“When will this be over?” “Will my back ever be good again?”
When consulting for back pain the first thing on many patients’ minds is “How long will this last?” or “Will my back ever be as good as before?” In other words, they would like to know their prognosis [1]. However, it is actually not easy for clinicians to predict individual prognosis.
A number of tools have been developed to help clinicians assess prognosis [2,3], but in practice, clinicians will often rely on their clinical experience and an informal blend of personal and clinical information to predict outcomes.
We therefore wanted to investigate how well clinicians could predict patients’ outcomes without the use of a formal tool[4]. We did not expect the prediction to be 100% accurate and therefore decided to compare clinical judgement with the STarT Back Tool. The STarT Back Tool is a short questionnaire that stratifies patients into three ‘risk groups’[5,6]. It was developed to guide decisions about type of treatment and it includes prognostic factors that are likely to be changed by appropriate treatments. It is probably the most widely known tool to systematically assess the prognosis of patients with back pain.
In our study we asked chiropractors what outcome they expected for each patient included in a longitudinal cohort study of patients presenting with recent onset low back pain. The chiropractors could choose between three possible outcomes: 1) a short uncomplicated course of back pain, 2) prolonged back pain without lasting consequences, 3) long-lasting back pain with sustained consequences. They could also choose a fourth option, which was to say, “I don’t know.”
We found that the prognosis expected by the clinicians did systematically relate to the patients’ actual pain and disability levels three months and one year later. The average outcomes in the three expectation groups differed so much that we consider these groups to be truly clinically different. For example, after 3 months patients expected to have prolonged back pain or long-lasting back pain scored respectively 9 and 29 %-points higher on the Roland Morris Disability Questionnaire than patients who were expected to have short uncomplicated back pain . However, we also found that there was considerable variation within the groups, which means that the prediction for each individual patient was not always accurate. Still, in this cohort of (mostly recent onset) chiropractic patients with low back pain, the clinicians’ predictions were as accurate as those of the STarT Back Tool that similarly were not accurate. Related to this, it is worth noting that it appears that the STarT Back Tool has a weaker predictive ability in people with very recent onset back pain than in patients with episodes of longer duration.[7]
We were also interested to know the characteristics of patients who were predicted to have a poor outcome. We found that clinicians were much more likely to expect a long-lasting complicated course if patients consulted with long-lasting back pain and if patients had radiating pain or nerve root involvement. These are all known prognostic factors in back pain, so this made good sense. However, the presence of these factors did not fully explain the clinicians’ judgement and the other factors that we also measured did not relate to the prediction. It is thus likely that clinicians partly base their prediction of outcome on factors that we did not measure, and maybe we can learn about new prognostic factors from observing clinical practice and interviewing clinicians. It may also be that clinicians can become more precise in their prediction if including psychological and social information more systematically.
The study found that clinicians cannot predict individual back pain patients’ clinical course accurately, but overall they do predict outcomes as accurately as a simple standardised tool. We don’t think this means that standardised tools are not needed in clinical practice. Firstly, young and unexperienced clinicians may achieve the skill of predicting outcomes more rapidly if assisted by a tool. Secondly, the use of a prediction tool helps clinicians identifying specific prognostic factors that it might be helpful to address in their care for patients. Thirdly, the combination of standardised tools and clinical judgement may help clinicians in establishing a prognosis more precisely. Lastly, standardised tools can possibly be improved to perform better in patients with recent onset low back pain.
Our overall interpretation of the study results is that clinicians cannot rely solely on their gut feeling when telling LBP patients what to expect, but they do have a good sense of the likely overall course. Clinicians who do not give a firm answer to “When will this be over?” at the first consultation are not incompetent. On the contrary, they might be realistic about the very complex process of predicting back pain outcomes. It is, however, important to communicate that rapid improvement is a realistic expectation for almost everyone who seeks care for their low back pain.
About Alice Kongsted
Alice Kongsted is an associate professor at the University of Southern Denmark and a senior researcher at the Nordic Institute of Chiropractic and Clinical Biomechanics in Odense, Denmark. She has a clinical background as a chiropractor. Her research interest is in clinical epidemiology with a focus on neck and back pain and how these conditions are taken care of in primary care.
References
[1] Georgy EE, Carr EC, Breen AC. Back pain management in primary care: development and validity of the Patients’ and Doctors’ Expectations Questionnaire. Quality in primary care. 2013;21(2):113-122.
[2] Hayden JA, Dunn KM, van der Windt DA, Shaw WS. What is the prognosis of back pain? Best practice & research. Clinical rheumatology. Apr 2010;24(2):167-179.
[3] Haskins R, Rivett DA, Osmotherly PG. Clinical prediction rules in the physiotherapy management of low back pain: A systematic review. Man.Ther. 2012;17(1):9-21.
[4] Kongsted A, Andersen CH, Hansen MM, Hestbaek L. Prediction of outcome in patients with low back pain – A prospective cohort study comparing clinicians’ predictions with those of the Start Back Tool. Man Ther. Feb 2016;21:120-127.
[5] Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59(5):632-641.
[6] Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. Oct 29 2011;378(9802):1560-1571.
[7] Morso L, Kongsted A, Hestbaek L, Kent P. The prognostic ability of the STarT Back Tool was affected by episode duration. Eur Spine J. Mar 2016;25(3):936-944.
Editors: Lorimer Moseley and Neil O’Connell; Copy-editor: Adrian Traeger