Adding Psychosocial Factors Does Not Improve Predictive Models for People With Spinal Pain Enough to Warrant Extensive Screening for Them at Baseline

Can a Psychologic Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury?

BACKGROUND

Psychologic variables have been shown to have a strong relationship with recovery from injury and return to work or sports. The extent to which psychologic variables predict successful return to work in military settings is unknown.

QUESTIONS/PURPOSES

In a population of active duty soldiers, (1) can a psychologic profile determine the risk of injury after return to full duty? (2) Do psychologic profiles differ between soldiers sustaining injuries in the spine (thoracic or lumbar) and those with injuries to the lower extremities?

METHODS

Psychologic variables were assessed in soldiers returning to full, unrestricted duty after a recent musculoskeletal injury. Most of these were noncombat injuries from work-related physical activity. Between February 2016 and September 2017, 480 service members who were cleared to return to duty after musculoskeletal injuries (excluding those with high-velocity collisions, pregnancy, or amputation) were enrolled in a study that tracked subsequent injuries over the following year. Of those, we considered individuals with complete 12-month follow-up data as potentially eligible for analysis. Based on that, approximately 2% (8 of 480) were excluded because they did not complete baseline surveys, approximately 2% (11 of 480) were separated from the military during the follow-up period and had incomplete injury data, 1% (3 of 480) were excluded for not serving in the Army branch of the military, and approximately 2% (8 of 480) were excluded because they were not cleared to return to full duty. This resulted in 450 soldiers analyzed. Individuals were 86% (385 of 450) men; 74% (331 of 450) had lower extremity injuries and 26% (119 of 450) had spinal injuries, including soft tissue aches and pains (for example, strains and sprains), fractures, and disc herniations. Time-loss injury within 1 year was the primary outcome. While creating and validating a new prediction model using only psychological variables, 19 variables were assessed for nonlinearity, further factor selection was performed through elastic net, and models were internally validated through 2000 bootstrap iterations. Performance was deciphered through calibration, discrimination (area under the curve [AUC]), R 2 , and calibration in the large. Calibration assesses predicted versus actual risk by plotting the x and y intersection of these values; the more similar predicted risk values are to actual ones, the closer the slope of the line formed by the intersection points of all subjects is to equaling "1" (optimal calibration). Likewise, perfect discrimination (predicted injured versus actual injured) presents as an AUC of 1. Perfect calibration in the large would equal 0 because it represents the average predicted risk versus the actual outcome rate. Sensitivity analyses stratified groups by prior injury region (thoracic or lumbar spine and lower extremity) as well as the severity of injury by days of limited duty (moderate [7-27 days] and severe [28 + days]).

RESULTS

A model comprising primarily psychologic variables including depression, anxiety, kinesiophobia, fear avoidance beliefs, and mood did not adequately determine the risk of subsequent injury. The derived logistic prediction model had 18 variables: R 2 = 0.03, calibration = 0.63 (95% confidence interval [CI] 0.30 to 0.97), AUC = 0.62 (95% CI 0.52 to 0.72), and calibration in the large = -0.17. Baseline psychologic profiles between body regions differed only for depression severity (mean difference 1 [95% CI 0 to 1]; p = 0.04), with greater mean scores for spine injuries than for lower extremity injuries. Performance was poor for those with prior spine injuries compared with those with lower extremity injuries (AUC 0.50 [95% CI 0.42 to 0.58] and 0.63 [95% CI 0.57 to 0.69], respectively) and moderate versus severe injury during the 1-year follow-up (AUC 0.61 [95% CI 0.51 to 0.71] versus 0.64 [95% CI 0.64 to 0.74], respectively).

CONCLUSION

The psychologically based model poorly predicted subsequent injury. This study does not minimize the value of assessing the psychologic profiles of injured athletes, but rather suggests that models looking to identify injury risk should consider a multifactorial approach that also includes other nonpsychologic factors such as injury history. Future studies should refine the most important psychologic constructs that can add the most value and precision to multifactorial models aimed at identifying the risk of injury.

LEVEL OF EVIDENCE

Level III, prognostic study.

Identifying chronic low back pain phenotypic domains and characteristics accounting for individual variation: a systematic review

ABSTRACT

Interpatient variability is frequently observed among individuals with chronic low back pain (cLBP). This review aimed at identifying phenotypic domains and characteristics that account for interpatient variability in cLBP. We searched MEDLINE ALL (through Ovid), Embase Classic and EMBASE (through Ovid), Scopus, and CINAHL Complete (through EBSCOhost) databases. Studies that aimed to identify or predict cLBP different phenotypes were included. We excluded studies that focused on specific treatments. The methodological quality was assessed using an adaptation of the Downs and Black tool. Forty-three studies were included. Although the patient and pain-related characteristics used to identify phenotypes varied considerably across studies, the following were among the most identified phenotypic domains and characteristics that account for interpatient variability in cLBP: pain-related characteristics (including location, severity, qualities, and duration) and pain impact (including disability, sleep, and fatigue), psychological domains (including anxiety and depression), behavioral domains (including coping, somatization, fear avoidance, and catastrophizing), social domains (including employment and social support), and sensory profiling (including pain sensitivity and sensitization). Despite these findings, our review showed that the evidence on pain phenotyping still requires further investigation. The assessment of the methodological quality revealed several limitations. We recommend adopting a standard methodology to enhance the generalizability of the results and the implementation of a comprehensive and feasible assessment framework to facilitate personalized treatments in clinical settings.

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

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.

Addition of MoodGYM to physical treatments for chronic low back pain: A randomized controlled trial

Background

Low back pain (LBP) is prevalent, costly and disabling. A biopsychosocial treatment approach involving physical and cognitive behavioural therapy (CBT) is recommended for those with chronic LBP. It is not known if online psychological coaching tools might have a role in the secondary prevention of LBP related disability. To assess the effectiveness of an internet-delivered psychological program (MoodGYM) in addition to standard physical treatment in patients with chronic non-specific LBP at medium risk of ongoing disability.

Methods

A multisite randomized controlled trial was conducted with 108 participants (aged mean 50.4 ± 13.6 years) with chronic LBP attending one of six private physiotherapy or chiropractic clinics. Disability (Roland Morris Disability Questionnaire) and self-efficacy (Patient Self-Efficacy Questionnaire), were assessed at baseline, post-treatment (8-weeks) with follow-up at six- and twelve-months. Participants were randomized into either the intervention group, MoodGYM plus physical treatments, or the control group which received physical treatments alone.

Results

No statistically significant between group differences were observed for either disability at post-treatment (Effect size (standardised mean difference) 95% CI) RMD - 0.06 (- 0.45,0.31), 6-months RMD 0.01 (- 0.38,0.39) and 12-months - 0.20 (- 0.62,0.17) or self-efficacy at post-treatment PSEQ 0.06 (- 0.31,0.45), 6-months 0.02 (- 0.36,0.41) and 12-months 0.21 (- 0.16,0.63).

Conclusion

There was no additional benefit of an internet-delivered CBT program (MoodGYM) to physical treatments in those with chronic non-specific LBP at medium risk of ongoing disability measured at post-treatment, or at 6 and 12 months.

Trial registration

This trial was prospectively registered with Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000269538.

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

Background

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

Methods

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

Results

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

Conclusion

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

Clinical course and prognosis of musculoskeletal pain in patients referred for physiotherapy: does pain site matter?

Background

Danish patients with musculoskeletal disorders are commonly referred for primary care physiotherapy treatment but little is known about their general health status, pain diagnoses, clinical course and prognosis.

The objectives of this study were to 1) describe the clinical course of patients with musculoskeletal disorders referred to physiotherapy, 2) identify predictors associated with a satisfactory outcome, and 3) determine the influence of the primary pain site diagnosis relative to those predictors.

Methods

This was a prospective cohort study of patients (n = 2,706) newly referred because of musculoskeletal pain to 30 physiotherapy practices from January 2012 to May 2012. Data were collected via a web-based questionnaire 1–2 days prior to the first physiotherapy consultation and at 6 weeks, 3 and 6 months, from clinical records (including primary musculoskeletal symptom diagnosis based on the ICPC-2 classification system), and from national registry data. The main outcome was the Patient Acceptable Symptom State. Potential predictors were analysed using backwards step-wise selection during longitudinal Generalised Estimating Equation regression modelling. To assess the influence of pain site on these associations, primary pain site diagnosis was added to the model.

Results

Of the patients included, 66% were female and the mean age was 48 (SD 15). The percentage of patients reporting their symptoms as acceptable was 32% at 6 weeks, 43% at 3 months and 52% at 6 months. A higher probability of satisfactory outcome was associated with place of residence, being retired, no compensation claim, less frequent pain, shorter duration of pain, lower levels of disability and fear avoidance, better mental health and being a non-smoker. Primary pain site diagnosis had little influence on these associations, and was not predictive of a satisfactory outcome.

Conclusion

Only half of the patients rated their symptoms as acceptable at 6 months. Although satisfactory outcome was difficult to predict at an individual patient level, there were a number of prognostic factors that were associated with this outcome. These factors should be considered when developing generic prediction tools to assess the probability of satisfactory outcome in musculoskeletal physiotherapy patients, because the site of pain did not affect that prognostic association.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1487-3) contains supplementary material, which is available to authorized users.