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Back pain: long-term course and predictive factors
Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.ORCID iD: 0000-0003-3707-5869
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background. Better knowledge of the long-term course in patients treated in primary care for back pain (clinical course) and in patients that do not receive specific treatment after seeking care (clinical natural course) is needed to enable health professionals and their patients to understand the likely course of back pain and to make clinical decisions about treatment alternatives.

Aims. To increase and deepen the knowledge of the course of back pain during 2½ and 5 years, and of predictive factors for health condition and sick-leave at 1-year and 5-year follow-ups for patients with low back pain. In addition specific emphasis was on assessing the influence of type of outcome measure, timepoint of assessment of the outcome measure, timepoint of assessment of the predictive factors (baseline, after treatment or after four weeks) and inclusion of different combinations of predictive factors. Furthermore to assess the ability of physiotherapists to predict which patients will return for additional care if they do not receive specific treatment.

Material and Methods. The thesis is based on two cohorts of patients between 18 to 60 years of age seeking primary care for back pain. Exclusion criteria were having received active treatment for the current back pain within the previous month, other disease, recent accident, pregnancy, and inability to understand Swedish. In one cohort 254 patients previously treated in primary care filled out a 5-year follow-up questionnaire. Also in the other cohort almost the same questionnaire was used, including a package of well-known measures of pain, disability, recurrence rate, healthcare consumption, sick-leave, and questions regarding demographic data. The other cohort including 56 patients was used to describe the clinical natural course with 2½-year follow-up. Patients filled out questionnaires at baseline, after 4 weeks, at 6 months and at 1- and 2½ year follow-ups. Besides physical measures were assessed at baseline and after four weeks. The physiotherapist predicted whether the patient would or would not return for additional care. Main outcome measures for describing the course of back pain were pain and disability, and secondary measures were recurrence rate and health care consumption. Logistic regression was used to identify predictive factors for disability and sick-leave. Prediction models for the two outcome variables at the I-year and 5-year follow-up were created to assess whether the models were influenced by difference in outcome measure, timepoint of measuring the outcome, timepoint of assessment of potential predictive factors (baseline or after treatment), and different combinations of potential predictive factors included in the models. Potential predictive factors included were "standard" factors age, gender, sick-leave, pain frequency, disability, well-being, expectations of treatment, similar problems the previous 5 years, duration of the current episode, more than one localization, and physical activity-related and work-related independent variables. Linear regression was used to assess the predictive value of physical measures, assessed at baseline and at 4-week follow-up, for health condition at 1-year follow-up.

Results. About half the patients treated in primary care reported pain and disability at the land 5-year follow-up. Around two third of the patients reported recurrence or continuous pain, and approximately one third of the patients reported additional healthcare consumption during the previous 6 months at the 1-year and 5-year follow-up. These proportions were similar for the clinical natural course cohort at the 1-year and 2½-year follow-up. Predictive factors for disability and sick-leave were only partly the same. Disability appeared to be an important predictive factor for future disability. Sick-leave and dissatisfaction with the workplace appeared to be important predictive factors for future sick-leave. Predictive factors for outcome at 1-year  and 5-year follow-up were only partly the same. Health state related variables and duration of the current episode seemed to be stronger predictive factors for outcome at 1-year follow-up than for outcome at 5-year follow-up, whereas being a woman, and physical activity-related and work-related factors were stronger predictive factors for outcome at 5-year follow-up. Health state related variables assessed after treatment appeared to be stronger predictive factors for future disability or sick-leave compared with corresponding variables at baseline. Several confidence intervals were wide and the results must be interpreted with caution. Three out of four physical measures assessed at 4-week follow-up seemed to be predictive factors for health condition after one year. None of these four measures assessed at baseline had predictive value. The physiotherapists showed ability to predict which patients would or would not return for additional care.

Conclusions. A substantial proportion of patients seeking primary care for back pain continued to report back pain several years after seeking care. Future research should focus on prevention, as well as on management of patients with long-term back pain. Both selfreported measures related to health state, physical activity and work, as well as physical measures and prediction by health professionals seem helpful to identify patients at risk of worse future health condition and sick-leave. Further exploration of the predictive value of disability and sick-leave showed that future disability was predicted by disability only, and future sick-leave was predicted by both sick-leave and disability. In clinical practice, selfreported measures and physical measures can be assessed for various reasons. To improve the ability to predict future outcome, information obtained at a later timepoint than baseline should be used instead of information obtained at the first visit. Assessment of physical measures at baseline was useless for prediction purposes. Future studies should include other factors, such as psychosocial predictive factors found in other studies, to further improve the ability to predict future health condition and sick-leave. Another promising area of research is further exploration of the ability of health care professionals to predict outcomes, and on what grounds they base their predictions.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2005. , 76 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 881
Keyword [en]
back pain
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-29347Local ID: 14669ISBN: 91-7373-859-X (print)OAI: oai:DiVA.org:liu-29347DiVA: diva2:250159
Public defence
2005-02-04, Aulan, Hälsans hus, Ingång 16, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2013-09-03Bibliographically approved
List of papers
1. Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis
Open this publication in new window or tab >>Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis
2004 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 29, no 21, 2458-2465 p.Article in journal (Refereed) Published
Abstract [en]

Study Design. Prospective follow-up.

Objective. To describe the 5-year clinical course in a cohort of patients treated for back or neck pain in primary care and compare results with the 1-year outcome both for the whole group and for subgroups.

Summary of Background Data. A randomized study showed a decrease in perceived pain and disability after treatment by chiropractic or physiotherapy, but many reported recurrence or continual pain at the 1-year follow-up. Knowledge of the clinical course over longer follow-up periods is limited.

Methods. A 5-year follow-up questionnaire was sent to 314 individuals. Main outcome measures were pain intensity, Oswestry score, and general health. Recurrence, health care consumption, and other measures were described.

Results. Fifty-two percent of respondents reported pain (visual analog scale, >10 mm) and back-related disability (Oswestry, >10%) at the 5-year follow-up. This was similar to 1-year results, and 84% of these were the same individuals. Sixty-three percent reported recurrence or continual pain, and 32% reported health care consumption at the 5-year follow-up.

Conclusions. In a cohort of individuals of working age seeking primary care for nonspecific back or neck pain, it can be expected that about half of the population will report pain and disability at the 5-year follow-up. A significant proportion will report recurrence or continual pain and health care consumption. Pain and disability were associated with recurrence or continual pain and health care consumption. Further analysis is needed to identify additional predictors for 5-year outcome, taking into account 1-year follow-up results. Since many patients will have recurrence or continual pain, health policies and clinical decision models for long-term outcome must allow for these aspects.

Keyword
back pain, neck pain, primary care, disability, recurrence, health care consumption
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-22473 (URN)10.1097/01.brs.0000143025.84471.79 (DOI)1716 (Local ID)1716 (Archive number)1716 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption
Open this publication in new window or tab >>Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption
2003 (English)In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 5, no 3, 98-108 p.Article in journal (Refereed) Published
Abstract [en]

The aim was to describe the clinical course without active treatment in patients with low back and neck pain visiting primary care. A prospective consecutive study was done with follow-ups weekly for 6 weeks and at 3, 6, 12 and 30 months. Main outcome measures were proportion of patients who were free of pain and back-related disability and proportion of patients found to have received additional healthcare at 3-, 6-, 12- and 30-month follow-ups. The physiotherapist predicted additional treatment. Eighty consecutive patients were included. 39 low back pain and 17 neck pain patients underwent 30 months of follow-up. The results on a group level were consistent from about 4 weeks. In the low back pain group, 41% reported no pain and no disability after 30 months, within 3 months 33% and within 30 months 64% had received additional healthcare. In the neck pain group, 12% reported no pain and no disability after 30 months, within 3 months 59% and within 30 months 71% had received additional healthcare. A higher proportion of the patients, predicted with a high probability to seek additional care also reported additional care. It can be expected that half the back pain patients being cared for in primary care will continue to suffer from problems 30 months later. The slope of recovery is most prominent during the first 4 weeks, and a worse outcome is in the neck pain patients. Further healthcare is not equal to self-reported back pain problems at baseline. The 4-week evaluation can be used to predict groups with future healthcare utilization up until 30 months. Further studies including larger cohorts are needed to confirm the results.

National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-26265 (URN)10.1080/14038190310004862 (DOI)10775 (Local ID)10775 (Archive number)10775 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care
Open this publication in new window or tab >>Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care
2006 (English)In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 122, no 1-2, 137-144 p.Article in journal (Refereed) Published
Abstract [en]

Many patients seeking primary care for low back pain continue to report disability several years after their initial visit. The aims of this study were to assess the independent predictive value of a number of potential predictive factors for disability at the 1-year and 5-year follow-ups, and to examine whether prediction models were improved by replacing baseline health-state-related variables with corresponding variables after treatment. A further aim was to describe possible differences between those on sick leave, early retirement or disability pension, and those who were not. Baseline factors were age, gender, self-reported physical-activity-related and work-related factors, expectations of treatment, similar problems previously, duration of episode, more than one localization, sick leave, pain frequency, disability, and well-being. The study sample comprised 148 participants in a previous randomized trial who were eligible for sick-leave benefits. Multiple logistic regression was used to identify predictive factors. At the 5-year follow-up, 37% (n = 19/52) of the patients with disability were on sick leave or were receiving early retirement or disability pension. For those without disability the corresponding figure was 9% (n = 8/92). Being a woman, duration of the current episode, similar problems during the previous 5 years, exercise level before the current episode, pain frequency at baseline, and disability after treatment emerged as predictive factors for disability at the 5-year follow-up. Replacing baseline health-state-related measures with corresponding measures after the treatment period, and adding physical-activity-related and possibly work-related factors might improve the likelihood of predicting future disability.

National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-33458 (URN)10.1016/j.pain.2006.01.022 (DOI)19479 (Local ID)19479 (Archive number)19479 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
4. Course of back pain in primary care: a prospective study of physical measures
Open this publication in new window or tab >>Course of back pain in primary care: a prospective study of physical measures
2003 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 35, no 4, 168-173 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To describe physical measures used in patients with back pain when no specific treatment is given, to examine associations between change over time in these measures and changes in pain and back-related disability, and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months.

DESIGN: A prospective consecutive study.

SUBJECTS: Forty-four patients presenting with low back pain in primary care.

METHODS: The patients underwent a physical examination at baseline and at 4 weeks. Follow-up was carried out using questionnaires until 12 months. Linear regression was used to identify predictors.

RESULTS: Most measures had improved significantly at the 4-week follow-up. Thoracolumbar rotation, isometric endurance back extensors, and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up. Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline. This group of patients improved more in physical measures between baseline and the 4-week follow-up.

CONCLUSION: Physical measures assessed at the 4-week follow-up, but not at baseline, could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months.

National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-26264 (URN)10.1080/16501970306124 (DOI)10774 (Local ID)10774 (Archive number)10774 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved

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