Outcomes of Patients With Acute Low Back Pain Stratified by the STarT Back Screening Tool: Secondary Analysis of a Randomized Trial

Implementation of an integrated primary care prevention and management program for chronic low back pain (LBP): patient-reported outcomes and predictors of pain interference after six months

BACKGROUND

Integrated primary care programs for patients living with chronic pain which are accessible, interdisciplinary, and patient-centered are needed for preventing chronicity and improving outcomes. Evaluation of the implementation and impact of such programs supports further development of primary care chronic pain management. This study examined patient-reported outcomes among individuals with low back pain (LBP) receiving care in a novel interdisciplinary primary care program.

METHODS

Patients were referred by primary care physicians in four regions of Quebec, Canada, and eligible patients received an evidence-based interdisciplinary pain management program over a six-month period. Patients were screened for risk of chronicity. Patient-reported outcome measures of pain interference and intensity, physical function, depression, and anxiety were evaluated at regular intervals over the six-month follow-up. A multilevel regression analysis was performed to evaluate the association between patient characteristics at baseline, including risk of chronicity, and change in pain outcomes.

RESULTS

Four hundred and sixty-four individuals (mean age 55.4y, 63% female) completed the program. The majority (≥ 60%) experienced a clinically meaningful improvement in pain intensity and interference at six months. Patients with moderate (71%) or high risk (81%) of chronicity showed greater improvement in pain interference than those with low risk (51%). Significant predictors of improvement in pain interference included a higher risk of chronicity, younger age, female sex, and lower baseline disability.

CONCLUSION

The outcomes of this novel LBP program will inform wider implementation considerations by identifying key components for further effectiveness, sustainability, and scale-up of the program.

The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study

BACKGROUND

Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain.

METHODS

This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up.

RESULTS

A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up.

CONCLUSION

The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain.

TRIAL REGISTRATION

Clinicaltrials.gov: 109,643.

Digital Rehabilitation for Acute Low Back Pain: A Prospective Longitudinal Cohort Study

Background

Low back pain (LBP) has a lifetime prevalence of 70–80%. Access to timely and personalized, evidence-based care is key to prevent chronic progression. Digital solutions may ease accessibility to treatment while reducing healthcare-related costs.

Purpose

We aim to report the results of a fully remote digital care program (DCP) for acute LBP.

Patients and Methods

This was an interventional, single-arm, cohort study of patients with acute LBP who received a DCP. Primary outcome was the mean change in disability (Oswestry Disability Index – ODI) after 12 weeks. Secondary outcomes included change in pain (NPRS), analgesic consumption, surgery likelihood, depression (PHQ-9), anxiety (GAD-7), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

A total of 406 patients were enrolled in the program and of those, 332 (81.8%) completed the intervention. A significant disability reduction of 55.1% (14.93, 95% CI 13.95; 15.91) was observed, corresponding to a 76.1% responder rate (30% cut-off). Disability reduction was accompanied by significant improvements in pain (61.0%), depression (55.4%), anxiety (59.5%), productivity (65.6%), fear-avoidance beliefs (46.3%), intent to pursue surgery (59.1%), and analgesic consumption (from 35.7% at baseline to 10.8% at program end). DCP-related patient satisfaction score was 8.7/10.0 (SD 1.4).

Conclusion

This study demonstrated the utility of a multimodal DCP for patients with acute LBP. Very high adherence rates and patient satisfaction were observed, alongside significant reductions in all assessed outcomes, consistent with the growing body of evidence supporting the management of acute LBP with DCPs.

Effect of low back pain on clinical-functional factors and its associated potential risk of chronicity in adolescent dancers of classical ballet: cross-sectional study

BACKGROUND

Low back pain (LBP) is a common symptom in classical ballet dancers, which can limit their daily activities and dance training routines. The purpose of the study was to verify the association and comparison of clinical-functional outcomes (spine flexibility and foot posture) between different levels of intensity low back pain in adolescents of classical ballet and the potential risk of chronicity using the STarT back tool.

METHODS

Cross-sectional study.

PARTICIPANTS

78 adolescent girls who practice classical ballet were evaluated and divided into groups according to level of low back pain: mild (n = 21), moderate (n = 17), and high (n = 20), and a control group (n = 20).

MAIN OUTCOME MEASURES

Pain, flexibility of the spine (thoracic and lumbosacral), risk of chronicity for low back pain, and foot posture were assessed using the visual analogue scale, clinical tests, STarT back screening tool (SBST) questionnaire, and foot posture index (FPI), respectively.

RESULTS

Dancers with high-intensity low back pain showed a potential risk of chronicity by the SBST. The spine pain intensity was not different considering thoracic and lumbosacral flexibility in the sagittal plane, but was different with greater supine FPI when compared to control dancers. Mild low back pain was associated with greater supine FPI. The SBST score was associated with higher exposure time-frequency and time of dancing.

CONCLUSION

Adolescents of classical ballet with high-intensity low back pain showed a potential risk of chronicity by the SBST. The level of intensity low back pain did not influence the clinical-functional aspects of spine flexibility in the sagittal plane, but the level of intensity moderate pain promoted changes in foot posture (more supinated). The potential risk of chronicity using the SBST was also associated with higher exposure time-frequency and time of dancing, in adolescents of classical ballet.

Use of the STarT Back Screening Tool in patients with chronic low back pain receiving physical therapy interventions

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.

Baseline characteristics did not identify people with low back pain who respond best to a Movement System Impairment-Based classification treatment

STUDY DESIGN

Secondary analysis of data from a randomized controlled trial.

BACKGROUND

Treatment based on the Movement System Impairment-Based classification for chronic low back pain results in the same benefit when compared to other forms of exercise. It is possible that participant's characteristics measured at baseline can identify people with chronic low back pain who would respond best to a treatment based on the Movement System Impairment model.

OBJECTIVES

To assess if specific characteristics of people with chronic low back pain measured at baseline can modify the effects of a treatment based on the Movement System Impairment model on pain and disability.

METHODS

Four variables assessed at baseline that could potentially modify the treatment effects of the treatment based on the Movement System Impairment model were selected (age, educational status, physical activity status and STarT back tool classification). Separate univariate models were used to investigate a possible modifier treatment effect of baseline participant's characteristics on pain and disability after the treatment. Findings of interaction values above 1 point for the outcome mean pain intensity or above 3 points for disability (Roland Morris questionnaire) were considered clinically relevant.

RESULTS

Linear regression analyses for the outcomes of pain and disability did not show interaction values considered clinically relevant for age, educational status, physical activity status and STarT back tool classification.

CONCLUSION

Age, educational status, physical activity status and STarT back tool classification did not modify the effects of an 8-week treatment based on the Movement System Impairment model in patients with chronic low back pain. Registered at www.clinicaltrials.gov: NCT02221609 (https://clinicaltrials.gov/ct2/show/NCT02221609).

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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