.63 to 0.78) and overall acceptable agreement in calibration.

CONCLUSION

Most prediction models for prognosis of patients with recent-onset LBP did not perform well at discrimination, few studies reported calibration and their performance varied across studies. It seems premature to advocate use of the available models, at their current state of development and validation, for low back pain in primary care, considering their generally poor methods and performance.

REGISTRATION

CRD42020160988.

Translation and Adaptation of the French Version of the Risk Stratification Index, a Tool for Stratified Care in Chronic Low Back Pain: A Pilot Study

Background and Objectives: Low back pain is a worldwide health problem. An early diagnosis is required to develop personalized treatment strategies. The Risk Stratification Index (RSI) was developed to serve the purpose. The aim of this pilot study is to cross-culturally translate the RSI to a French version (RSI-F) and evaluate the test-retest reliability of RSI-F using a French active population. Materials and Methods: The RSI was translated from German to French (RSI-F) based on the guidelines of cross-cultural adaptation of self-report measures. A total of 42 French recreational athletes (age 18−63 years) with non-specific low back pain were recruited and filled in the RSI-F twice. The test-retest reliability was examined using intraclass correlation coefficient (ICC1,2) and Pearson correlation coefficient. Results: Finally, 33 questionnaires were analyzed (14 males and 19 females, age 31 ± 10 years, 9.5 ± 3.2 h/week of training). The test-retest of RSI-F CPI and DISS were excellent (CPI: ICC1,2 = 0.989, p < 0.001; r = 0.989, p < 0.001; DISS: ICC1,2 = 0.991, p < 0.001; r = 0.991, p < 0.001), as well as Korff pain intensity (ICC1,2 = 0.995, p < 0.001; r = 0.995, p < 0.001) and disability (ICC1,2 = 0.998, p < 0.001; r = 0.998, p < 0.001). Conclusion: The RSI-F is linguistically accurate and reliable for use by a French-speaking active population with non-specific low back pain. The RSI-F is considered a tool to examine the evolution of psychosocial factors and therefore the risk of chronicity and the prognostic of pain. Further evaluations, such as internal, external validity, and responsiveness should be evaluated in a larger population.

Axial Spondyloarthritis in the Chiropractic Care Setting: A Systematic Literature Review

ABSTRACT

Diagnosis of axial spondyloarthritis (axSpA), an immune-mediated inflammatory disease, is commonly associated with chronic inflammatory back pain (IBP) and often occurs years after initial onset of clinical symptoms. Recognition of IBP is important for timely referral of patients with suspected axSpA to a rheumatologist. Patients with all types of back pain are treated in chiropractic care, but the proportion of patients with undiagnosed axSpA is unknown. This systematic literature review investigated the presence of axSpA in patients treated by chiropractors and identified the chiropractor's role in axSpA diagnosis, referral, and management. A PubMed search was conducted using the following search strings: "chiropract*" AND ("sacroiliac" OR "back pain" OR "spondyloarthritis" OR "ankylosing spondylitis"); English language, since 2009; and (chiropractic OR chiropractor) AND (ankylosing spondylitis OR axial spondyloarthritis), with no date limits. Of 652 articles identified in the searches, 27 met the inclusion criteria. Although back pain was identified as a common reason for patients seeking chiropractic care, there was no mention of axSpA, ankylosing spondylitis, or the distinction between mechanical and IBP. Data from relevant articles suggested that the majority of patients seeking chiropractic care have lower back pain, whereas no articles reported axSpA in this patient population. The near absence of any identified articles on axSpA in chiropractic care may be due to underrecognition of axSpA, resulting in delayed rheumatology referral and appropriate management. Better awareness and increased use of validated screening tools could reduce diagnostic delay of axSpA in chiropractic care.

Effectiveness of stratified treatment for back pain in Danish primary care: A randomized controlled trial

Background

A randomized controlled trial (RCT) of stratified care demonstrated superior clinical outcomes and cost‐effectiveness for low back pain (LBP) patients in UK primary care. This is the first study in Europe, outside of the original UK study, to investigate the clinical efficacy and cost‐effectiveness of stratified care compared with current practice for patients with non‐specific LBP.

Methods

The study was a two‐armed RCT. Danish primary care patients with LBP were randomized to stratified care (n = 169) or current practice (n = 164). Primary outcomes at 3‐ and 12‐months' follow‐up were Roland Morris Disability Questionnaire (RDMQ), patient‐reported global change and time off work. Secondary outcomes included pain intensity, patient satisfaction, healthcare resource utilization and quality‐adjusted life years.

Results

Intention‐to‐treat analyses found no between‐group difference in RMDQ scores at 3 months (0.5, 95% CI −1.8 to 0.9) or 12 months (0.4, −2.1 to 1.3). No overall differences were found between the arms at 3 and 12 months with respect to time off work or secondary outcomes. Stratified care intervention resulted in significantly fewer treatment sessions (3.5 [SD 3.1] vs. 4.5 [3.5]) and significantly lower total healthcare costs (€) (13.4 [529] vs. 228 [830], p = .002). There was no difference in cost‐effectiveness (0.09, 0.05 to 0.13 vs. 0.10, 0.07–0.14, p = .70).

Conclusions

There was no significant difference in clinical outcomes between patients with non‐specific LBP receiving stratified care and those receiving current practice. However, stratified care may reduce total healthcare costs if implemented in Danish primary care.

Significance

Stratified care for low back pain based on risk profile is recommended by recent evidence based clinical guidelines. This study is the first broad replication of the STarT Back Trial in Europe. Therefore, the study adds to the body of knowledge evaluating the effectiveness of stratified care for low back pain in primary care, and provides insight into the effects of stratification on clinical practice.

Prognostic ability of STarT Back Screening Tool combined with work-related factors in patients with low back pain in primary care: a prospective study

OBJECTIVE

Primary care screening tools for patients with low back pain may improve outcome by identifying modifiable obstacles for recovery. The STarT Back Screening Tool (SBST) consists of nine biological and psychological items, with less focus on work-related factors. We aimed at testing the prognostic ability of SBST and the effect of adding items for future and present work ability.

METHODS

Prospective observational study in patients (n=158) attending primary care physical therapy for low back pain. The prognostic ability of SBST and the added prognostic value of two work items; expectation for future work ability and current work ability, were calculated for disability, pain and quality of life outcome at 3 months follow-up. The medium and high-risk group in the SBST were collapsed in the analyses due to few patients in the high-risk group. The prognostic ability was assessed using the explained variance (R²) of the outcomes from univariable and multivariable linear regression and beta values with 95% CIs were used to assess the prognostic value of individual items.

RESULTS

The SBST classified 107 (67.7%) patients as low risk and 51 (32.3%) patients as medium/high risk. SBST provided prognostic ability for disability (R²=0.35), pain (R²=0.25) and quality of life (R²=0.28). Expectation for return to work predicted outcome in univariable analyses but provided limited additional prognostic ability when added to the SBST. Present work ability provided additional prognostic ability for disability (β=-2.5; 95% CI=-3.6 to -1.4), pain (β=-0.2; 95% CI=-0.5 to -0.002) and quality of life (β=0.02; 95% CI=0.001 to 0.04) in the multivariable analyses. The explained variance (R²) when work ability was added to the SBST was 0.60, 0.49 and 0.47 for disability, pain and quality of life, respectively.

CONCLUSIONS

Adding one work ability item to the SBST gives additional prognostic information across core outcomes. Clinical trial number: NCT03626389.

Derivation of a Risk Assessment Tool for Prediction of Long-Term Pain Intensity Reduction After Physical Therapy

Rationale

Risk assessment tools can improve clinical decision-making for individuals with musculoskeletal pain, but do not currently exist for predicting reduction of pain intensity as an outcome from physical therapy.

Aims and Objective

The objective of this study was to develop a tool that predicts failure to achieve a 50% pain intensity reduction by 1) determining the appropriate statistical model to inform the tool and 2) select the model that considers the tradeoff between clinical feasibility and statistical accuracy.

Methods

This was a retrospective, secondary data analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort. Two hundred and seventy-nine individuals seeking physical therapy for neck, shoulder, back, or knee pain who completed 12-month follow-up were included. Two modeling approaches were taken: a longitudinal model included demographics, presence of previous episodes of pain, and regions of pain in addition to baseline and change in OSPRO Yellow Flag scores to 12 months; two comparison models included the same predictors but assessed only baseline and early change (4 weeks) scores. The primary outcome was failure to achieve a 50% reduction in pain intensity score at 12 months. We compared the area under the curve (AUC) to assess the performance of each candidate model and to determine which to inform the Personalized Pain Prediction (P3) risk assessment tool.

Results

The baseline only and early change models demonstrated lower accuracy (AUC=0.68 and 0.71, respectively) than the longitudinal model (0.79) but were within an acceptable predictive range. Therefore, both baseline and early change models were used to inform the P3 risk assessment tool.

Conclusion

The P3 tool provides physical therapists with a data-driven approach to identify patients who may be at risk for not achieving improvements in pain intensity following physical therapy.

Exploring pain phenotypes in workers with chronic low back pain: Application of IMMPACT recommendations

Background: Chronic low back pain (CLBP) is a major cause of disability globally. Stratified care has been proposed as a means to improve prognosis and treatment but is generally based on limited aspects of pain, including biopsychosocial drivers.

Aims: Following Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations, the present study explored pain phenotypes with a sample of workers with CLBP, a population for which no pain phenotypes have been derived to date.

Methods: A cross-sectional design was used with a sample of 154 workers with CLBP attending a rehabilitation clinic, recruited in person and from social media. Latent class analysis was used to identify subgroups of patients with different pain profiles based on ten pain indicators (pain variability, pain intensity, pain quality, somatization, sleep quality, depression, fatigue, pain catastrophizing, neuropathic pain, and central sensitization).

Results: The majority of the sample (85%) were recruited through social media. Both the two-class and three-class solutions were found to be satisfactory in distinguishing phenotypes of workers with CLBP. Three variables proved particularly important in distinguishing between the pain phenotypes—pain quality, fatigue, and central sensitization—with higher scores on these indicators associated with pain phenotypes with higher pain burden. Increased chronic pain self-efficacy, work-related support, and perceived work abilities were protective risk factors for being in a higher pain burden class.

Conclusions: The present study is the first to explore IMMPACT recommendations for pain phenotyping with workers with CLBP. Future prospective research will be needed to validate the proposed pain phenotypes.

A descriptive analysis of clinical application of patient-reported outcome measures and screening tools for low back pain patients in US chiropractic teaching institutions

OBJECTIVE

To describe the clinical use of patient-reported outcome measures (PROMs) and screening tools (STs) for low back pain (LBP) in clinics of chiropractic teaching institutions in the United States.

METHODS

A descriptive analysis was completed with data collection achieved between June 2018 and March 2019. PROMs/STs were classified as disability/functional measures, pain measures, psychosocial measures, and other measures. Frequencies of use of PROM/ST instruments were calculated.

RESULTS

Representatives from 18 of 19 chiropractic institutions (94.75%) provided a description of PROM/ST use for LBP in their teaching clinics. Seventeen institutions (94.4%) reported the routine clinical use of PROMs/STs for LBP. Disability/functional measures were the most common type of instruments used, followed by pain measures, psychosocial measures, and others. The 4 most common individual PROMs/STs reported were (1) Oswestry Disability Index, (2) a variation of a pain rating scale, (3) Keele STarT Back Tool, and (4) Patient Specific Functional Scale. Six out of 18 (33%) institutions reported the use of a PROM/ST specifically designed to focus on psychosocial influences.

CONCLUSION

Most chiropractic institution teaching clinics in the United States reported the clinical use of PROMs/STs for patients presenting with LBP. This mirrors trends in chiropractic literature of increasing use of PROMs/STs. A minority of institutions described the clinical use of a PROM/ST specifically designed to detect psychosocial influences.

The Danish Chiropractic Low Back Pain Cohort (ChiCo): Description and Summary of an Available Data Source for Research Collaborations

BACKGROUND

Back pain is among the most frequent reasons for care seeking globally. Observational clinical cohorts are useful for understanding why people seek care, the content of that care, and factors related to prognosis. This paper describes the Danish Chiropractic low back pain Cohort (ChiCo) and summarizes the primary characteristics of the population to inform the scientific community of the availability of these data as a resource for collaborative research projects.

METHODS

Adults seeking chiropractic care for a new episode of non-specific back pain were enrolled at the initial visit and followed up after 2, 13, and 52 weeks, with a subpopulation having weekly follow-ups for 1 year. Patient-reported and clinical-reported data were collected in an electronic database using the REDCap software (REDCap Consortium, projectredcap.org). Variables were chosen to measure pre-defined research domains and questions and to capture information across health constructs deemed relevant for additional research. Non-responders at 13 and 52 weeks were contacted by phone to maximize follow-up data and explore differences on core outcomes between responders and non-responders.

RESULTS

A total of 2848 patients (mean age 45 years, 59% men) were included from 10 clinics with 71%, 68% and 64% responding to follow-ups at 2, 13 and 52 weeks, respectively. Most participants (82%) were employed, nearly half reported current LBP for 1-7 days, and 83% had experienced LBP episodes previously. We did not identify indications of serious attrition bias.

CONCLUSION

We have described the aims and procedures for establishing the ChiCo cohort, characteristics of the cohort, and available information about attrition bias. These data have the potential to be linked, at an individual participant level, to the extensive Danish population-based registries that measure diverse health and social characteristics.

Artificial intelligence to improve back pain outcomes and lessons learnt from clinical classification approaches: three systematic reviews

Artificial intelligence and machine learning (AI/ML) could enhance the ability to detect patterns of clinical characteristics in low-back pain (LBP) and guide treatment. We conducted three systematic reviews to address the following aims: (a) review the status of AI/ML research in LBP, (b) compare its status to that of two established LBP classification systems (STarT Back, McKenzie). AI/ML in LBP is in its infancy: 45 of 48 studies assessed sample sizes <1000 people, 19 of 48 studies used ≤5 parameters in models, 13 of 48 studies applied multiple models and attained high accuracy, 25 of 48 studies assessed the binary classification of LBP versus no-LBP only. Beyond the 48 studies using AI/ML for LBP classification, no studies examined use of AI/ML in prognosis prediction of specific sub-groups, and AI/ML techniques are yet to be implemented in guiding LBP treatment. In contrast, the STarT Back tool has been assessed for internal consistency, test-retest reliability, validity, pain and disability prognosis, and influence on pain and disability treatment outcomes. McKenzie has been assessed for inter- and intra-tester reliability, prognosis, and impact on pain and disability outcomes relative to other treatments. For AI/ML methods to contribute to the refinement of LBP (sub-)classification and guide treatment allocation, large data sets containing known and exploratory clinical features should be examined. There is also a need to establish reliability, validity, and prognostic capacity of AI/ML techniques in LBP as well as its ability to inform treatment allocation for improved patient outcomes and/or reduced healthcare costs.

Personalized Treatment Suggestions: The Validity and Applicability of the Risk-Prevention-Index Social in Low Back Pain Exercise Treatments

Background: The back pain screening tool Risk-Prevention-Index Social (RPI-S) identifies the individual psychosocial risk for low back pain chronification and supports the allocation of patients at risk in additional multidisciplinary treatments. The study objectives were to evaluate (1) the prognostic validity of the RPI-S for a 6-month time frame and (2) the clinical benefit of the RPI-S. Methods: In a multicenter single-blind 3-armed randomized controlled trial, n = 660 persons (age 18–65 years) were randomly assigned to a twelve-week uni- or multidisciplinary exercise intervention or control group. Psychosocial risk was assessed by the RPI-S domain social environment (RPI-S_SE) and the outcome pain by the Chronic Pain Grade Questionnaire (baseline M1, 12-weeks M4, 24-weeks M5). Prognostic validity was quantified by the root mean squared error (RMSE) within the control group. The clinical benefit of RPI-S_SE was calculated by repeated measures ANOVA in intervention groups. Results: A subsample of n = 274 participants (mean = 38.0 years, SD 13.1) was analyzed, of which 30% were classified at risk in their psychosocial profile. The half-year prognostic validity was good (RMSE for disability of 9.04 at M4 and of 9.73 at M5; RMSE for pain intensity of 12.45 at M4 and of 14.49 at M5). People at risk showed significantly stronger reduction in pain disability and intensity at M4/M5, if participating in a multidisciplinary exercise treatment. Subjects at no risk showed a smaller reduction in pain disability in both interventions and no group differences for pain intensity. Regarding disability due to pain, around 41% of the sample would gain an unfitted treatment without the back pain screening. Conclusion: The RPI-S_SE prognostic validity demonstrated good applicability and a clinical benefit confirmed by a clear advantage of an individualized treatment possibility.

Use and perceived added value of patient-reported measurement instruments by physiotherapists treating acute low back pain: a survey study among Dutch physiotherapists

BACKGROUND

This study aims to explore (i) physiotherapists' current use in daily practice of patient-reported measurement instruments (screening tools and questionnaires) for patients with acute low back pain (LBP), (ii) the underlying reasons for using these instruments, (iii) their perceived influence on clinical decision-making, and (iv) the association with physiotherapist characteristics (gender, physiotherapy experience, LBP experience, overall e-health affinity).

METHODS

Survey study among Dutch physiotherapists in a primary care setting. A sample of 650 physiotherapists recruited from LBP-related and regional primary care networks received the survey between November 2018 and January 2019, of which 85 (13%) completed it.

RESULTS

Nearly all responding physiotherapists (98%) reported using screening tools or other measurement instruments in cases of acute LBP; the Quebec Back Pain Disability Scale (64%) and the STarT Back Screening Tool (61%) are used most frequently. These instruments are primarily used to evaluate treatment effect (53%) or assess symptoms (51%); only 35% of the respondents mentioned a prognostic purpose. Almost three-quarters (72%) reported that the instrument only minimally impacted their clinical decision-making in cases of acute LBP.

CONCLUSIONS

Our survey indicates that physiotherapists frequently use patient-reported measurement instruments in cases of acute LBP, but mostly for non-prognostic reasons. Moreover, physiotherapists seem to feel that current instruments have limited added value for clinical decision-making. Possibly, a new measurement instrument (e.g., screening tool) needs to be developed that does fit the physiotherapist's needs and preferences. Our findings also suggest that physiotherapist may need to be more critical about which measurement instrument they use and for which purpose.

Multidimensional screening for predicting pain problems in adults: a systematic review of screening tools and validation studies

Screening tools allowing to predict poor pain outcomes are widely used. Often these screening tools contain psychosocial risk factors. This review (1) identifies multidimensional screening tools that include psychosocial risk factors for the development or maintenance of pain, pain-related distress, and pain-related disability across pain problems in adults, (2) evaluates the quality of the validation studies using Prediction model Risk Of Bias ASsessment Tool (PROBAST), and (3) synthesizes methodological concerns. We identified 32 articles, across 42 study samples, validating 7 screening tools. All tools were developed in the context of musculoskeletal pain, most often back pain, and aimed to predict the maintenance of pain or pain-related disability, not pain-related distress. Although more recent studies design, conduct, analyze, and report according to best practices in prognosis research, risk of bias was most often moderate. Common methodological concerns were identified, related to participant selection (eg, mixed populations), predictors (eg, predictors were administered differently to predictors in the development study), outcomes (eg, overlap between predictors and outcomes), sample size and participant flow (eg, unknown or inappropriate handling of missing data), and analysis (eg, wide variety of performance measures). Recommendations for future research are provided.

Comparison between the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Screening Questionnaire: Which tool for what purpose? A semi-systematic review

BACKGROUND

Prevention of chronicization of low back pain requires accurate detection of at-risk patients. Questionnaires have been validated, including the STarT Back Screening Tool (SBST) and the Örebro Musculoskeletal Pain Screening Questionnaire (OMPSQ). This review aims to compare these questionnaires in terms of predictive value and in terms of aims, to guide the choice in clinical practice.

METHODS

This study is a semi-systematic literature review. Studies evaluating at least one of the questionnaires and written between 1997 and October 10th 2017 were selected from Pubmed database. Inclusion criteria were pain duration<3months, outcomes including pain, function and/or global recovery. For work outcomes, inclusion criteria were extended to chronic patients. Studies had to provide information on sensitivity, specificity and area under the ROC Curve (AUC).

RESULTS

Twenty-eight studies met our inclusion criteria (7 SBST, 21 original OMPSQ, 3 short OMPSQ). The OMPSQ best predicted a Pain NRS≥3 at 3 months (AUC=0.64 (0.50-0.78)) and at 6 months (AUC between 0.70 (no confidence interval provided) and 0.84 (0.71-0.97)). The SBST and the OMPSQ are comparable to predict an Oswestry Disability Index≥30% at 6 months. A single study showed no difference between the SBST and the OMPSQ to predict absenteeism≥30 days at 6 months. The two questionnaires cannot be compared for "global recovery" outcomes.

CONCLUSION

The OMPSQ seems better than the SBST for predicting "pain" and "work" outcomes, the SBST may be better for "function" outcomes. These results should be taken with caution because of the high heterogeneity between studies. It should be noted that the OMPSQ was elaborated with the aim of creating a prognostic tool while the SBST was devised as a treatment-allocating tool and is easier to use in clinical practice. This should guide the choice of using one questionnaire rather than the other.

Prognostic ability of the German version of the STarT Back tool: analysis of 12-month follow-up data from a randomized controlled trial

BACKGROUND

Stratified care is an up-to-date treatment approach suggested for patients with back pain in several guidelines. A comprehensively studied stratification instrument is the STarT Back Tool (SBT). It was developed to stratify patients with back pain into three subgroups, according to their risk of persistent disabling symptoms. The primary aim was to analyse the disability differences in patients with back pain 12 months after inclusion according to the subgroups determined at baseline using the German version of the SBT (STarT-G). Moreover, the potential to improve prognosis for disability by adding further predictor variables, an analysis for differences in pain intensity according to the STarT-Classification, and discriminative ability were investigated.

METHODS

Data from the control group of a randomized controlled trial were analysed. Trial participants were members of a private medical insurance with a minimum age of 18 and indicated as having persistent back pain. Measurements were made for the risk of back pain chronification using the STarT-G, disability (as primary outcome) and back pain intensity with the Chronic Pain Grade Scale (CPGS), health-related quality of life with the SF-12, psychological distress with the Patient Health Questionnaire-4 (PHQ-4) and physical activity. Analysis of variance (ANOVA), multiple linear regression, and area under the curve (AUC) analysis were conducted.

RESULTS

The mean age of the 294 participants was 53.5 (SD 8.7) years, and 38% were female. The ANOVA for disability and pain showed significant differences (p < 0.01) among the risk groups at 12 months. Post hoc Tukey tests revealed significant differences among all three risk groups for every comparison for both outcomes. AUC for STarT-G's ability to discriminate reference standard 'cases' for chronic pain status at 12 months was 0.79. A prognostic model including the STarT-Classification, the variables global health, and disability at baseline explained 45% of the variance in disability at 12 months.

CONCLUSIONS

Disability differences in patients with back pain after a period of 12 months are in accordance with the subgroups determined using the STarT-G at baseline. Results should be confirmed in a study developed with the primary aim to investigate those differences.

Development and validation of a pain monitoring app for patients with musculoskeletal conditions (The Keele pain recorder feasibility study)

Background

Assessing daily change in pain and related symptoms help in diagnosis, prognosis, and monitoring response to treatment. However, such changes are infrequently assessed, and usually reviewed weeks or months after the start of treatment. We therefore developed a smartphone application (Keele Pain Recorder) to record information on the severity and impact of pain on daily life. Specifically, the study goal was to assess face, content and construct validity of data collection using the Pain Recorder in primary care patients receiving new analgesic prescriptions for musculoskeletal pain, as well as to assess its acceptability and clinical utility.

Methods

The app was developed with Keele’s Research User Group (RUG), a clinical advisory group (CAG) and software developer for use on Android devices. The app recorded pain levels, interference, sleep disturbance, analgesic use, mood and side effects. In a feasibility study, patients aged > 18 attending their general practitioner (GP) with a painful musculoskeletal condition were recruited to use the app twice per day for 28 days. Face and construct validity were assessed through baseline and post-study questionnaires (Spearman’s rank correlation coefficient). Usability and acceptability were determined through post-study questionnaires, and patient, GP, RUG and CAG interviews.

Results

An app was developed which was liked by both patients and GPs. It was felt that it offered the opportunity for GPs to discuss pain control with their patients in a new way. All participants found the app easy to use (it did not interfere with their activities) and results easy to interpret. Strong associations existed between the first 3 days (Spearman r = 0.79) and last 3 days (r = 0.60) of pain levels and intensity scores on the app with the validated questionnaires.

Conclusions

Collaborating with patient representatives and clinical stakeholders, we developed an app which can be used to help clinicians and patients monitor painful musculoskeletal conditions in response to analgesic prescribing. Recordings were accurate and valid, especially, for pain intensity ratings, and it was easy to use. Future work needs to examine how pain trajectories can help manage changes in a patient’s condition, ultimately assisting in self-management.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0741-z) contains supplementary material, which is available to authorized users.

Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey

Background

The Keele STarT Back Screening Tool (SBT), a 9-item questionnaire, screens for pain, physical functioning, fear-avoidance beliefs, catastrophizing, anxious thoughts, low mood, and bothersomeness in persons with back pain. SBT scores designate low, medium, or high risk for developing persistent disabling back pain. The primary study aim was to report the prevalence of SBT-calculated risk for back pain disability in US patients seeking chiropractic care.

Methods

The SBT questionnaire was administered to patients ≥18 years in 3 Chiropractic College outpatient teaching clinics in Iowa and Illinois (May 2017). Descriptive statistics were used to analyze respondent characteristics and prevalence of SBT-calculated risk subgroups. Binary logistic regression analysis was used to examine the relationship between respondent characteristics and SBT scores (including psychological subscores).

Results

Of 550 respondents, 496 completed the SBT; 392 (79%) scored low-risk, 81 (16%) medium-risk, and 23 (5%) high-risk. Mean (SD) age was 44.8 (15.9), 56.9% were female, 88.2% white, 62.6% employed, mean current pain was 2.9 (2.1) out of 10, and 62% reported symptom duration > 3 months. Eighteen percent of respondents reported anxious thoughts, 32% low mood, 41% ≥ 1 and 21% ≥ 3 SBT psychological risk factors. Respondents reporting higher average pain (OR = 1.8 [1.4, 2.3]) and pain severity (OR = 1.3 [1.0 to 1.6]) were more likely to score with medium or high risk. Respondents reporting mid back versus low back pain (OR = 0.2 [0.1, 0.7]), and those employed less than full-time versus full-time (0.2 [01, 0.5]) were less likely to score with medium or high risk. Respondents reporting higher average pain were more likely to report ≥1 psychological factor (OR = 1.8 [1.5, 2.0]). Respondents employed part-time were less likely to report ≥1 psychological factor than those employed full-time (OR = 0.4 [0.2, 0.7]).

Conclusion

The sample surveyed was less likely to score with medium or high risk for back pain disability than previous samples studied, perhaps due to differences in study design and sample characteristics. Rates of low mood and anxious thoughts indicate a need for future research to explore psychological factors among persons seeking chiropractic care.

General group exercise in low back pain management in a military population, a comparison with specific spine group exercise: a service evaluation

Objective

To investigate whether general group exercise (GGE) offers the same outcomes compared with a specific spinal group exercise (SSGE) for chronic low back pain (CLBP) in a military population.

Design

Retrospective service evaluation using routine service activity data.

Setting

A UK military rehabilitation centre.

Participants

A total of 106 patients with CLBP.

Interventions

Three-week intensive (5 days per week, 15-day intervention) rehabilitation course for patients with CLBP. Six SSGE groups (n=64); CLBP only. Six GGE groups (n=42); CLBP patients grouped with chronic lower limb (LL) injuries.

Outcome measures

Oswestry Disability Index (ODI), Numerical Pain-Rating Scores and the Modified Multi-Stage Fitness Test (Mod-MSFT). Long-term effects were measured by Medical Employment Standard (MES) status and physiotherapy follow-up at 3 and 12 months.

Results

A between-group analysis showed no significant difference in GGE compared with SSGE. Mean changes (SD) in pain were −2.71±2.35 and −1.20±1.99 (p=0.018), ODI were −3.6±5.7 and −4±8.5 respectively (p=0.649) and Mod-MSFT 28.4±30.8 and 29.7±31.7 respectively (p=0.792). At 3 months, a greater proportion of the GGE were having ongoing physiotherapy; GGE=50%, SSGE=30.2%, (p=0.016) although some differences were evident across MES with 32.5 % of GGE compared with 20.6 % of SSGE being medically fit with no restrictions. At 12 months, groups were largely comparable for follow-up physiotherapy and MES; 22.5% of GGE and 20.6% of SSGE continued to have physiotherapy input; 47.5% of GGE and 50.8% of SSGE were medically fit with no restrictions.

Conclusion

Patients with CLBP who completed a 3-week rehabilitation programme had comparable outcomes when grouped with patients with LL, although only improvements in pain in the GGE group achieved a meaningful change. Further evaluation of potential costs and savings to service costs is now required.

[Psychosocial risk factors for chronic back pain in the general population and in competitive sports : From theory to clinical screening-a review from the MiSpEx network]

BACKGROUND

Lumbar back pain and the high risk of chronic complaints is not only an important health concern in the general population but also in high performance athletes. In contrast to non-athletes, there is a lack of research into psychosocial risk factors in athletes. Moreover, the development of psychosocial screening questionnaires that would be qualified to detect athletes with a high risk of chronicity is in the early stages. The purpose of this review is to give an overview of research into psychosocial risk factors in both populations and to evaluate the performance of screening instruments in non-athletes.

METHODS

The databases MEDLINE, PubMed, and PsycINFO were searched from March to June 2016 using the keywords "psychosocial screening", "low back pain", "sciatica" and "prognosis", "athletes". We included prospective studies conducted in patients with low back pain with and without radiation to the legs, aged ≥18 years and a follow-up of at least 3 months.

RESULTS

We identified 16 eligible studies, all of them conducted in samples of non-athletes. Among the most frequently published screening questionnaires, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) demonstrated a sufficient early prediction of return to work and the STarT Back Screening Tool (SBT) revealed acceptable performance predicting pain-related impairment. The prediction of future pain was sufficient with the Risk Analysis of Back Pain Chronification (RISC-BP) and the Heidelberg Short Questionnaire (HKF).

CONCLUSION

Psychosocial risk factors of chronic back pain, such as chronic stress, depressive mood, and maladaptive pain processing are becoming increasingly more recognized in competitive sports. Screening instruments that have been shown to be predictive in the general population are currently being tested for suitability in the German MiSpEx research consortium.

Physical Therapists' Ability to Identify Psychological Factors and Their Self-Reported Competence to Manage Chronic Low Back Pain

BACKGROUND

In the management of chronic low back pain (LBP), identifying and managing more patients who are at high risk and who have psychological barriers to recovery is important yet difficult.

OBJECTIVE

The objective of this study was to test physical therapists' ability to allocate patients into risk stratification groups, test correlations between therapists' assessments of psychological factors and patient questionnaires, and explore relationships between psychological factors and therapists' self-reported competence to manage patients with chronic LBP.

DESIGN

This was a pragmatic, observational study.

METHODS

Patients completed the STarT Back Tool (SBT, for risk stratification), the Four-Dimensional Symptom Questionnaire (distress, depression, anxiety), and the Tampa Scale of Kinesiophobia (kinesiophobia) prior to the intake session. After this session, physical therapists estimated patient prognostic risk using the 3 SBT categories and rated patient psychological factors using a 0-to-10 scale. Finally, therapists reported their self-reported competence to manage the patient. Intraclass and Spearman rank correlations tested correlations between therapists' intuitive assessments and patient questionnaires. A linear-mixed model explored relationships between psychological factors and therapists' self-reported competence.

RESULTS

Forty-nine patients were managed by 20 therapists. Therapists accurately estimated SBT risk allocation in only 41% of patients. Correlations between therapist perceptions and patient questionnaires were moderate for distress (r = 0.602) and fair for depression (r = 0.304) and anxiety (r = 0.327). There was no correlation for kinesiophobia (r = -0.007). Patient distress was identified as a negative predictor of therapists' self-reported competence.

LIMITATIONS

This was a cross-sectional study, conducted in only 1 center.

CONCLUSIONS

Physical therapists were not very accurate at allocating patients into risk stratification groups or identifying psychological factors. Therapists' self-reported competence in managing patients was lowest when patients reported higher distress.

The use of STarT BACK Screening Tool in emergency departments for patients with acute low back pain: a prospective inception cohort study

PURPOSE

(1) To analyse the clinical utility of the STarT Back Screening Tool (SBST) in emergency departments by describing changes in classification over time and; (2) to identify what would be the best time to use the SBST to predict long-term clinical outcomes in patients with acute nonspecific low back pain (LBP) seeking emergency care.

METHODS

A 6 months prospective inception cohort study was conducted. 200 participants with LBP seeking emergency medical treatment were included. Pain intensity, disability and SBST were collected at baseline, 6 and 26 weeks. Categories of improvement, clinical worsening, and stability were created to calculate the changes in the SBST subgroups. Linear regression models were built to analyse the predictive ability of SBST when applied at baseline, 6 weeks as well as changes in the subgroup from baseline to 6 weeks. These models were adjusted for potential confounders.

RESULTS

45% of patients were classified as high risk of chronicity at baseline. Most patients classified as medium (86.7%) or high (52.4%) risk changed their risk subgroup after 6 weeks and most of them improved. The SBST improved the prediction for all outcomes when applied at 6 weeks (R² = 22.1% for disability and R² = 15.6% for pain intensity), but not at baseline.

CONCLUSION

Most of patients seeking care in emergency departments with a new episode of acute LBP improved after 6 weeks. The use of SBST to guide initial treatment and to predict clinical outcomes are most indicated when the instrument is applied after 6 weeks after presentation to emergency care. These slides can be retrieved under Electronic Supplementary material.

The predictive ability of the STarT Back Tool was limited in people with chronic low back pain: a prospective cohort study

QUESTIONS

In people with chronic non-specific low back pain (LBP), what is the predictive and discriminative validity of the STarT Back Tool (SBT) for pain intensity, self-reported LBP-related disability, and global self-perceived change at 1-year follow-up? What is the profile of the SBT risk subgroups with respect to demographic variables, pain intensity, self-reported LBP-related disability, and psychological measures?

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 290 adults with dominant axial LBP of≥3months' duration recruited from the general community, and private physiotherapy, psychology, and pain-management clinics in Western Australia.

OUTCOME MEASURES

The 1-year follow-up measures were pain intensity, LBP-related disability, and global self-perceived change.

RESULTS

Outcomes were collected on 264 participants. The SBT categorised 82 participants (28%) as low risk, 116 (40%) as medium risk, and 92 (32%) as high risk. The risk subgroups differed significantly (p<0.05) on baseline pain, disability, and psychological scores. The SBT's predictive ability was strongest for disability: RR was 2.30 (95% CI 1.28 to 4.10) in the medium-risk group and 2.86 (95% CI 1.60 to 5.11) in the high-risk group. The SBT's predictive ability was weaker for pain: RR was 1.25 (95% CI 1.04 to 1.51) in the medium-risk group and 1.26 (95% CI 1.03 to 1.52) in the high-risk group. For the SBT total score, the AUC was 0.71 (95% CI 0.64 to 0.77) for disability and 0.63 (95% CI 0.55 to 0.71) for pain.

CONCLUSION

This was the first large study to investigate the SBT in a population exclusively with chronic LBP. The SBT provided an acceptable indication of 1-year disability, had poor predictive and discriminative ability for future pain, and was unable to predict or discriminate global perceived change. In this cohort with chronic non-specific LBP, the SBT's predictive and discriminative abilities were restricted to disability at 1year. [Kendell M, Beales D, O'Sullivan P, Rabey M, Hill J, Smith A (2018) The predictive ability of the STarT Back Tool was limited in people with chronic low back pain: a prospective cohort study. Journal of Physiotherapy 64: 107-113].

Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice

Background

Low back pain (LBP) is a common cause of contact with the primary healthcare sector. In some patients, symptoms quickly resolve, but others develop long-lasting pain and disability. To improve the care pathway for patients with LBP, the STarT Back Tool (STarT) questionnaire has been developed. It helps initial decision-making by subgrouping patients on the basis of their prognosis and helps to target treatment according to prognosis. An assumption behind the use of STarT is the ability to predict functional improvement. This assumption has never been tested in a population that consists exclusively of patients enrolled when consulting a Danish general practitioner for LBP. The aim of this study was to investigate STarT’s ability to predict a 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score.

Methods

This was an ancillary analysis using data from a Danish guideline implementation study (registered at ClinicalTrials.gov NCT01699256). An inclusion criterion was age 18 to 65 years of age. Exclusion criteria were pregnancy, fractures, and signs of underlying pathology. Patient-reported STarT score and the Roland Morris Disability Questionnaire were administered at baseline and again after 4, 8, and 52 weeks.

Results

Between January 2013 and July 2014, 475 patients from the original trial participated with questionnaires. From this subpopulation, 441 (92.8%) patients provided information regarding STarT. Baseline and eight-week RMDQ data were available for 304 (64.0%) patients. After 8 weeks, 61 (65.6%) in the low-risk group, 67 (54.9%) in the medium-risk group, and 33 (37.1%) in the high-risk group had achieved a 30% improvement in the RMDQ score. After 8 weeks, high-risk patients were at 61% (95% CI: 20–125%, P < 0.001) higher risk of not achieving a 30% improvement in the RMDQ score compared with patients in either the low-risk group or the medium-risk group.

Conclusion

STarT was predictive for functional improvement in patients from general practice with LBP.

Trial registration

ClinicalTrials.gov NCT01699256, Nov 29, 2016 (registered retrospectively).

How can latent trajectories of back pain be translated into defined subgroups?

Background

Similar types of trajectory patterns have been identified by Latent Class Analyses (LCA) across multiple low back pain (LBP) cohorts, but these patterns are impractical to apply to new cohorts or individual patients. It would be useful to be able to identify trajectory subgroups from descriptive definitions, as a way to apply the same definitions of mutually exclusive subgroups across populations. In this study, we investigated if the course trajectories of two LBP cohorts fitted with previously suggested trajectory subgroup definitions, how distinctly different these subgroups were, and if the subgroup definitions matched with LCA-derived patterns.

Methods

Weekly measures of LBP intensity and frequency during 1 year were available from two clinical cohorts. We applied definitions of 16 possible trajectory subgroups to these observations and calculated the prevalence of the subgroups. The probability of belonging to each of eight LCA-derived patterns was determined within each subgroup. LBP intensity and frequency were described within subgroups and the subgroups of ‘fluctuating’ and ‘episodic’ LBP were compared on clinical characteristics.

Results

All of 1077 observed trajectories fitted with the defined subgroups. ‘Severe episodic LBP’ was the most frequent pattern in both cohorts and ‘ongoing LBP’ was almost non-existing. There was a clear relationship between the defined trajectory subgroups and LCA-derived trajectory patterns, as in most subgroups, all patients had high probabilities of belonging to only one or two of the LCA patterns. The characteristics of the six defined subgroups with minor LBP were very similar. ‘Fluctuating LBP’ subgroups were significantly more distressed, had more intense leg pain, higher levels of activity limitation, and more negative expectations about future LBP than ‘episodic LBP’ subgroups.

Conclusion

Previously suggested definitions of LBP trajectory subgroups could be readily applied to patients’ observed data resulting in subgroups that matched well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with minor LBP. Stable levels of LBP were almost not observed and we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.

Longitudinal Monitoring of Patients With Chronic Low Back Pain During Physical Therapy Treatment Using the STarT Back Screening Tool

Study Design Preplanned secondary analysis of a randomized clinical trial. Background The STarT Back Screening Tool (SBST) was developed to screen and to classify patients with low back pain into subgroups for the risk of having a poor prognosis. However, this classification at baseline does not take into account variables that can influence the prognosis during treatment or over time. Objectives (1) To investigate the changes in risk subgroup measured by the SBST over a period of 6 months, and (2) to assess the long-term predictive ability of the SBST when administered at different time points. Methods Patients with chronic nonspecific low back pain (n = 148) receiving physical therapy care as part of a randomized trial were analyzed. Pain intensity, disability, global perceived effect, and the SBST were collected at baseline, 5 weeks, 3 months, and 6 months. Changes in SBST risk classification were calculated. Hierarchical linear regression models adjusted for potential confounders were built to analyze the predictive capabilities of the SBST when administered at different time points. Results A large proportion of patients (60.8%) changed their risk subgroup after receiving physical therapy care. The SBST improved the prediction for all 6-month outcomes when using the 5-week risk subgroup and the difference between baseline and 5-week subgroup, after controlling for potential confounders. The SBST at baseline did not improve the predictive ability of the models after adjusting for confounders. Conclusion This study shows that many patients change SBST risk subgroup after receiving physical therapy care, and that the predictive ability of the SBST in patients with chronic low back pain increases when administered at different time points. Level of Evidence Prognosis, 2b. J Orthop Sports Phys Ther 2017;47(5):314-323. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7199.

The STarT back tool in chiropractic practice: a narrative review

Background

The Keele STarT Back Tool was designed for primary care medical physicians in the UK to determine the risk for persistent disabling pain in patients with musculoskeletal pain and to tailor treatments accordingly. In medical and physical therapy settings, STarT Back Tool’s tailored care plans improved patients’ low back pain outcomes and lowered costs.

Objective

Review studies using the STarT Back Tool in chiropractic patient populations.

Methods

PubMed, The Cochrane Library, Index to Chiropractic Literature, and Science Direct databases were searched. Articles written in English, published in peer-reviewed journals, that studied the STarT Back Tool in patients seeking chiropractic care were included.

Results

Seven articles were selected based on inclusion and exclusion criteria. The STarT Back Tool was feasibly incorporated into 19 chiropractic clinics in Denmark. Total STarT Back 5-item score correlated moderately with total Bournemouth Questionnaire score. Two studies reported that the STarT Back Tool’s predictive ability was poor, while another reported that the tool predicted outcomes in patients scoring in the medium and high risk categories who completed the STarT Back 2 days after their initial visit. A study examining Danish chiropractic, medical and physical therapy settings revealed that only baseline episode duration affected STarT Back’s prognostic ability across all care settings. The tool predicted pain and disability in chiropractic patients whose episode duration was at least 2 weeks, but not in patients with an episode duration <2 weeks.

Conclusion

While the STarT Back Tool can be incorporated into chiropractic settings and correlates with some elements of the Bournemouth Questionnaire, its prognostic ability is sometimes limited by the shorter low back pain episodes with which chiropractic patients often present. It may be a better predictor in patients whose episode duration is at least 2 weeks. Studies examining outcomes of stratified care in chiropractic patients are needed.

Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis

BACKGROUND

Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration.

METHODS

Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure).

RESULTS

We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was 'non-informative' (pooled AUC = 0.59 (0.55-0.63), n = 1153) and 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74 (0.66-0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was 'poor' for discriminating pain outcomes (pooled AUC = 0.69 (0.62-0.76), n = 360), 'acceptable' for disability outcomes (pooled AUC = 0.75 (0.69-0.82), n = 512), and 'excellent' for absenteeism outcomes (pooled AUC = 0.83 (0.75-0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only.

CONCLUSIONS

LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO international prospective register of systematic reviews registration number CRD42015015778 .

First episode of acute low back pain - an exploratory cluster analysis approach for early detection of unfavorable recovery

PURPOSE

To identify recovery patterns in patients with a first episode of acute low back pain (LBP) and to define risk factors for unfavorable outcome.

METHODS

One hundred and eight patients (55 male, 53 female; mean age = 40.8, SD 14.2 years) rated pain (NRS) and disability [Oswestry Disability Index (ODI)] before the first treatment and 1 week, 1, 3, 6, and 12 months later. Hierarchical cluster analysis identified recovery patterns based on NRS data. Clusters were compared for age, NRS and ODI at baseline, pain reduction in the first week, gender, radicular signs and traumatic onset using one-way ANOVA (post hoc Bonferroni) and χ² tests.

RESULTS

The cluster analysis revealed four clusters: moderate baseline pain/fast recovery; high baseline pain/fast recovery; high baseline pain/persistent mild pain; high baseline pain/persistent high pain. These clusters differed in baseline NRS [F(3,104) = 39.61, p < 0.001], baseline ODI [F(3,104) = 12.17, p < 0.001], pain reduction in the first week [F(3,104) = 11.51, p < 0.001] and in radicular signs [χ²(3) = 9.20, p = 0.027].

CONCLUSIONS

These results suggest that an initial and regularly repeated assessment of pain intensity and functional disability is important. Initial pain intensity does not seem to be a prognostic factor per se, as it did not negatively affect recovery provided that it decreased early in treatment. Implications for Rehabilitation Prediction of outcome is particularly important in patients with a first episode of acute LBP as one third did not completely recover. Pain intensity and functional disability should be initially assessed and regularly repeated in the first phase of treatment. High initial pain intensity and disability combined with small pain reduction during the first week might predict unfavorable outcome and require adequate treatment.

Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

BACKGROUND

Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP.

METHODS AND FINDINGS

We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a "treat all" approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings.

CONCLUSIONS

Based on its performance in these cohorts, this five-item prognostic model for patients with acute LBP may be a useful tool for estimating risk of chronic LBP. Further validation is required to determine whether screening with this model leads to a net reduction in unnecessary interventions provided to low-risk patients.

Do psychological and behavioral factors classified by the West Haven-Yale Multidimensional Pain Inventory (Swedish version) predict the early clinical course of low back pain in patients receiving chiropractic care?

Background

To investigate if psychological and behavioral factors (as determined by the Swedish version of the West Haven-Yale Multidimensional Pain Inventory, MPI-S) can predict the early clinical course of Low Back Pain (LBP).

Methods

MPI-S data from patients (18–65 years of age) seeking chiropractic care for recurrent and persistent LBP were collected at the 1^st visit. A follow-up questionnaire was administered at the 4^th visit. The predictive value of the MPI-S subgroups Adaptive Copers (AC), Interpersonally Distressed (ID) and Dysfunctional (DYS) was calculated against the subjective improvement at the 4^th visit and clinically relevant difference in pain intensity between the 1^st and 4^th visit.

Results

Of the 666 subjects who were included at the 1^st visit, 329 completed the questionnaire at the 4^th visit. A total of 64.7 % (AC), 68.0 % (ID) and 71.3 % (DYS) reported a definite improvement. The chance of “definite improvement”, expressed as relative risk (95 % CI) with the AC group as reference, was 1.05 (.87–1.27) for the ID and 1.10 (.93–1.31) for the DYS groups, respectively. The DYS and ID groups reported higher values in pain intensity both at the 1^st and the 4^th visit. The proportion of subjects who reported an improvement in pain intensity of 30 % or more (clinically relevant) were 63.5 % AC, 72.0 % ID and 63.2 % DYS. Expressed as relative risk (95 % CI) with the AC group as reference, this corresponded to 1.26 (.91–1.76) for the ID and 1.09 (.78–1.51) for the DYS groups, respectively.

Conclusions

The MPI-S instrument could not predict the early clinical course of recurrent and persistent LBP in this sample of chiropractic patients.

Trial registration

Clinical trials.gov; NCT01539863, February 22, 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0933-y) contains supplementary material, which is available to authorized users.

Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients

Background

Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics.

Methods

In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed).

Results

The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D.

Conclusions

The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different.

Trial registration

Sample A comes from an ongoing trial registered at clinical trials.gov; NCT01539863, February 22, 2012.