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.