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Clinical decision rule for primary care patient with acute low back pain at risk of developing chronic pain

  • Author(s): Mehling, WE
  • Mehling, WE
  • Ebell, MH
  • Avins, AL
  • Avins, AL
  • Hecht, FM
  • Hecht, FM
  • et al.
Abstract

© 2015 Elsevier Inc. Background context: Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain. Purpose: We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low-, medium-, and high-risk groups for chronic pain. Study design/Setting: This is a prospective cohort study in primary care. Patient sample: Patients with acute low back pain (LBP, ≤30 days duration) were included. Outcome measures: Outcome measures were self-reported perceived nonrecovery and chronic pain. Methods: Patients were surveyed at baseline, 6 months, and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical, and psychosocial variables for chronic pain outcomes, developed a CDR, and assessed its performance by calculating the bootstrapped areas under the receiver-operating characteristic curve (AUC) and likelihood ratios. Results: Six hundred five patients enrolled: 13% had chronic pain at 6 months and 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70-0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8-11.4) for developing chronic pain. Using a less than 5% probability of chronic pain as the cutoff for low risk and a greater than 40% probability for high risk, likelihood ratios were 0.26 (0.14-0.48) and 4.4 (3.0-6.3) for these groups, respectively. Conclusions: A CDR was developed that may help primary care clinicians classify patients with strictly defined acute LBP into low-, moderate-, and high-risk groups for developing chronic pain and performed acceptably in 1,000 bootstrapped replications. Validation in a separate sample is needed.

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