Predicting Outcomes in Low Back Pain Patients

Low back pain is a common problem seen in clinical practice, and one that can be difficult to treat. One patient may have an acute case of back pain that resolves on its own in a few days, while the next may suffer for years with chronic pain.

Being able to predict which patients are the best candidates for chiropractic would be useful for optimizing care and resources. A new study looks at how effective the Bournemouth Questionnaire (BQ), a new 7-item questionnaire, is as a tool for measuring outcomes during the treatment of lower back pain when compared with the Oswestry Questionnaire, a well-known standard tool.

The study was conducted by 7 chiropractors and an experienced researcher as part of a larger multi-center, multi-clinic study on low back pain (LBP). Each chiropractor studied 10 consecutive patients with low back pain, with the current problem present for a minimum of 14 days. The patient could not have received treatment for the last 6 months prior to entering the study.

The Oswestry and Bournemouth Questionnaires were conducted at the first treatment, at the fourth treatment (or before, if treatment was concluded), at 3 months, and at 12 months. At the 12-month follow up, additional assessment questions were given to discern the total number of days with LBP and total number of days off from work during the past year due to LBP.

Only 4 of the 7 items on the BQ accurately predicted specific outcomes. The following items on the BQ accurately predicted outcomes:

Question 2: Over the past few days, how much has your LBP interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

Question 3: Over the past few days, how much has your LBP interfered with your ability to take part in recreational, social and family activities?

Question 6: How have you felt that your work (both inside and outside the home) these last few days has affected (or would affect) your LBP? (Patients with a low score on this question were unlikely to take sick leave during the next year.)

Question 7: Over the past few days, how much have you been able to control (reduce/help) your LBP on your own? (Those who do not have control over their pain are likely to have reoccurrence of LBP within the next year.)

The BQ is able to predict fairly accurately which patients will (or will not) take more than 30 days of sick leave and which ones will (or will not) not report more than 30 days of disability during the next 12 months, based on three of the items noted above: questions 2, 3, and 7. Three of the items in the BQ were of little value in predicting outcomes: pain, anxiety and depression.  

Daily activities and own pain control were two of the highest predictors of patient outcomes.

Based on a comparison of results, and predictive accuracy, the study authors conclude that the shorter Bournemouth Questionnaire is not as good than the Oswestry questionnaire (the tool considered to be the “gold standard”) for predicting patient outcomes a year after the beginning of chiropractic treatment. Two items on the BQ questionnaire (anxiety and depression) were found to be irrelevant in predicting patient outcomes. There was also poor agreement between the two questionnaires, especially in patient populations experiencing greater pain, which makes the BQ relatively unreliable during baseline assessment and at later intervals if pain has reoccurred.

The authors found that:

“...by asking up to 3 simple but relevant questions from the BQ, it was possible to predict outcome already in approximately 65% of chiropractic patients with persistent LBP. If these questions are asked again at the fourth visit and the mean value calculated for these…this percentage will increase to approximately 70%.”

Larsen K, Leboeuf-Yde C. The Bournemouth Questionnaire: can it be used to monitor and predict treatment outcome in chiropractic patients with persistent low back pain? Journal of Manipulative and Physiological Therapeutics 2005;28:219-227.

Treating Chronic Back Pain With Chiropractic

Low back pain is a very common condition, and one that is very expensive for our health care system. Experts estimate that chronic back pain costs the US about $100 billion each year in direct and indirect costs. As the authors of a new study write:

“One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders…It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.”

Because of the enormous costs of treating chronic back pain, prevention is an important goal. This current study set out to examine the role of chiropractic in treating chronic low back pain. The authors studied 30 patients who had back pain for at least six months. All patients were subjected to a one-month control period that consisted of no treatment. This was included so that the researchers could observe the natural course of the back pain symptoms.

After this baseline period, half of the patients (Group 1) received intensive chiropractic treatment consisting of 12 treatments in one month, then no treatments for nine months. The other half of the patients (Group 2) received the same intensive treatment, but also received maintenance chiropractic treatments every 3 weeks for nine months. At the end of the nine-month period, both groups were again examined.

After analyzing the results, the authors found the following:

• Pain levels were reduced in both groups of patients. The intensive month of chiropractic adjustments reduced pain, even without follow-up care.
• Disability levels, however, showed a different response. For the patients with no continuing treatment, the disability levels returned to their pretreatment levels on the Oswestry. The Group 2 patients – who received maintenance care – continued to see improvement in disability scores over the whole nine months.

 The following graph illustrates the differences between the two groups on disability levels:

The authors conclude:

“This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.”

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of Manipulative and Physiological Therapeutics 2004;27:509-514.

Active Rehabilitation of Low Back Pain

Over the last few years, a consensus has emerged in the medical literature that active treatment of back pain is more successful than passive approaches, such as bed rest and medications.

This is yet another study that compares the two different approaches. Active rehabilitation in this case was defined as, "educational, psychological, and social components along with therapeutic exercises;" the regimen included 24 (1^1/2 hour) exercise sessions over 12 weeks, with encouragement to perform at home. The purpose of the plan was to improve mobility and teach coordination of the spine. The passive treatment was a non-exercise-based controlled treatment designed for minor efficacy, and included thermal therapy and massage once a week for a month. 30 LBP patients were enrolled in the active group, and 24 in the passive. The authors assessed patient's pain, self-experienced disability, and lumbar fatigability. Subjects were evaluated immediately before and after treatment, at six months, and one year after treatment.

At the baseline, pain intensity and disability was the same in both groups. The self-reports indicated moderate to severe intensity, but minor disability caused by low back pain. At follow-up assessment reductions in back pain intensity and disability were larger in the active group than in the passive control.
An aspect of this study focused on lumbar endurance. The authors utilized a complex test, which provided objective measure of endurance both before and after treatment. They found:

"Active rehabilitation was effective in improving objectively assessed lumbar paraspinal muscle endurance, at least in the short term. However, the change tended to diminish during the follow-up, one year after the rehabilitation."

Furthermore, the results also showed that improved lumbar endurance correlated to lessened intensity. This finding was significant since it allowed the practitioners to monitor patient progress objectively and individually during the active treatment program.

Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O. The efficacy of active rehabilitation in chronic low back pain. Spine 1999;24(10):1034-1042.

Disappearing Herniated Disc

This interesting report details the case of a 48-year-old woman who developed right-sided scapular pain after some heavy lifting. MRI showed loss of normal cervical lordosis, degeneration between C5-6 and C6-7, as well as disc herniations at C3-4, C5-6, and C6-7. The C6-7 herniation was large and was compressing the spinal cord. She was scheduled for surgery two weeks after the initial MRI scan.

On the day of her scheduled surgery, she reported that her symptoms had resolved and she declined surgery; two years later, complaining of intermittent scapular pain, she was given another MRI. "Follow-up MR imaging again demonstrated loss of normal cervical lordosis; however, the C6-7 disc herniation had resolved dramatically and, to a lesser extent, so had the herniations at the C3-4 and C5-6 levels."

The authors (neurosurgeons) conclude, "We do not advocate conservative management of a large herniated cervical disc that becomes symptomatic with myelopathy; however, this case illustrates the potential for the spontaneous regression of even significantly sized herniated cervical discs."

Westmark RM, Westmark KD, Sonntag VKH. Disappearing cervical disc: case report. Journal of Neurosurgery 1997;86:289-290.

Influence of MRIs on Low Back and Leg Pain

This study compared the clinical features of low back and leg pain patients at the time of requesting a lumbar spine MRI to the subsequent pain management plan.

72 Patients were reffered for MRI. In 65 of the cases, leg pain emerged as the main symptom. 40 Patients showed no evidence of nerve compression, but in 28 patients nerve compression was evident. Interestingly, patients planned for surgery dropped from 48 to 30, while the conservative treatment plans rose 35% after the MRI. Overall, 50% of patients' diagnoses were altered after the MRI.

MRI is typically used in the medical setting to support surgical intervention, as the physician can pinpoint the area that is to be operated on. Ironically, this study found that the real effect of MRI is to move patients to the conservative treatment.

Rankine JJ, Gill KP, Hutchinson CE, Ross ER, Williamson JB. The therapeutic impact of lumbar spine MRI on patients with low back and leg pain. Clinical Radiology 1998;53(9):688-93.

Informative Approach to Low Back Pain

This study tested the long-term effects of a light mobilization program and informative approach to low back pain (LBP). The authors compared 245 patients in an intervention group to 244 patients in a control group, to gauge the benefits of such a program, and to determine the factors that would indicate eventual return to work.

The intervention included an exam and clinical advice, and 3 hours of a "Mini Back School." The information covered the basics of coping with LBP amidst everyday living, discussed the link between pain and emotions, and stressed the importance of continuing normal activity. The program attempted to heighten awareness, rather than ordering instructions.
198 (81%) of the patients in the intervention group returned to work within five years; 160 (65%) in the control group. The control group patients were nearly twice as likely to end up permanently disabled.

After the five-year study, the researchers went back to determine the predictors of return or nonreturn to work. Nonreturners had more children, less income, and feelings of no control or power over their health status.

The authors conclude with the benefits of the program:

"The thorough examination coupled with the assurance that the patient's situation was not serious, gave the patient the confidence needed to follow the advice and resume light normal activity. Lasting behavioral modification is achieved only through experience. It is believed that it was the patient's positive experience that resulted in the favorable long-term effect. The outcome supports the view that a substantial part of LBP may be a functional disturbance, and that light normal activity may restore normal function."

Indahl A, Haldorsen E, Holm S, et al. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998; 23(23):2625-2630.