Temporal stability of self-reported visual back pain trajectories

Development and application of predictive clinical biomarkers for low back pain care: recommendations from the ISSLS phenotype/precision spine focus group

Predictive biomarkers (or moderators of treatment) are features, or more likely feature clusters, that discriminate individuals who are more likely to experience a favourable or unfavourable effect from a specific treatment. Utilization of validated predictive biomarkers for chronic low back pain (CLBP) treatments is a plausible strategy to guide patients more rapidly to effective treatments thereby reducing wastage of finite healthcare funds on treatments that are ineffective (or potentially harmful). Yet, few predictive biomarkers have been successfully validated in clinical studies. This paper summarizes work by the Phenotype/Precision Spine Focus Group of the International Society for the Study of the Lumbar Spine that addressed: (1) relevant definitions for terminology; (2) advantages and disadvantages of different research approaches for the specification of predictive biomarkers; (3) methods for assessment of clinical validity; (4) approaches for their implementation; (5) barriers to predictive biomarker identification; and (6) a prioritised list of recommendations for the development and refinement of predictive biomarkers for CLBP. Key recommendations include the harmonisation of data collection, data sharing, integration of theoretical models, development of new treatments, and health economic analyses to inform cost-benefit of assessments and the application of matched treatments. The complexity of CLBP demands large datasets to derive meaningful progress. This will require coordinated and substantive collaboration involving multiple disciplines and across the research spectrum from the basic sciences to clinical applications.

Prospective Back Pain Trajectories or Retrospective Recall-Which Tells Us Most About the Patient?

In patients with low back pain (LBP), a visually identified retrospective pain trajectory often mismatches with a trajectory derived from prospective repeated measures. To gain insight into the clinical relevance of the 2 trajectory types, we investigated which showed a higher association with clinical outcomes. Participants were 724 adults seeking care for LBP in Danish chiropractic primary care. They answered weekly short-message-services on pain intensity and frequency over 52 weeks, which we translated into 8 trajectory classes. After 52 weeks, participants selected a retrospective visual pain trajectory from the same 8 trajectory classes. Clinical outcomes included disability, back/leg pain intensity, back beliefs, and work ability. The patient-selected pain trajectory classes were more strongly associated with clinical outcomes than the short-message-service trajectory classes at baseline, at follow-up, and with outcome changes between baseline and follow-up. This held across all 5 clinical outcomes, with the strongest associations observed at week 52 and the weakest at baseline. Patients' retrospective assessment of their LBP is more strongly associated with their clinical status than their prospective assessments translated into trajectory classes. This suggests that retrospective assessments of pain trajectories may provide valuable information not captured by prospective assessments. Researchers collecting prospective pain data should know that the captured pain trajectories are not strongly reflected in patients' perceptions of clinical status. Patients' retrospective assessments seem to offer an interpretation of their pain course that is likely more clinically relevant in understanding the perceived impact of their condition than trajectories based on repeated measures. PERSPECTIVE: Prospective pain data inadequately reflect patients' clinical status. Retrospective assessments provide a more clinically valuable understanding of the impact of their condition.

Characteristics and outcomes of patients with low back pain with and without radiating leg pain following the GLA:D back program

BACKGROUND

Some patients with low back pain (LBP) also report radiating leg pain which is a prognostic factor for poorer clinical outcomes. We aimed: 1) to compare the baseline characteristics of patients with LBP with - (LBP + leg pain) and without radiating leg pain (LBP - alone); 2) to investigate whether patients with LBP + leg pain show similar post-treatment outcomes as compared to LBP - alone, after participation in an exercise and patient education program, i.e. the GLA:D Back program.

METHODS

The patient sample included 3508 patients in the GLA:D Back program between March 2018 and August 2022. The outcomes were mean changes in LBP intensity, back-related activity limitation, self-efficacy and fear of movement measured from baseline to 3, 6 and 12 months. Baseline characteristics were compared with descriptive statistics, and linear mixed models were used to estimate group differences in changes from baseline to 3-, 6- and 12 months.

RESULTS

1915 (55%) of the patients were in the group LBP- alone and 1593 (45%) in the LBP + leg pain. The LBP + leg pain group displayed higher STarT back classification (greater risk of chronicity) compared to the LBP-alone. The LBP + leg pain group showed almost similar improvements in all outcomes compared to LBP - alone after the GLA:D Back program.

CONCLUSION

In long-lasting (chronic) LBP patients, the LBP + leg pain group improved to the same extent as LBP - alone regarding LBP intensity, disability, and fear of movement following an exercise and patient education program, GLA:D Back.

Development, validation and use of custom software for the analysis of pain trajectories

In chronic musculoskeletal conditions, the prognosis tends to be more informative than the diagnosis for the future course of the disease. Many studies have identified clusters of patients who seemingly share similar pain trajectories. In a dataset of low back pain (LBP) patients, pain trajectories have been identified, and distinct trajectory types have been defined, making it possible to create pattern recognition software that can classify patients into respective pain trajectories reflecting their condition. It has been suggested that the classification of pain trajectories may create clinically meaningful subgroups of patients in an otherwise heterogeneous population of patients with LBP. A software tool was created that combined the ability to recognise the pain trajectory of patients with a system that could create subgroups of patients based on their characteristics. This tool is primarily meant for researchers to analyse trends in large heterogeneous datasets without large losses of data. Prospective analysis of pain trajectories is not directly helpful for clinicians. However, the tool might aid in the identification of patient characteristics which have predictive capabilities of the most likely trajectory a patient might experience in the future. This will help clinicians to tailor their advice and treatment for a specific patient.

Do Visual Pain Trajectories Reflect the Actual Course of Low Back Pain? A Longitudinal Cohort Study

Different trajectories of low back pain (LBP) have been identified prospectively using repeated measures. For these trajectories to inform clinical practice, they must be available in the clinical consultation. Therefore, identified LBP trajectories have been translated into visual pain trajectories (VPTs) that allow people with LBP, at the time of consult, to reflect upon their pain experience and identify the VPT that best categorizes their pain course. We have limited knowledge regarding the extent to which a chosen VPT reflects the prospectively experienced trajectory. Thus, we explored the distribution of pain intensity and pain pattern characteristics (from prospective pain trajectory data) within the retrospectively chosen VPT classes. We enrolled patients with LBP from Danish chiropractic practice. Using SMS, participants (n = 719) scored their pain weekly on an 11-point numerical rating scale for 52 weeks. At week 52, participants identified 1 of 8 VPTs that reflected their perceived back pain trajectory during the preceding year. We found that the chosen VPTs reflected pain intensity, but that pain patterns (episodic, fluctuating, and persistent) were not systematically recognized, and the experienced course varied substantially amongst participants within the same VPT. The VPTs are related to some aspects of the experienced LBP course but are not a proxy for the SMS-measured trajectories. Reasons for apparent mismatches between the experienced course of LBP and VPT recall warrant further investigation. PERSPECTIVE: Self-reported back pain trajectories reflected pain intensities obtained through weekly SMS tracking over a year, but participants' recall did not reflect the pain patterns (episodes and fluctuations) discovered prospectively. Clinicians can use self-reported pain trajectories to facilitate a dialog about pain experience, but not as a proxy for prospective measures.

Multidisciplinary team-based management approach for secondary-care patients with severe and persistent low back pain: A mixed-method feasibility trial

BACKGROUND

Persistent and severe low back pain is challenging to treat. Multidisciplinary care with systematic follow-up may be more effective than usual care. However, such a model has yet to be developed and tested.

OBJECTIVE

Our objectives were to develop and test the feasibility of a three-month multidisciplinary intervention with systematic follow-up in a specialized hospital spine center for patients with severe and persistent low back pain.

METHODS

Using the Medical Research Council and National Institute for Health and Care Research framework for the development and testing of complex interventions, we developed a multidisciplinary intervention with systematic follow-up and tested its feasibility, using a-priori-determined outcomes during three months for 24 patients seen at a regional diagnostic spine center unit. As part of the evaluation, we conducted semi-structured interviews with participants and a focus-group interview with clinicians.

RESULTS

Of the 24 patients included, only 17 completed the course of care and provided complete data for feasibility assessment. We failed to reach our a-priori feasibility outcomes, had difficulty with inclusion, and participants did not find the intervention effective or satisfactory.

CONCLUSIONS

The intervention was not feasible as barriers existed on multiple levels (e.g., clinical, administrative, and patient). Excessive study moderations must be made before the intervention is feasible in a randomized trial.

Exploring visual pain trajectories in neck pain patients, using clinical course, SMS-based patterns, and patient characteristics: a cohort study

Background

The dynamic nature of neck pain has so far been identified through longitudinal studies with frequent measures, a method which is time-consuming and impractical. Pictures illustrating different courses of pain may be an alternative solution, usable in both clinical work and research, but it is unknown how well they capture the clinical course. The aim of this study was to explore and describe self-reported visual trajectories in terms of details of patients’ prospectively reported clinical course, their SMS-based pattern classification of neck pain, and patient’s characteristics.

Methods

Prospective cohort study including 888 neck pain patients from chiropractic practice, responding to weekly SMS-questions about pain intensity for 1 year from 2015 to 2017. Patients were classified into one of three clinical course patterns using definitions based on previously published descriptors. At 1-year follow-up, patients selected a visual trajectory that best represented their retrospective 1-year course of pain: single episode, episodic, mild ongoing, fluctuating and severe ongoing.

Results

The visual trajectories generally resembled the 1-year clinical course characteristics on group level, but there were large individual variations. Patients selecting Episodic and Mild ongoing visual trajectories were similar on most parameters. The visual trajectories generally resembled more the clinical course of the last quarter.

Discussion

The visual trajectories reflected the descriptors of the clinical course of pain captured by weekly SMS measures on a group level and formed groups of patients that differed on symptoms and characteristics. However, there were large variations in symptoms and characteristics within, as well as overlap between, each visual trajectory. In particular, patients with mild pain seemed predisposed to recall bias. Although the visual trajectories and SMS-based classifications appear related, visual trajectories likely capture more elements of the pain experience than just the course of pain. Therefore, they cannot be seen as a proxy for SMS-tracking of pain over 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00443-3.