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Ford JJ, Kaddour O, Gonzales M, Page P, Hahne AJ. Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskelet Disord 2020; 21:567. [PMID: 32825815 PMCID: PMC7442978 DOI: 10.1186/s12891-020-03590-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022] Open
Abstract
Background An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice. Purpose This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). Study design Cohort Study. Methods Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy. Results Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%. Conclusion In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. Clinical relevance These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.
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Affiliation(s)
- Jon J Ford
- College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, 3085, Australia.
| | - Omar Kaddour
- Back in Form Physiotherapy, Ascot Vale, Victoria, Australia
| | | | - Patrick Page
- Box Hill Radiology, Epworth Eastern Hospital, Box Hill, Victoria, Australia
| | - Andrew J Hahne
- College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, 3085, Australia
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Ford JJ, Kaddour O, Page P, Richards MC, McMeeken JM, Hahne AJ. A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy. Br J Neurosurg 2020; 34:381-387. [PMID: 32216592 DOI: 10.1080/02688697.2020.1742288] [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] [Indexed: 10/24/2022]
Abstract
Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.
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Affiliation(s)
- Jon J Ford
- College of Science, Health & Engineering, La Trobe University, Bundoora, Australia.,Advance Healthcare, Boronia, Australia
| | | | - Patrick Page
- Box Hill Radiology, Epworth Eastern Hospital, Box Hill, Australia
| | - Matthew C Richards
- College of Science, Health & Engineering, La Trobe University, Bundoora, Australia.,Advance Healthcare, Boronia, Australia
| | - Joan M McMeeken
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Parkville, Australia
| | - Andrew J Hahne
- College of Science, Health & Engineering, La Trobe University, Bundoora, Australia
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Wiitavaara B, Heiden M. Content and psychometric evaluations of questionnaires for assessing physical function in people with low back disorders. A systematic review of the literature. Disabil Rehabil 2018; 42:163-172. [PMID: 30324809 DOI: 10.1080/09638288.2018.1495274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: The purpose was to investigate how physical function is assessed in people with musculoskeletal disorders in the low back. Specifically:Which questionnaires are used to assess physical function in people with musculoskeletal disorders in the low back?What aspects of physical function do those questionnaires measure?What are the measurement properties of the questionnaires?Materials and methods: A systematic review was performed to identify questionnaires and psychometric evaluations of them. The content of the questionnaires was categorised according to the International Classification of Function, Disability and Health, and the psychometric evaluations were categorised using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist.Results: The questionnaires measured disability or ability to cope in everyday life, rather than physical function as such. Different aspects of a person's mobility and ability to attend to one's personal care were most often included regarding activity and participation. For body functions, items about sleep and pain were most often included. The Oswestry Disability Index and the Quebec Back Pain Disability Scale showed adequate psychometric properties in most evaluations.Conclusions: The extent of psychometric evaluations differed substantially, as did the items included. Focus of measurement was predominantly on activities in daily life.Implications for rehabilitationValid and reliable instruments that measure relevant aspects of low back disorders are needed to provide early diagnostics and effective treatment.Most questionnaires need more psychometric evaluations to establish the quality.The Oswestry Disability Index and the Quebec Back Pain Disability Scale showed adequate psychometric properties in most evaluations.The results may be useful when making decisions about which measurement instruments to use when evaluating low back disorders.
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Affiliation(s)
- Birgitta Wiitavaara
- Department of Occupational and Public Health Sciences, Faculty of Health and Occupational Studies, Centre for Musculoskeletal Research, University of Gävle, Gävle, Sweden
| | - Marina Heiden
- Department of Occupational and Public Health Sciences, Faculty of Health and Occupational Studies, Centre for Musculoskeletal Research, University of Gävle, Gävle, Sweden
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Ford JJ, Richards MC, Surkitt LD, Chan AYP, Slater SL, Taylor NF, Hahne AJ. Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy. Arch Phys Med Rehabil 2018; 99:2504-2512.e12. [PMID: 29852152 DOI: 10.1016/j.apmr.2018.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/19/2018] [Accepted: 04/21/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs). DESIGN Prospective inception cohort study. SETTING Primary care private physiotherapy clinics in Melbourne, Australia. PARTICIPANTS Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale. RESULTS Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome. CONCLUSIONS This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.
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Affiliation(s)
- Jon J Ford
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia.
| | - Matt C Richards
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Luke D Surkitt
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Alexander Y P Chan
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Sarah L Slater
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Nicholas F Taylor
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Andrew J Hahne
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
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Clinical classification criteria for nonspecific low back pain: A Delphi-survey of clinical experts. Musculoskelet Sci Pract 2018; 34:66-76. [PMID: 29367122 DOI: 10.1016/j.msksp.2018.01.002] [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: 08/09/2017] [Revised: 12/14/2017] [Accepted: 01/05/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Nonspecific low back pain (NSLBP) is a common problem. Attempts have been made to classify NSLBP patients into homogenous subgroups. Classification systems based on identifying the underlying mechanism(s) driving the disorder are clinically useful to guide specific interventions. OBJECTIVE To establish consensus among experts regarding clinical criteria suggestive of a dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns (DPs) in NSLBP patients. STUDY DESIGN A 2-phase sequential design of a focus group and Delphi-study. METHODS A focus group with 10 academic experts was organized to elaborate on the different DPs discernible in LBP patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 DPs resulting from the focus group. RESULTS Fifteen musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating LBP patients completed the Delphi-survey. Respectively, 34 (response rate, 100.0%), 20 (58.8%) and 15 (44.12%) respondents replied to rounds 1, 2 and 3. Twenty-two 'articular', 20 'myofascial', 21 'neural', 18 'central' and 11 'sensorimotor control' criteria reached a predefined ≥80% consensus level. For example, after round 2, 85.0% of the Delphi-experts agreed to identify 'referred pain below the knee' as a subjective examination criterion suggestive for a predominant 'neural DP'. CONCLUSION These indicators suggestive of a clinical dominance of the proposed DPs could help clinicians to assess and diagnose NSLBP patients. Future reliability and validity testing is needed to determine how these criteria may help to improve physical therapy outcome for NSLBP patients.
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Optimising conservative management of chronic low back pain: study protocol for a randomised controlled trial. Trials 2017; 18:184. [PMID: 28427472 PMCID: PMC5399383 DOI: 10.1186/s13063-017-1913-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/22/2017] [Indexed: 12/19/2022] Open
Abstract
Background Lower back pain is a global health issue affecting approximately 80% of people at some stage in their life. The current literature suggests that any exercise is beneficial for reducing back pain. However, as pain is a subjective evaluation and physical deficits are evident in low back pain, using it as the sole outcome measure to evaluate superiority of an exercise protocol for low back pain treatment is insufficient. The overarching goal of the current clinical trial is to implement two common, conservative intervention approaches and examine their impact on deficits in chronic low back pain. Methods/design Forty participants, 25–45 years old with chronic (>3 months), non-specific low back pain will be recruited. Participants will be randomised to receive either motor control and manual therapy (n = 20) or general strength and conditioning (n = 20) exercise treatments for 6 months. The motor control/manual therapy group will receive twelve 30-min sessions, ten in the first 3 months (one or two per week) and two in the last 3 months. The general exercise group will attend two 1-hour sessions weekly for 3 months, and one or two a week for the following 3 months. Primary outcome measures are average lumbar spine intervertebral disc T2 relaxation time and changes in thickness of the transversus abdominis muscle on a leg lift using magnetic resonance imaging (MRI). Secondary outcomes include muscle size and fat content, vertebral body fat content, intervertebral disc morphology and water diffusion measured by MRI, body composition using dual energy X-ray absorptiometry, physical function through functional tests, changes in corticospinal excitability and cortical motor representation of the spinal muscles using transcranial magnetic stimulation and self-reported measure of pain symptoms, health and disability. Outcome measures will be conducted at baseline, at the 3-month follow-up and at 6 months at the end of intervention. Pain, depressive symptomology and emotions will be captured fortnightly by questionnaires. Discussion Chronic low back pain is ranked the highest disabling disorder in Australia. The findings of this study will inform clinical practice guidelines to assist with decision-making approaches where outcomes beyond pain are sought for adults with chronic low back pain. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12615001270505. Registered on 20 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1913-8) contains supplementary material, which is available to authorized users.
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Hahne AJ, Ford JJ, Surkitt LD, Richards MC, Chan AYP, Thompson SL, Hinman RS, Taylor NF. Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders. BMC Musculoskelet Disord 2011; 12:104. [PMID: 21599941 PMCID: PMC3121656 DOI: 10.1186/1471-2474-12-104] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 05/20/2011] [Indexed: 11/29/2022] Open
Abstract
Background Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups. Methods/Design A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes. Discussion This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.
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Affiliation(s)
- Andrew J Hahne
- Musculoskeletal Research Centre and School of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia.
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Cleland J, Gillani R, Bienen EJ, Sadosky A. Assessing dimensionality and responsiveness of outcomes measures for patients with low back pain. Pain Pract 2011; 11:57-69. [PMID: 20602714 DOI: 10.1111/j.1533-2500.2010.00390.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide a systematic literature review of the responsiveness of patient-reported health outcomes measures for the evaluation of low back pain (LBP). METHODS AND DESIGN Searches of MEDLINE and EMBASE were performed for articles published in English through June 29, 2009 using the search terms "back pain" or "low back pain" and "questionnaires" or "instrument" or "survey" or "measure" or "patient report outcome." Information on responsiveness was gathered through additional measure-specific searches that included the measure name, first author of the original paper, and "respons*" or "sensit*." Responsiveness was determined based on use of a receiver operating characteristics curve or effect size statistics. RESULTS Of 43 identified measures, 31 were reported as being responsive to treatment or clinical change, 25 of which were evaluated for responsiveness using methods considered adequate. When considering both the responsiveness evaluation and the underlying factor structure, 13 measures were identified as being adequately validated for use in evaluating responsiveness in the research or clinical practice setting. The majority of the LBP outcome assessment studies were comprised of patients undergoing physical and interventional therapies from clinical practice and clinical trials. The Roland Morris Disability Questionnaire and the Oswestry Disability Index were the most comprehensively validated measures with respect to responsiveness. CONCLUSIONS We identified 13 measures of LBP that can be used to evaluate responsiveness to change. Choice of a measure warrants careful evaluation of its construct and responsiveness properties in order to maximize the observed impact on pain and functional improvement in subjects with LBP.
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Affiliation(s)
- Josh Cleland
- Franklin Pierce University, Concord, New Hampshire, USA
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Slack WV, Kowaloff HB, Davis RB, Delbanco T, Locke SE, Bleich HL. Test-retest reliability in a computer-based medical history. J Am Med Inform Assoc 2011; 18:73-6. [PMID: 21113077 PMCID: PMC3005870 DOI: 10.1136/jamia.2010.005983] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 11/03/2010] [Indexed: 11/04/2022] Open
Abstract
The authors developed a computer-based medical history for patients to take in their homes via the internet. The history consists of 232 'primary' questions asked of all patients, together with more than 6000 questions, explanations, and suggestions that are available for presentation as determined by a patient's responses. The purpose of this research was to measure the test-retest reliability of the 215 primary questions that have preformatted, mutually exclusive responses of 'Yes,' 'No,' 'Uncertain (Don't know, Maybe),' 'Don't understand,' and 'I'd rather not answer.' From randomly selected patients of doctors affiliated with Beth Israel Deaconess Medical Center in Boston, 48 patients took the history twice with intervals between sessions ranging from 1 to 35 days (mean 7 days; median 5 days). High levels of test-retest reliability were found for most of the questions, but as a result of this study the authors revised five questions. They recommend that structured medical history questions that will be asked of many patients be measured for test-retest reliability before they are put into widespread clinical practice.
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Affiliation(s)
- Warner V Slack
- Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
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