Abstracts
BACKGROUND CONTEXT
Identifying optimal stratification techniques for subgrouping patients with low back
pain (LBP) into treatment groups for the purpose of identifying optimal management
and improving clinical outcomes is an important area for further research.
PURPOSE
Our study aimed to compare performance of the STarT Back Tool (SBT) and 3 stratification
techniques involving PROMIS domain scores for use in patients presenting to a spine
clinic for chronic LBP.
STUDY DESIGN
Retrospective cohort study.
PATIENT SAMPLE
Adult patients with chronic LBP seen in a spine center between November 14, 2018 and
May 14, 2019 who completed patient-reported outcomes (PROs) as part of routine care,
and were followed up with completed PROs 1-year later.
OUTCOME MEASURES
Four stratification techniques, including SBT, and 3 PROMIS-based techniques: the
NIH Task Force recommended Impact Stratification Score (ISS), symptom clusters based
on latent class analysis (LCA), and SPADE symptom clusters.
METHODS
The 4 stratification techniques were compared according to criterion validity, construct
validity, and prognostic utility. For criterion validity, overlap in characterization
of mild, moderate, and severe subgroups were compared to SBT, which was considered
the gold standard, using quadratic weighted kappa statistic. Construct validity compared
techniques’ ability to differentiate across disability groups defined by modified
Oswestry LBP Disability Questionnaire (MDQ), median days in the past month unable
to complete activities of daily living (ADLs), and worker's compensation using standardized
mean differences (SMD). Prognostic utility was compared based on the techniques’ ability
to predict long-term improvement in outcomes, defined as improvement in global health
and MDQ at 1-year.
RESULTS
There were 2,246 adult patients with chronic LBP included in our study (mean age 61.0
[SD 14.0], 55.0% female, 83.4% white). All stratification techniques resulted in roughly
a third of patients grouped into mild, moderate, and severe categories, with ISS and
LCA demonstrating substantial agreement with SBT, while SPADE had moderate agreement.
Construct validity was met for all techniques, with large effects demonstrated between
mild and severe categories for differentiating MDQ, ADLs, and worker's compensation
disability groups (SMD range 0.57–2.48). All stratification techniques demonstrated
ability to detect improvement by 1-year, with severe groups experiencing the greatest
improvement in multivariable logistic regression models.
CONCLUSIONS
All 4 stratification techniques demonstrated validity and prognostic utility for subgrouping
patients with chronic LBP based on risk of long-term disability. ISS and LCA symptom
clusters may be the optimal methods given the improved feasibility of including only
a few relevant PROMIS domains. Future research should investigate multidisciplinary
treatment approaches to target mild, moderate, and severe patients based on these
techniques.
Keywords
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References
- Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222
- The global burden of occupationally related low back pain: Estimates from the Global Burden of Disease 2010 study.Ann Rheum Dis. 2014; 73: 975-981
- Overtreating chronic back pain: Time to back off?.J Am Board Fam Med. 2009; 22: 62-68
- The Lancet Series call to action to reduce low value care for low back pain: An update.Pain. 2020; 161: S57-S64
- Model simulations challenge reductionist research approaches to studying chronic low back pain.J Orthop Sports Phys Ther. 2019; 49: 477-481
- Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis.Spine (Phila Pa 1976). 2018; 43: 1512-1520
- Prevention and treatment of low back pain: Evidence, challenges, and promising directions.Lancet. 2018; 391: 2368-2383
- Transforming low back pain care delivery in the United States.Pain. 2020; 161: 2667-2673
- Symptom clusters: Myth or reality?.Palliat Med. 2010; 24: 373-385
- The SPADE symptom cluster in primary care patients with chronic pain.Clin J Pain. 2016; 32: 388-393
- Classification and low back pain: A review of the literature and critical analysis of selected systems.Phys Ther. 1998; 78: 708-737
- Methodologic issues in low back pain research in primary care.Spine (Phila Pa 1976). 1998; 23: 2014-2020
- Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial.Spine (Phila Pa 1976). 2003; 28 (discussion 72): 1363-1371
- Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: Results of a randomized clinical trial.Spine (Phila Pa 1976). 2006; 31: 623-631
- A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study.Ann Intern Med. 2004; 141: 920-928
- Adding physical impairment to risk stratification improved outcome prediction in low back pain.Phys Ther. 2021; 101
- A primary care back pain screening tool: Identifying patient subgroups for initial treatment.Arthritis Rheum. 2008; 59: 632-641
- Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program.Arch Phys Med Rehabil. 2005; 86: 1753-1762
- Comparison of stratified primary care management for low back pain with current best practice (STarT Back): A randomised controlled trial.Lancet. 2011; 378: 1560-1571
- Report of the NIH Task Force on research standards for chronic low back pain.Phys Ther. 2015; 95: e1-e18
- Stratification of spine patients based on self-reported clinical symptom classes.Spine J. 2022; 22: 1131-1138
- The knowledge Program: An innovative, comprehensive electronic data capture system and warehouse.AMIA Annu Symp Proc. 2011; 2011: 683-692
- Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.Qual Life Res. 2009; 18: 873-880
- The PHQ-9: Validity of a brief depression severity measure.J Gen Intern Med. 2001; 16: 606-613
- A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale.Phys Ther. 2001; 81: 776-788
- Implementing a scientifically valid, cost-effective, and scalable data collection system at point of care: The Cleveland Clinic OME cohort.J Bone Joint Surg Am. 2019; 101: 458-464
- Validation of PROMIS CATs and PROMIS global health in an interdisciplinary pain program for patients with chronic low back pain.Spine (Phila Pa 1976). 2020; 45: E227-EE35
- Minimally important differences were estimated for six patient-reported outcomes measurement information system-cancer scales in advanced-stage cancer patients.J Clin Epidemiol. 2011; 64: 507-516
- Interpretation of changes in health-related quality of life: The remarkable universality of half a standard deviation.Med Care. 2003; 41: 582-592
- The clinical importance of changes in outcome scores after treatment for chronic low back pain.Eur Spine J. 2003; 12: 12-20
- Subgrouping low back pain: A comparison of the STarT back tool with the Orebro musculoskeletal pain screening questionnaire.Eur J Pain. 2010; 14: 83-89
- Comparing the STarT back screening tool's subgroup allocation of individual patients with that of independent clinical experts.Clin J Pain. 2010; 26: 783-787
- Performance of a patient reported outcomes measurement information system (PROMIS) short form in older adults with chronic musculoskeletal pain.Pain Med. 2016; 17: 314-324
- Support for the reliability and validity of the national institutes of health impact stratification score in a sample of active-duty U.S. military personnel with low back pain.Pain Med. 2021; 22: 2185-2190
- Stratification of spine patients based on self-reported clinical symptom classes: Evaluation of long-term outcomes and subsequent interventions.N Am Spine Soc J. 2023; 14: 100205
HealthMeasures. PROMIS® score cut points. (Accessed July 15, 2022, Available at: https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/promis-score-cut-points).
- The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study.Qual Life Res. 2010; 19: 539-549
- COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures.Qual Life Res. 2021; 30: 2197-2218
- Statistical Power Analysis for the Behavioral Sciences. Taylor & Francis, New York2013
- Relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers' compensation claimants: A historical cohort study.Occup Environ Med. 2019; 76: 573-581
- Patient-reported outcomes predict future emergency department visits and hospital admissions in patients with stroke.J Am Heart Assoc. 2021; 10e018794
- Hybrid approach to treatment tailoring for low back pain: A proposed model of care.J Orthop Sports Phys Ther. 2019; 49: 453-463
- Classification systems of soft tissue disorders of the neck and upper limb: Do they satisfy methodological guidelines?.J Clin Epidemiol. 1996; 49: 141-149
- Disentangling classification systems from their individual categories and the category-specific criteria: an essential consideration to evaluate clinical utility.J Man Manip Ther. 2010; 18: 205-208
- An examination of the reliability of a classification algorithm for subgrouping patients with low back pain.Spine (Phila Pa 1976). 2006; 31: 77-82
- Trajectories of disability and low back pain impact: 2-year follow-up of the groningen spine cohort.Spine (Phila Pa 1976). 2020; 45: 1649-1660
- Validation of the subgroups for targeted treatment for back (STarT Back) screening tool at a tertiary care centre.Can J Surg. 2022; 65: E352-E3E8
- Effect of low back pain risk-stratification strategy on patient outcomes and care processes: The MATCH randomized trial in primary care.J Gen Intern Med. 2018; 33: 1324-1336
- Adaptation and implementation of the STarT back risk stratification strategy in a US Health Care Organization: A process evaluation.Pain Med. 2019; 20: 1105-1119
- Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: The whole is greater than the sum of its parts.Pain. 2012; 153: 2182-2191
- A treatment-based classification approach to low back syndrome: Identifying and staging patients for conservative treatment.Phys Ther. 1995; 75 (discussion 85-9): 470-485
- Clustering of patients with chronic low back pain in terms of physical and psychological factors: A cross-sectional study based on the STarT Back Screening Tool.J Back Musculoskelet Rehabil. 2020; 33: 581-587
Article info
Publication history
Published online: May 04, 2023
Accepted:
April 27,
2023
Received:
February 13,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
FDA device/drug status: Not applicable.
Author disclosures: BL: Nothing to disclose; YL: Nothing to disclose; SD: Nothing to disclose; MS: Nothing to disclose; JKJ: Nothing to disclose; EB: Nothing to disclose; GH: Nothing to disclose; IK: Nothing to disclose.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
