1
|
Wirth B, Schweinhardt P. Personalized assessment and management of non-specific low back pain. Eur J Pain 2024; 28:181-198. [PMID: 37874300 DOI: 10.1002/ejp.2190] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/22/2023] [Accepted: 09/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients. DATABASES AND DATA TREATMENT Narrative review. RESULTS NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively. CONCLUSIONS The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient. SIGNIFICANCE STATEMENT Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.
Collapse
Affiliation(s)
- Brigitte Wirth
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Petra Schweinhardt
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
2
|
Fang Y, Chen J, Lin S, Cai Y, Huang LH. Predictive performance of the STarT Back tool for poor outcomes in patients with low back pain: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069818. [PMID: 37562930 PMCID: PMC10423782 DOI: 10.1136/bmjopen-2022-069818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/21/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Subgroups for Targeted Treatment Back Tool (SBT) is a brief multiple-construct risk prediction tool for patients with low back pain (LBP). Thus far, the predictive ability of this tool has been inconsistent. Therefore, we aim to conduct a literature review on the predictive ability of the SBT to determine the outcomes of patients with LBP. The results of this review should improve the ability of the SBT to predict poor outcomes in patients with LBP. METHODS AND ANALYSIS Databases including PubMed, EMBASE, Cochrane Central, Web of Science, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Journal Database, and Wanfang will be searched for studies on SBT and LBP from their inception until 31 March 2023. Longitudinal studies investigating the association between SBT subgroups and LBP outcomes, including pain, disability and quality of life, will be included. The identified studies will be independently screened for eligibility by two reviewers. A standardised sheet will be used to extract data. The Newcastle-Ottawa Scale will be used to assess the methodological quality of the included studies. Heterogeneity will be evaluated by the χ2 test with Cochran's Q statistic and quantified by the I2 statistic. The results will be synthesised qualitatively and presented as pooled risk ratios or beta coefficients quantitatively. The results will also be presented using their 95% confidence limits. Publication bias will be assessed using the method proposed by Egger and by visual inspection of funnel plots. ETHICS AND DISSEMINATION This study is a secondary analysis of original studies that received ethics approval. Therefore, prior ethical approval is not required for this study. The findings will be submitted to relevant peer-reviewed journals for publication and presented at profession-specific conferences. TRIAL REGISTRATION NUMBER PROSPERO registration numberCRD42022309189.
Collapse
Affiliation(s)
- Yunhua Fang
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
- Rehabilitation medicine department, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jie Chen
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
| | - Shengmei Lin
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
| | - Yangfan Cai
- Encephalopathy rehabilitation fifth department, Rehabilitation Hospital affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
- Fujian Key Laboratory of Rehabilitation Technology, Fuzhou, China
| | - Lian-Hong Huang
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
| |
Collapse
|
3
|
Budtz CR, Rønnow MM, Stæhr TAB, Andersen NBDV, Christiansen DH. The usefulness of the STarT back screening tool and single-item general health measures when predicting future disability in patients with low back pain treated in Danish primary care physiotherapy. Musculoskelet Sci Pract 2023; 65:102767. [PMID: 37116370 DOI: 10.1016/j.msksp.2023.102767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/13/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The extent to which disease specific screening tools or other health measures add to the predictive value of common clinical factors (pain, disability and socio-demographics) has been sparsely investigated. The aim of this study was to investigate whether a disease specific screening tool and a single-item general health measure adds predictive value to basic information collected in primary physiotherapy care when predicting future disability in patients with low back pain. MATERIAL AND METHODS This longitudinal cohort study included 354 patients with low back pain from Danish primary care physiotherapy. Information was collected on socio-demographics, common clinical factors, The STarT Back Screening Tool (SBT) and general health perceptions measured as a single item from the SF-36 (GH-1). Disability at 6-month follow-up, measured by the Roland-Morris Disability Questionnaire, was predicted using multiple linear regression models. RESULTS Clinical factors and baseline disability level explained 28.3% of the variance in 6-month disability scores. With SBT and GH-1 added separately to the baseline model, the explained variance increased by 2.1% (p = 0.01) and 3.6% (p < 0.001), respectively. CONCLUSION The added value of the disease specific screening tools or the single-item general measure when predicting disability in patients with low back pain was generally small. Moreover, the predictive value of the single-item general measure seems comparable to and slightly better than the disease specific screening tool. Overall these findings may question the clinical utility of such measures.
Collapse
Affiliation(s)
- Cecilie Rud Budtz
- Elective Surgery Centre, Silkeborg Regional Hospital, Falkevej 1, 8600, Silkeborg, Denmark.
| | - Mathias Moselund Rønnow
- Department of Occupational Medicine, University Research Clinic, Goedstrup Hospital, Hospitalsparken 15, 7400, Herning, Denmark
| | - Thor Andre Brøndberg Stæhr
- Department of Occupational Medicine, University Research Clinic, Goedstrup Hospital, Hospitalsparken 15, 7400, Herning, Denmark
| | - Nils-Bo de Vos Andersen
- Central Denmark Region, Primary Health Care and Quality Improvement, Skottenborg 26, 8800, Viborg, Denmark
| | - David Høyrup Christiansen
- Elective Surgery Centre, Silkeborg Regional Hospital, Falkevej 1, 8600, Silkeborg, Denmark; Regional Hospital Central Jutland, Heibergs Allé 2K, 8000, Viborg, Denmark; Deartment of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark
| |
Collapse
|
4
|
Morsø L, Lykkegaard J, Andersen MK, Hansen A, Stochkendahl MJ, Madsen SD, Christensen BS. Providing information at the initial consultation to patients with low back pain across general practice, chiropractic and physiotherapy - a cross-sectorial study of Danish primary care. Scand J Prim Health Care 2022; 40:370-378. [PMID: 36314134 PMCID: PMC9848345 DOI: 10.1080/02813432.2022.2139465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Clinical guidelines for managing low back pain (LBP) emphasise patient information, patient education and physical activity as key components. Little is known about who actually receives information. This study investigates to what extent information at the first consultation with general practitioner (GP), chiropractor (DC) and physiotherapist (PT) in Danish primary care is provided to patients with LBP. DESIGN AND SETTING This cross-sectorial study was conducted as a prospective survey registration of LBP consultations at the three primary health care professions in Denmark. INTERVENTION Clinicians ticked off a paper survey chart during or after consultations with patients who visited the clinic for LBP (Approval number: ID # 11.220). SUBJECTS 33 GPs, 43 DCs and 61 PTs registered first-time consultations. MAIN OUTCOME MEASURES The primary outcome was provision of information, overall and across care settings. RESULTS The overall proportion of patients provided with information was 72%, but this varied among professions (GP, 44%; DC, 76%; and PT, 74%). Provision of information increased to 78% if patients had increased emotional distress or back-related leg pain below the knee. The strongest association with provision of information was having two or three signs of elevated distress (OR 2.58 and 5.05, respectively, p= 0.00) or physical disability (OR 2.55, p= 0.00). CONCLUSION In more than a quarter of first-time consultations, patient information was not provided. Large variation in providing information was found across the settings. The proportion provided with information increased for sub-populations having elevated distress or back-related leg pain below the knee.Key Points Clinical guidelines recommend patient information, patient education and physical activity for managing low back pain (LBP) • Information is not provided in more than a quarter of first-time consultations in Danish primary care settings that manage these patients. • Information increased for the sub-populations having elevated distress and back-related leg pain below the knee. • The conducted primary care surveys monitored clinical activity and illustrated variations in provision of information.
Collapse
Affiliation(s)
- Lars Morsø
- Department of Clinical Research, Research Unit OPEN, University of Southern Denmark, Odense, Denmark
- OPEN – Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
- CONTACT Lars Morsø Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Merethe Kirstine Andersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Hansen
- Spine Centre of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
| | - Mette Jensen Stochkendahl
- Chiropractic Knowledge Hub, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Simon Dyrløv Madsen
- Chiropractic Knowledge Hub, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Berit Schiøttz Christensen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
5
|
Morsø L, Olsen Rose K, Schiøttz-Christensen B, Sowden G, Søndergaard J, Christiansen DH. Effectiveness of stratified treatment for back pain in Danish primary care: A randomized controlled trial. Eur J Pain 2021; 25:2020-2038. [PMID: 34101953 PMCID: PMC8518659 DOI: 10.1002/ejp.1818] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/30/2021] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lars Morsø
- Clinical Department, University of Southern Denmark, Odense, Denmark
| | - Kim Olsen Rose
- Department of Business and Economics, DaCHE, University of Southern Denmark, Odense, Denmark
| | | | | | - Jens Søndergaard
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - David H Christiansen
- Department of Occupational Medicine, Regional Hospital West Jutland, University Research Clinic, Herning, Denmark
| |
Collapse
|
6
|
Unsgaard-Tøndel M, Vasseljen O, Nilsen TIL, Myhre G, Robinson HS, Meisingset I. Prognostic ability of STarT Back Screening Tool combined with work-related factors in patients with low back pain in primary care: a prospective study. BMJ Open 2021; 11:e046446. [PMID: 34083340 PMCID: PMC8183211 DOI: 10.1136/bmjopen-2020-046446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Monica Unsgaard-Tøndel
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
- Department of Physiotherapy, Trondheim Municipality, Trondheim, Norway
| | - Ottar Vasseljen
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim, Norway
| | - Gard Myhre
- Department of Physiotherapy, Trondheim Municipality, Trondheim, Norway
| | | | - Ingebrigt Meisingset
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
- Department of Physiotherapy, Trondheim Municipality, Trondheim, Norway
| |
Collapse
|
7
|
Kongsted A, Nielsen OL, Christensen HW, Hartvigsen J, Doktor K, Kent P, Jensen TS. The Danish Chiropractic Low Back Pain Cohort (ChiCo): Description and Summary of an Available Data Source for Research Collaborations. Clin Epidemiol 2020; 12:1015-1027. [PMID: 33061649 PMCID: PMC7537847 DOI: 10.2147/clep.s266220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/02/2020] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Alice Kongsted
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M 5230, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Orla Lund Nielsen
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M 5230, Denmark
| | | | - Jan Hartvigsen
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M 5230, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Klaus Doktor
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M 5230, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Peter Kent
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Tue Secher Jensen
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M 5230, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| |
Collapse
|
8
|
Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model? Pain Rep 2020; 5:e843. [PMID: 33235943 PMCID: PMC7678800 DOI: 10.1097/pr9.0000000000000843] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/03/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is Available in the Text. Substantial overlap between interventions and models of care for osteoarthritis and low back pain suggests potential for one common model, which may facilitate implementation. The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.
Collapse
|
9
|
Use of the STarT Back Screening Tool in patients with chronic low back pain receiving physical therapy interventions. Braz J Phys Ther 2020; 25:286-295. [PMID: 32773289 DOI: 10.1016/j.bjpt.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 05/28/2020] [Accepted: 07/17/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The STarT Back Screening Tool (SBST) is used to stratify care. It is unclear if the SBST approach works as well for patients in low- and medium-income countries as for patients from high-income countries. OBJECTIVES (1) To investigate whether patients with chronic low back pain (LBP) stratified by the SBST are different at baseline; (2) to describe the clinical course for each SBST subgroup; (3) to investigate the SBST utility to predict clinical outcomes; and (4) to determine which SBST subgroup show greater clinical improvement. DESIGN This is a secondary analysis of data derived from a previously published clinical trial. METHODS 148 patients with chronic nonspecific LBP were included. Pain intensity, disability, global perceived effect, and the SBST were assessed at baseline and at 5, 12, and 24 weeks after baseline. Descriptive data were provided and ANOVA, unadjusted and adjusted regression models, and linear mixed models were used for data analysis. RESULTS Duration of symptoms, use of medication, pain, disability, and global perceived effect were different between SBST subgroups. Clinical improvements over a 6-month period were consistently greater in patients classified as high risk. The SBST was able to predict disability but this predictability decreased when the analysis was adjusted for possible confounders. CONCLUSION Clinical outcomes were different between SBST subgroups over 6 months. Adjusting for confounders influenced the predictability of SBST. Patients classified as high risk presented higher improvements in terms of disability.
Collapse
|
10
|
Hartvigsen L, Kongsted A, Vach W, Salmi LR, Hestbaek L. Baseline Characteristics May Help Indicate the Best Choice of Health Care Provider for Back Pain Patients in Primary Care: Results From a Prospective Cohort Study. J Manipulative Physiol Ther 2020; 43:13-23. [PMID: 32081512 DOI: 10.1016/j.jmpt.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Baseline characteristics of patients low back pain differ substantially between care settings, but it is largely unknown whether predictors are of equal importance across settings. The aim of this study was to investigate whether 8 known predictors relate differently to outcomes in chiropractic practice and in general practice and to which degree these factors may be helpful in selecting patients benefiting more from one setting or the other. METHODS Patient characteristics were collected at baseline, and outcomes of pain intensity (numeric rating scale 0-10) and activity limitation (Roland-Morris Disability Questionnaire 0-100) after 2, 12, and 52 weeks. Differences in the prognostic strength between settings were investigated for each prognostic factor separately by estimating the interaction between setting and the prognostic factor using regression models. Between-setting differences in outcome in high-risk and low-risk subgroups, formed by single prognostic factors, were assessed in similar models adjusted for a propensity score to take baseline differences between settings into account. RESULTS Prognostic factors were generally associated more strongly with outcomes in general practice compared with chiropractic practice. The difference was statistically significant for general health, duration of pain, and musculoskeletal comorbidity. After propensity score adjustment, differences in outcomes between settings were insignificant, but negative prognostic factors tended to be less influential in chiropractic practice except for leg pain and depression, which tended to have less negative impact in general practice. CONCLUSION Known prognostic factors related differently to outcomes in the 2 settings, suggesting that some subgroups of patients might benefit more from one setting than the other.
Collapse
Affiliation(s)
- Lisbeth Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Werner Vach
- Institute of Medical Biometry and Statistics, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany; Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Louis-Rachid Salmi
- Université de Bordeaux, Institute of Public Health, Epidemiology and Development, INSERM, Bordeaux, France
| | - Lise Hestbaek
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| |
Collapse
|
11
|
The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain. J Clin Med 2019; 8:jcm8091334. [PMID: 31466408 PMCID: PMC6780711 DOI: 10.3390/jcm8091334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.
Collapse
|
12
|
Lheureux A, Berquin A. Comparison between the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Screening Questionnaire: Which tool for what purpose? A semi-systematic review. Ann Phys Rehabil Med 2019; 62:178-188. [PMID: 30342997 DOI: 10.1016/j.rehab.2018.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 08/31/2018] [Accepted: 09/15/2018] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Alexis Lheureux
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal lab, Avenue Mounier 53/B1.53.07, 1200 Brussels, Belgium.
| | - Anne Berquin
- Department of Physical and Rehabilitation Medicine, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10/1650, 1200 Brussels, Belgium.
| |
Collapse
|
13
|
Khan Y, Lawrence D, Vining R, Derby D. Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey. Chiropr Man Therap 2019; 27:2. [PMID: 30675336 PMCID: PMC6332914 DOI: 10.1186/s12998-018-0228-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 12/14/2018] [Indexed: 11/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yasmeen Khan
- 1Parker University, 2500 Walnut Hill Lane, Dallas, TX 75229 USA
| | - Dana Lawrence
- 1Parker University, 2500 Walnut Hill Lane, Dallas, TX 75229 USA
| | - Robert Vining
- 2Palmer Center for Chiropractic Research, 741 Brady Street, Davenport, IA 52803 USA
| | - Dustin Derby
- 3Palmer College of Chiropractic, 1000 Brady Street, Davenport, IA 52803 USA
| |
Collapse
|
14
|
Does a Diagnostic Classification Algorithm Help to Predict the Course of Low Back Pain? A Study of Danish Chiropractic Patients With 1-Year Follow-up. J Orthop Sports Phys Ther 2018; 48:837-846. [PMID: 29739300 DOI: 10.2519/jospt.2018.8083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A diagnostic classification algorithm, "the Petersen classification," consisting of 12 categories based on a standardized examination protocol, was developed for the primary purpose of identifying clinically homogeneous subgroups of individuals with low back pain (LBP). OBJECTIVES To investigate whether a diagnostic classification algorithm is associated with activity limitation and LBP intensity at follow-up assessments of 2 weeks, 3 months, and 1 year, and whether the algorithm improves outcome prediction when added to a set of known predictors. METHODS This was a prospective observational study of 934 consecutive adult patients with new episodes of LBP who were visiting chiropractic practices in primary care and categorized according to the Petersen classification. Outcomes were disability and pain intensity measured with questionnaires at 2 weeks and 3 months, and 1-year trajectories of LBP based on weekly responses to text messages. Associations were analyzed with linear and logistic regression models. In a subgroup of patients, the numbers of visits to primary and secondary care were described. RESULTS The Petersen classification was statistically significantly associated with all outcomes (P<.001) but explained very little of the variance (R2 = 0.00-0.05). Patients in the nerve root involvement category had the most pain and activity limitation and the most visits to primary and secondary care. Patients in the myofascial pain category were the least affected. CONCLUSION The Petersen classification was not helpful in determining individual prognosis in patients with LBP receiving usual care in chiropractic practice. However, patients should be examined for potential nerve root involvement to improve prediction of likely outcomes. LEVEL OF EVIDENCE Prognosis, level 1b. J Orthop Sports Phys Ther 2018;48(11):837-846. Epub 8 May 2018. doi:10.2519/jospt.2018.8083.
Collapse
|
15
|
Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through stratified care (STarT Back). Braz J Phys Ther 2018; 22:255-264. [PMID: 29970301 PMCID: PMC6095099 DOI: 10.1016/j.bjpt.2018.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/07/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care. RESULTS The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care. CONCLUSIONS The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.
Collapse
Affiliation(s)
- Gail Sowden
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK; Interdisciplinary Musculoskeletal Pain Assessment and Community Treatment Service, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent ST6 7AG, UK.
| | - Jonathan Charles Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Lars Morso
- Centre for Quality, Department of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 3 Odense C DK 5000, Denmark
| | - Quninette Louw
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nadine Elizabeth Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| |
Collapse
|
16
|
Suri P, Delaney K, Rundell SD, Cherkin DC. Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting. Arch Phys Med Rehabil 2018; 99:1533-1539.e2. [PMID: 29625095 DOI: 10.1016/j.apmr.2018.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/25/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care. DESIGN Secondary analysis of data from participants receiving usual care in a randomized clinical trial. SETTING Primary care clinics. PARTICIPANTS Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up. RESULTS The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group. CONCLUSIONS The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
Collapse
Affiliation(s)
- Pradeep Suri
- Seattle Epidemiologic Research and Information Center (ERIC), Department of Veterans Affairs Office of Research and Development, Seattle, Washington; Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington.
| | - Kristin Delaney
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, Seattle, Washington
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | - Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, Seattle, Washington
| |
Collapse
|
17
|
Kendell M, Beales D, O'Sullivan P, Rabey M, Hill J, Smith A. The predictive ability of the STarT Back Tool was limited in people with chronic low back pain: a prospective cohort study. J Physiother 2018; 64:107-113. [PMID: 29602747 DOI: 10.1016/j.jphys.2018.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/03/2017] [Accepted: 02/06/2018] [Indexed: 12/24/2022] Open
Abstract
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].
Collapse
Affiliation(s)
- Michelle Kendell
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Darren Beales
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Martin Rabey
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Jonathan Hill
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Anne Smith
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| |
Collapse
|
18
|
Riis A, Rathleff MS, Jensen CE, Jensen MB. Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice. BMC Musculoskelet Disord 2017; 18:360. [PMID: 28835238 PMCID: PMC5569517 DOI: 10.1186/s12891-017-1727-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/15/2017] [Indexed: 01/09/2023] Open
Abstract
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).
Collapse
Affiliation(s)
- Allan Riis
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Fyrkildevej 7, 1. sal, lejl. 3, 9220, Aalborg Øst, Denmark.
| | - Michael Skovdal Rathleff
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Fyrkildevej 7, 1. sal, lejl. 3, 9220, Aalborg Øst, Denmark
| | - Cathrine Elgaard Jensen
- Danish Center for Healthcare Improvements, Aalborg University, Fibigerstræde 11, 9220, Aalborg Øst, Denmark
| | - Martin Bach Jensen
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Fyrkildevej 7, 1. sal, lejl. 3, 9220, Aalborg Øst, Denmark
| |
Collapse
|
19
|
Molgaard Nielsen A, Hestbaek L, Vach W, Kent P, Kongsted A. Latent class analysis derived subgroups of low back pain patients - do they have prognostic capacity? BMC Musculoskelet Disord 2017; 18:345. [PMID: 28793903 PMCID: PMC5551030 DOI: 10.1186/s12891-017-1708-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the 'comparator variables'). METHODS This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above. RESULTS The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants' recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%-6.9% for pain intensity and from 6.8%-20.3% for disability, and highest at the 2 weeks follow-up. CONCLUSIONS Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.
Collapse
Affiliation(s)
- Anne Molgaard Nielsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
| | - Lise Hestbaek
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, 5230, Odense M, Denmark
| | - Werner Vach
- Institute for Medical Biometry and Statistics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany.,Department of Orthopaedics and Traumatology, University Hospital Basel, 4031, Basel, Switzerland
| | - Peter Kent
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, 5230, Odense M, Denmark
| |
Collapse
|
20
|
Karran EL, Traeger AC, McAuley JH, Hillier SL, Yau YH, Moseley GL. The Value of Prognostic Screening for Patients With Low Back Pain in Secondary Care. THE JOURNAL OF PAIN 2017; 18:673-686. [DOI: 10.1016/j.jpain.2016.12.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/25/2016] [Accepted: 12/30/2016] [Indexed: 12/23/2022]
|
21
|
Longitudinal Monitoring of Patients With Chronic Low Back Pain During Physical Therapy Treatment Using the STarT Back Screening Tool. J Orthop Sports Phys Ther 2017; 47:314-323. [PMID: 28355979 DOI: 10.2519/jospt.2017.7199] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
22
|
Khan Y. The STarT back tool in chiropractic practice: a narrative review. Chiropr Man Therap 2017; 25:11. [PMID: 28439405 PMCID: PMC5399842 DOI: 10.1186/s12998-017-0142-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 04/12/2017] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yasmeen Khan
- Palmer College of Chiropractic Center for Chiropractic Research, 741 Brady Street, Davenport, IA 52803 USA
| |
Collapse
|
23
|
Evaluation of the STarT Back Screening Tool for Prediction of Low Back Pain Intensity in an Outpatient Physical Therapy Setting. J Orthop Sports Phys Ther 2017; 47:261-267. [PMID: 28257616 DOI: 10.2519/jospt.2017.7284] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Prospective cohort study. Background Optimal management of patients with low back pain (LBP) relies on accurate prognosis of future clinical outcomes. The STarT Back Screening Tool (SBT), a prognostic index developed and validated in the primary care setting, has 3 scoring measures: SBT overall, psychosocial, and categorical scores. Objective Our study aimed to compare the predictive validity of 3 SBT measures with future pain intensity in patients receiving physical therapy for LBP. Methods Two hundred seven patients with LBP receiving physical therapy completed the SBT at initial (baseline) evaluation and were evaluated 12 weeks later for their pain intensity. Multivariable proportional odds regression was used to evaluate the associations of the various SBT measures with pain intensity at follow-up. Results Adjusting for covariates, all SBT measures were positively and significantly associated with the odds of greater pain intensity at follow-up evaluation (P<.01). Adding SBT psychosocial scores to a covariate-only model improved its predictive accuracy (concordance statistic increase, 0.03; 95% confidence interval: 0.01, 0.09), while improvements in prediction were smaller or negligible with the SBT overall and categorical scores (concordance statistic increase, 0.02 and 0.007, respectively). In mutually adjusted analyses, SBT psychosocial scores added incremental predictive value over SBT overall scores in predicting future pain intensity (P = .03). Conclusion Among the 3 SBT measures, the SBT psychosocial subscale was a significant predictor of future pain intensity in patients with LBP and had comparable, if not better, prognostic significance compared with the SBT overall score. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2017;47(4):261-267. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7284.
Collapse
|
24
|
Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis. BMC Med 2017; 15:13. [PMID: 28100231 PMCID: PMC5244583 DOI: 10.1186/s12916-016-0774-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/20/2016] [Indexed: 11/10/2022] Open
Abstract
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 .
Collapse
|
25
|
Wirth B, Ehrler M, Humphreys BK. First episode of acute low back pain - an exploratory cluster analysis approach for early detection of unfavorable recovery. Disabil Rehabil 2016; 39:2559-2565. [PMID: 27758141 DOI: 10.1080/09638288.2016.1239765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Brigitte Wirth
- a Department of Chiropractic Medicine , University of Zurich, Balgrist University Hospital , Zurich , Switzerland
| | - Marco Ehrler
- a Department of Chiropractic Medicine , University of Zurich, Balgrist University Hospital , Zurich , Switzerland
| | - Barry Kim Humphreys
- a Department of Chiropractic Medicine , University of Zurich, Balgrist University Hospital , Zurich , Switzerland
| |
Collapse
|
26
|
Hill JC, Afolabi EK, Lewis M, Dunn KM, Roddy E, van der Windt DA, Foster NE. Does a modified STarT Back Tool predict outcome with a broader group of musculoskeletal patients than back pain? A secondary analysis of cohort data. BMJ Open 2016; 6:e012445. [PMID: 27742627 PMCID: PMC5073547 DOI: 10.1136/bmjopen-2016-012445] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The STarT Back Tool has good predictive performance for non-specific low back pain in primary care. We therefore aimed to investigate whether a modified STarT Back Tool predicted outcome with a broader group of musculoskeletal patients, and assessed the consequences of using existing risk-group cut-points across different pain regions. SETTING Secondary analysis of prospective data from 2 cohorts: (1) outpatient musculoskeletal physiotherapy services (PhysioDirect trial n=1887) and (2) musculoskeletal primary-secondary care interface services (SAMBA study n=1082). PARTICIPANTS Patients with back, neck, upper limb, lower limb or multisite pain with a completed modified STarT Back Tool (baseline) and 6-month physical health outcome (Short Form 36 (SF-36)). OUTCOMES Area under the receiving operator curve (AUCs) tested discriminative abilities of the tool's baseline score for identifying poor 6-month outcome (SF-36 lower tertile Physical Component Score). Risk-group cut-points were tested using sensitivity and specificity for identifying poor outcome using (1) Youden's J statistic and (2) a clinically determined rule that specificity should not fall below 0.7 (false-positive rate <30%). RESULTS In PhysioDirect and SAMBA, poor 6-month physical health was 18.5% and 28.2%, respectively. Modified STarT Back Tool score AUCs for predicting outcome in back pain were 0.72 and 0.79, neck 0.82 and 0.88, upper limb 0.79 and 0.86, lower limb 0.77 and 0.83, and multisite pain 0.83 and 0.82 in PhysioDirect and SAMBA, respectively. Differences between pain region AUCs were non-significant. Optimal cut-points to discriminate low-risk and medium-risk/high-risk groups depended on pain region and clinical services. CONCLUSIONS A modified STarT Back Tool similarly predicts 6-month physical health outcome across 5 musculoskeletal pain regions. However, the use of consistent risk-group cut-points was not possible and resulted in poor sensitivity (too many with long-term disability being missed) or specificity (too many with good outcome inaccurately classified as 'at risk') for some pain regions. The draft tool is now being refined and validated within a new programme of research for a broader musculoskeletal population. TRIAL REGISTRATION NUMBER ISRCTN55666618; Post results.
Collapse
Affiliation(s)
- J C Hill
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - E K Afolabi
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - M Lewis
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - K M Dunn
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - E Roddy
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - D A van der Windt
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - N E Foster
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| |
Collapse
|
27
|
Adding Psychosocial Factors Does Not Improve Predictive Models for People With Spinal Pain Enough to Warrant Extensive Screening for Them at Baseline. Phys Ther 2016; 96:1179-89. [PMID: 26847011 DOI: 10.2522/ptj.20150304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chiropractors throughout the world by and large focus on patients with musculoskeletal complaints who are generally in good health. Currently, it is widely accepted that neck pain and low back pain are best understood as biopsychosocial phenomena. OBJECTIVE The purpose of this study was to determine whether certain psychosocial factors provide added value for predicting recovery. DESIGN This was a prospective, multicenter, chiropractic, practice-based cohort study in Belgium and the Netherlands. METHODS A total of 917 participants, 326 with neck pain and 591 with low back pain, completed self-administered questionnaires at baseline and at 3, 6, and 12 months. They provided information on several demographic, biomedical, and psychosocial variables. Lasting perceived recovery was used as the outcome measure, that is, recovery at all follow-up assessments from 3 months on. Twenty-seven potential predictors of outcome were used to build the predictive model. Stepwise, backward generalized estimating equation regression models were used to take into account the clustering of participants within practices. For assessment of the added value of psychosocial variables, 2 model fit indexes were compared. RESULTS After the addition of psychosocial variables, predictors in the final model for neck pain included occupational status, body mass index, duration of complaints, previous treatment, and participant expectations (the model fit was marginally improved from 0.684 to 0.695 for the area under the curve and from 65.0% to 66.1% for the percentage correctly predicted). In the final model for low back pain, the selected predictors included country of treatment, age, duration of complaints, previous imaging, and somatization (the area under the curve changed from 0.669 to 0.715, and the percentage correctly predicted changed from 68.6% to 69.5%). Only a minority of participants had high scores on psychological variables. LIMITATIONS The reliability and validity of lasting recovery as an outcome measure have not been tested. The cohort needs to be seen as a convenience sample. Selection bias, therefore, not be ruled out. There are no indications, however, that patients with complex psychosocial profiles were excluded from this study. CONCLUSIONS Psychosocial variables provided little added value for predicting outcome in people who had neck pain or low back pain and sought chiropractic care. Therefore, chiropractors should not screen extensively for them at baseline. With regard to the identification of the small subgroup of people with high scores on psychosocial variables and a high risk for chronic pain, further investigation is needed.
Collapse
|