Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis

Abstract

BackgroundDelivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration.MethodsMedline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure).ResultsWe identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was ‘non-informative’ (pooled AUC = 0.59 (0.55–0.63), n = 1153) and ‘acceptable’ for discriminating disability outcomes (pooled AUC = 0.74 (0.66–0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was ‘poor’ for discriminating pain outcomes (pooled AUC = 0.69 (0.62–0.76), n = 360), ‘acceptable’ for disability outcomes (pooled AUC = 0.75 (0.69–0.82), n = 512), and ‘excellent’ for absenteeism outcomes (pooled AUC = 0.83 (0.75–0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only.ConclusionsLBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict.Systematic review registrationPROSPERO international prospective register of systematic reviews registration number CRD42015015778.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0774-4) contains supplementary material, which is available to authorized users.

Use and perceived added value of patient-reported measurement instruments by physiotherapists treating acute low back pain: a survey study among Dutch physiotherapists

“…One reason could be that none of the existing instruments (including screening tools) are yet able to adequately predict the course of LBP symptoms, so they do not provide any relevant prognostic information for the physiotherapist. Despite the enormous effort put into prognostic LBP research, LBP screening tools all perform poorly in identifying those patients at higher risk for chronic LBP [32]. Even for the SBT, the accuracy of prediction of outcome of patients with LBP was low [33].…”

Optimal Screening for Prediction of Referral and Outcome (OSPRO) for Musculoskeletal Pain Conditions: Results From the Validation Cohort

“…First, the OSPRO-YF tool was predictive of multiple outcome domains, while the other assessment tools tend to have stronger predictive capabilities for functional outcomes. 36 Second, the OSPRO-YF tool included items for pain resilience, a dimension not captured in the other tools but may be relevant for predicting pain-related outcomes. Third, the OSPRO-YF tool can be used as total score (e.g.…”

Non-pharmacological treatment of low back pain in primary care

“…The STarT Back Screening Tool was cited as an example, but other validated tools include the Orebro Musculoskeletal Pain Questionnaire and PICKUP (Preventing the Inception of Chronic Pain) model for patients with acute LBP 28–31. However, a systematic review found that screening tools only yield modest accuracy 30. Therefore, clinicians may need to be careful using these tools to solely guide management as they could over treat patients with a good prognosis or undertreat patients with a poor prognosis 4…”