Background

Lumbar spinal stenosis is a leading indication for spine surgery, but outcomes are heterogeneous. We aimed to develop and externally validate prediction models for 12-month disability and pain to inform shared decision-making.

Methods

This registry-based multicentre cohort study used data from three national spine registries of patients (≥16 years) undergoing elective lumbar spinal stenosis surgery. Data from the Norwegian Registry for Spine Surgery (NORspine, 2007–2023) were used for model development and internal-external cross-validation (IECV). External validation was carried out in the Swedish Registry (SweSpine, 2016–2022) and Danish Registry (DaneSpine, 2009–2022) with data collected by the Spine Centre of Southern Denmark. The primary outcome was the Oswestry Disability Index (ODI) at 12 months, modelled as a continuous and binary measure (acceptable symptom state). Secondary outcomes were Numeric Rating Scale (NRS) back and leg pain at 12 months. Logistic regression, linear regression, and XGBoost models were applied with 16 predictors. Missing data were handled using multiple imputation. Performance was assessed by calibration, mean absolute error (MAE), adjusted R2, and C-statistics. This study is registered with Open Science Framework (https://osf.io/qz27b/).

Findings

The development cohort included 31,908 patients (52.4% female, 47.6% male). The external validation cohorts included 30,700 from SweSpine (52.8% female, 47.2% male) and 4063 from DaneSpine (54.6% female, 45.4% male). Twelve-month outcome completeness was 77% in the development cohort and ranged from 66% to 80% across the external validation cohorts. For ODI, linear regression achieved a pooled MAE of 12.4 (95% CI 11.8–13.1) after IECV, and 13.3 (95% CI 13.2–13.4) and 12.3 (95% CI 12.0–12.7) at external validation. Adjusted R2 values ranged from 0.26 to 0.33. Calibration was acceptable, with slopes near 1 and calibration-in-the-large ranging from −0.47 after IECV to 1.28–1.54 at external validation, indicating minor systematic underprediction. The binary ODI model achieved C-statistics of 0.75 (95% CI 0.74–0.76) after IECV, and 0.78 (95% CI 0.78–0.79) and 0.76 (95% CI 0.74–0.77) at external validation. Pain models showed lower performance (MAE 2.2–2.6; C-statistics 0.64–0.73). XGBoost yielded similar results.

Interpretation

Models predicting disability and pain were well calibrated and generalisable across Scandinavian countries, with the best overall performance for disability. These findings provide a foundation for prospective evaluation in future studies to determine the impact on decision-making and patient outcomes in clinical practice.

Background Clinical guidelines recommend a biopsychosocial approach to low back pain (LBP) management, with physiotherapists playing a key role in occupational health primary care (OHPC). However, little is known about how their clinical behaviours at the first visit align with guideline-oriented biopsychosocial principles. Therefore, we evaluated LBP management quality in OHPC by applying predefined criteria to physiotherapists' documentation. Methods Based on a cluster-randomised implementation study data (ISRCTN11875357) we analysed 98 electronic patient records (EPRs) documented by 28 physiotherapists across diverse OHPC units. The intervention arm had received 3-7 days of biopsychosocial training. A stratified random sample of EPRs from individuals with LBP was reviewed using a structured researcher's evaluation tool. Each item was scored dichotomously (yes/no) and evaluated against predefined quality criteria with stepwise thresholds for different work disability risk groups. Results Step I, multidimensional biopsychosocial assessment of LBP, was documented in fewer than half of the records (36.5% in the intervention vs 16.7% in the control arm, p=0.081). The biological dimension was well documented in both arms (100% vs 95.8%, p=0.245), while psychological (58.1% vs 25%, p=0.009) and social (54.1% vs 29.2%, p=0.038) dimensions were more frequently documented in the intervention arm. Step II quality criteria (low-risk patients) were met in 58.1% of intervention versus 4.2% of control records (p<0.001), and step III (medium-risk) in 55.4% versus 4.2% (p<0.001). No EPRs met step IV (high-risk) quality criteria. The intervention arm more often documented psychosocial assessments, risk stratification, behavioural strategies and advice to stay active. Person-centredness (ie, goals, values, resources, expectations) was rarely documented (36.5% vs 0%, p<0.001).Results Step I, multidimensional biopsychosocial assessment of LBP, was documented in fewer than half of the records (36.5% in the intervention vs 16.7% in the control arm, p=0.081). The biological dimension was well documented in both arms (100% vs 95.8%, p=0.245), while psychological (58.1% vs 25%, p=0.009) and social (54.1% vs 29.2%, p=0.038) dimensions were more frequently documented in the intervention arm. Step II quality criteria (low-risk patients) were met in 58.1% of intervention versus 4.2% of control records (p<0.001), and step III (medium-risk) in 55.4% versus 4.2% (p<0.001). No EPRs met step IV (high-risk) quality criteria. The intervention arm more often documented psychosocial assessments, risk stratification, behavioural strategies and advice to stay active. Person-centredness (ie, goals, values, resources, expectations) was rarely documented (36.5% vs 0%, p<0.001).Results Step I, multidimensional biopsychosocial assessment of LBP, was documented in fewer than half of the records (36.5% in the intervention vs 16.7% in the control arm, p=0.081). The biological dimension was well documented in both arms (100% vs 95.8%, p=0.245), while psychological (58.1% vs 25%, p=0.009) and social (54.1% vs 29.2%, p=0.038) dimensions were more frequently documented in the intervention arm. Step II quality criteria (low-risk patients) were met in 58.1% of intervention versus 4.2% of control records (p<0.001), and step III (medium-risk) in 55.4% versus 4.2% (p<0.001). No EPRs met step IV (high-risk) quality criteria. The intervention arm more often documented psychosocial assessments, risk stratification, behavioural strategies and advice to stay active. Person-centredness (ie, goals, values, resources, expectations) was rarely documented (36.5% vs 0%, p<0.001). Conclusion Training in guideline-oriented biopsychosocial approach was associated with more frequent documentation of behaviours aligned with high-quality LBP management. However, overall quality varied, and person-centred aspects remained underreported. Complementary implementation strategies are required to ensure consistent delivery and documentation of biopsychosocial clinical practice in OHPC.

Objectives This study aimed to investigate the effect of a brief training intervention for occupational health services (OHS) professionals on multiprofessional resource utilization and the costs of biopsychosocial management of patients with low-back pain (LBP) compared to usual care among all participants and those in work disability-based risk groups. Methods OHS utilization and back-related sick leave data were collected from electronic patient records over one-year follow-up comparing 232 patients in the intervention arm and 80 control-arm patients, stratified for risk of work disability based on the Orebro Musculoskeletal Pain Screening Questionnaire. We estimated costs using linear mixed models by multiplying unit costs (in euros) by each type of OHS resource use (visits to physicians, physiotherapists, nurses, use of imaging) and the number of sick leaves. Estimated mean cost differences with confidence intervals (CI) were reported using bootstrapping to deal with skewed cost data. Results The median number of visits to physicians and physiotherapists in the intervention versus control arms was 1 [interquartile range (IQR) 0-3] and 2 (IQR 1-4) versus 2 (IQR 1-3) and 1 (IQR 0-2), respectively. The intervention arm accrued lower physician costs (<euro>-43, 95% CI <euro>-82--3, P=0.034) and higher physiotherapist costs (<euro>55, 95% CI <euro>26-84, P<0.001) compared to the control arm. There was no statistically significant difference in average total costs between the arms (<euro>-1908, 95% CI <euro>-6734-2919). In the low- and medium-risk groups of work disability, physiotherapist costs were higher in the intervention than control arm, but no statistically significant differences were observed between the arms in the total resource utilization or sickness absence costs. Conclusions Brief biopsychosocial training may support shifting OHS resources towards multiprofessional physiotherapist-driven care, instead of solely physician-driven care, for management of patients with LBP in differing risk groups of work disability with no substantial differences in total costs.

Introduction: This project aimed to develop a Person-Centred Co-ordinated Care (P3C) pathway for low back pain (LBP).

Description: A national working group was formed consisting of representatives from all regional healthcare organisations in Sweden and included all relevant healthcare professions, academia, and patient organisations. A mixed method iterative design and consensus approach was applied in the development of the P3C pathway.

Discussion: As a foundation, patient interviews along with a review of literature were conducted investigating the evidence base for healthcare interventions, earlier regional care programs/pathways and guidelines in Sweden as well as patient experiences and challenges with healthcare for LBP. Updated evidence-based clinical recommendations, tools supporting the practical use of the national P3C pathway and national healthcare data registry-based quality outcome indicators were then developed. Thereafter, an open consultation period provided review and feedback for final revisions and consensus.

Conclusions: Essential factors for integrating best praxis according to scientific evidence and patient and healthcare professional perspectives were identified to establish a Swedish national P3C pathway for LBP. This provides a novel and innovative example of feasible methodology applicable in the international context. Future research will evaluate potential improvements in healthcare quality outcomes and effectiveness of dissemination and implementation strategies.

Background and purpose — Data on effectiveness of nighttime bracing compared with full-time bracing in ado-lescent idiopathic scoliosis is scarce. We aimed to investigate risk of curve progression and surgery with nighttime bracing vs full-time bracing for patients with moderate-grade adolescent idiopathic scoliosis.

Methods — Skeletally immature individuals with idio-pathic scoliosis (25°–40°) treated with a nighttime brace as part of a parallel-group randomized controlled trial (RCT) were compared with non-participants treated with a full-time brace. In the case of curve progression of more than 6° in the nighttime brace group individuals were offered transition to a full-time brace. Surgery was offered if curve sizes were 45° or larger.

Results — Median age at treatment start was 12.8 years (nighttime brace n = 45, full-time brace n = 44). Female sex (odds ratio [OR] 6.5, 95% confidence interval [CI] 1.1–37.4), lower Risser grade (OR 1.6, CI 1.01–2.7), and larger curve size at the beginning of brace treatment (OR 1.4, CI 1.2–1.5) increased the risk of curve progression to ≥ 45°. Major curves in the groups were similar at median 33 months’ follow-up (P = 0.7). After 94 months of follow-up, 11 patients in the nighttime brace group and 6 in the full-time brace group had undergone surgery (OR 2.0, CI 0.7–6.1).

Conclusion —Nighttime bracing, including a possibility to transition to full-time brace in the case of progression, dem-onstrated comparable effectiveness in preventing curve pro-gression, but a tendency to a higher risk of surgical treatment.

Objective This study evaluated the effects of a 6-week osteoarthritis (OA) exercise and education intervention on metabolic health markers, including blood pressure (BP), glycated haemoglobin (HbA1c), high-density lipoprotein (HDL), cholesterol levels and weight in individuals with both OA and diabetes.Methods Data originated from the Swedish Osteoarthritis and Diabetes cohort, which is composed of the Swedish Osteoarthritis Register (SOAR) and National Diabetes Register. We included individuals diagnosed with OA and diabetes who underwent the intervention between January 2008 and December 2019, matched with controls with diabetes who did not based on birth year, sex, OA site (hip/knee) and OA diagnosis year. Outcomes included BP, HbA1c, HDL, total cholesterol levels and weight measured up to 3 years before and after SOAR enrolment. Statistical analyses used two-way fixed-effect models.Results The study included 4571 individuals with OA and diabetes (mean age: 69.5, SD: 7.8; women: 52.7%; knee OA: 71.2%) and 7925 controls. The intervention group showed a systolic BP decrease of approximately 1.0 mm Hg at 6 and 12 months compared with the control group. HDL levels increased by about 0.02 mmol/L at 12, 18 and 24 months. Weight decreased by approximately 0.5 kg at 6, 18 and 30 months. HbA1c levels increased by approximately 0.5 mmol/mol at 6 months. No essential differences were found in the total cholesterol levels.Conclusion An OA exercise and education intervention designed following OA clinical practice guidelines led to small and unlikely clinically relevant improvements in metabolic health markers in individuals with OA and diabetes.

Background and purpose: The study’s purpose was to develop and internally validate a prognostic survival model exploring baseline variables for adolescent idiopathic scoliosis curve progression.

Methods: A longitudinal prognostic cohort analysis was performed on trial data (n = 135) including girls and boys, Cobb angle 25–40°, aged 9–17 years, remaining growth > 1 year, and previously untreated. Prognostic outcome was defined as curve progression of Cobb angle of > 6° prior to skeletal maturity. 34 candidate prognostic variables were tested. Time-to-event was measured with 6-month intervals. Cox proportional hazards regression survival model (CoxPH) was used for model development and validation in comparison with machine learning models (66.6/33.3 train/test data set). The models were adjusted for treatment exposure.

Results: The final primary prognostic model included 127 patients, predicting progress with acceptable discriminative ability (concordance = 0.79, 95% confidence interval [CI] 0.72–0.86). Significant prognostic risk factors were Risser stage of 0 (HR 4.6, CI 2.1–10.1, P < 0.001), larger major curve Cobb angle (HRstandardized 1.5, CI 1.1–2.0, P = 0.005), and higher score on patient-reported pictorial Spinal Appearance Questionnaire (pSAQ) (HRstandardized 1.4, CI 1.0–1.9, P = 0.04). Treatment exposure, entered as a covariate adjustment, contributed significantly to the final model (HR 3.1, CI 1.5–6.0, P = 0.001). Sensitivity analysis displayed that CoxPH maintained acceptable discriminative ability (AUC 0.79, CI 0.65–0.93) in comparison with machine learning algorithms.

Conclusion: The prognostic model (Risser stage, Cobb angle, pSAQ, and menarche) predicted curve progression of > 6° Cobb angle with acceptable discriminative ability. Adding patient report of the pSAQ may be of clinical importance for the prognosis of curve progression.

Objective: To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs.Methods: Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups.Results: No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p &lt; .001) and from baseline to 3 (p = .037) and 12 (p = .003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p = .021) and from baseline to 3 (p = .001) and 6 (p = .044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p &lt; .001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p &lt; .001).Conclusion: NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness.

Purpose: People living with osteoarthritis (OA) often do not receive best evidence care. Coordinated OA management programs (OAMPs) have been implemented to address this global evidence-practice gap. An OAMP is defined as a package of care with the following: i) a personalized management plan; ii) with reassessment and progression; iii) using a minimum of 2 core treatments (education, exercise, weight control), and; iv) optional adjunctive therapies. Existing OAMP models differ in treatment mode, intensity, duration, the health professionals delivering care, and the healthcare systems and settings they operate within. Randomized trials (RCTs) and cohort studies assess the outcomes of different OAMPs, however, these models are unlikely to ever be compared in RCTs due to the huge expense and complicated logistics required. Prognosis research provides another method of comparing outcomes of different OAMP models. This study aimed to estimate the pain and self-reported function outcomes (at 12-, 26- and 52-weeks) of people with hip and/or knee OA who participated in international OAMPs. It also aimed to describe the characteristics of OAMP participants.

Methods: This study was undertaken by members of the OARSI Joint Effort Initiative (JEI), in collaboration with the OA Trial Bank (Erasmus MC, Netherlands). RCTs and clinical cohorts assessing OAMPs were identified through the JEI membership and literature searches. Eligible studies included data from an ongoing OAMP, in any real-world setting, with participants who were diagnosed with hip or knee OA, and longitudinal measures of patient-reported pain and function. The investigators of eligible studies were invited to complete data delivery agreements with the OA Trial Bank, share individual participant data (IPD), contribute to study design and authorship. Investigators ensured they had local ethics review board approval to contribute IPD to the OA Trial bank. Each dataset was converted to a common format to enable merging into one dataset. The IPD were evaluated to convert pain and function variables to standardized scales as appropriate. Pain scores were converted to a 0-100 point scale (100 worst). Function scores were converted to a 0-100 point scale (100 best). A generalized estimating equations (GEE) model analysis was performed to assess the change in pain and function from baseline across weeks 12, 26, and 52. The model specification was based on an unstructured correlation structure and robust standard errors. Pain and function estimates were adjusted by age, sex and body mass index (BMI). Data analyses were carried out using Stata 15 (StataCorp 2015) and SPSS 17.

Results: The investigators of 13 international OAMPs were invited to take part. IPD from 9 OAMPs were delivered: the OA Chronic Care Program, Ramsay Health OA Management Program, Joint Health Program, University of Wisconsin Health Knee and Hip Comprehensive Non-Surgical OA Management Clinic, Improved Management of Patients With Hip and Knee OA in Primary Health Care, Joint Academy, Amsterdam OA cohort, Management of OA In Consultations, and Collaborative model of care between Orthopaedics and allied healthcare professionals in knee OA. The characteristics of the OAMPs are summarised in table 1. The OAMPs were conducted in-person except for the Joint Academy that was implemented as an online OAMP. Individual participant data from 9819 participants were analyzed. The cohort studies were missing large amounts of data, as expected in clinical practice. The characteristics of OAMP participants are summarised in Table 2. The majority of OAMP participants reported the knee as their index joint, their mean age ranged between 62- 67 years, 58-74% were female, 25-48% were working and mean BMI indicated they were overweight at baseline. Pain was most commonly assessed using a Numeric Rating Scale or validated questionnaires e.g. the Knee Injury and OA Outcome Scale (KOOS). Function was mostly assessed using validated questionnaires such as the KOOS. The pain and fuction measured in the original datasets are reported in Table 1. The changes in pain and function of the OAMP participants from baseline across weeks 12, 26, and 52 are summarised in Table 3. There were reductions in pain scores and improvements in function scores seen across all programs at the majority of timepoints.

Conclusions: We established the first data bank of IPD from different international OAMPs. Analysis of the IPD demonstrated modest improvements in pain and function across the programs at all timepoints. The most rapid improvements were made by week-12, however, these gains were maintained at week-52. In future work this project will use IPD meta-analysis to identify prognostic factors of people with OA who participate in OAMPs.