Chris J. Main

Psychosocial predictors of outcome in acute and subchronic low back trouble.

Study Design A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year. Objectives To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis. Summary of Background Data Current treatment strategies for low back pain have failed to stem the rising levels of disability. Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients, but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated. Methods Two hundred fifty-two patients with low back pain, presenting to primary care, underwent a structured clinical interview and completed a battery of psychosocial instruments. Follow-up was done by mail at 1 year; outcome was measured using a back pain disability questionnaire. Predictive relationships were sought between the data at presentation and disability at follow-up. Results Most patients showed improved disability and pain scores, although more than half had persisting symptoms. Eighteen percent showed significant psychological distress at presentation. Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble. Discriminant models successfully allocated typically 76% of cases to recovered/not-recovered groups, largely on the basis of psychosocial factors evident at presentation. Conclusions Early identification of psychosocial problems is important in understanding, and hopefully preventing, the progression to chronicity in low back trouble.

Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial

Summary Background Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patients prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control). Methods 1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406. Findings 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 [SD 5·9] vs 3·0 [5·9], between-group difference 1·81 [95% CI 1·06–2·57]) and at 12 months (4·3 [6·4] vs 3·3 [6·2], 1·06 [0·25–1·86]), equating to effect sizes of 0·32 (0·19–0·45) and 0·19 (0·04–0·33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0·039 additional QALYs) and cost savings (£240·01 vs £274·40) compared with the control group. Interpretation The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care. Funding Arthritis Research UK.

A primary care back pain screening tool: identifying patient subgroups for initial treatment.

OBJECTIVE To develop and validate a tool that screens for back pain prognostic indicators relevant to initial decision making in primary care. METHODS The setting was UK primary care adults with nonspecific back pain. Constructs that were independent prognostic indicators for persistence were identified from secondary analysis of 2 existing cohorts and published literature. Receiver operating characteristic curve analysis identified single screening questions for relevant constructs. Psychometric properties of the tool, including concurrent and discriminant validity, internal consistency, and repeatability, were assessed within a new development sample (n = 131) and tool score cutoffs were established to enable allocation to 3 subgroups (low, medium, and high risk). Predictive and external validity were evaluated within an independent external sample (n = 500). RESULTS The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0-3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk. CONCLUSION We validated a brief screening tool, which is a promising instrument for identifying subgroups of patients to guide the provision of early secondary prevention in primary care. Further work will establish whether allocation to treatment subgroups using the tool, linked with targeting treatment appropriately, improves patient outcomes.

The Distress and Risk Assessment Method: A Simple Patient Classification to Identify Distress and Evaluate the Risk of Poor Outcome.

The integration of physical and psychological assessment is frequently problematic. Psychological tests are often cumbersome and difficult to interpret. There would appear to be a need for a simple assessment method that would identify distress and help alert the clinician to the need for a more comprehensive assessment. The Distress and Risk Assessment Method is derived from a simple set of scales validated for use with patients with low-back pain. It offers a simple classification of patients into those showing no psychological distress, those at risk of developing major psychological overlay, and those clearly distressed. Four patient types can be identified on the basis of scores on two short questionnaires. The construction of the Distress and Risk Assessment Method is described and validity data (both clinical and psychological) are presented. The use of the Distress and Risk Assessment Method in the prediction of outcome of treatment is presented, and the paper concludes with general guidelines for its use.

THE MODIFIED SOMATIC PERCEPTION QUESTIONNAIRE (MSPQ)

The development of a new scale to measure somatic and autonomic perception, the Modified Somatic Perception Questionnaire or MSPQ is described. It has been derived specifically for use with chronic backache patients, although its utility with other chronic pain problems is currently under investigation. Following pilot studies on anxious patients and normal controls a pool of items was subjected to reliability checks and parallel-form analysis. The final 13 item scale was derived from a pilot study of 102 chronic backache patients and its construct validity confirmed on a further study of 200 backache patients. Sex differences in the use of the scale were integrated into the final version. The scale was compared with the Zung Depression Inventory and the first three clinical scales of the M.M.P.I. Individual items were compared with clinical symptomatology rated independently by an orthopaedic surgeon. In a small experimental study the MSPQ was compared with electromyographic readings from the erector spinae muscles and biceps, with the rating of pain using the McGill Pain Questionnaire, and with experimental ischaemic pain using the submaximum effort tourniquet test. In other studies the scale has been shown to be of importance in the understanding of functional disability. Its predictive validity in response to treatment is currently under investigation in studies of spinal fusion, chemonucleosis and multidisciplinary pain programmes. The simple 13 item four-point self-report scale is easy to administer, has high patient compliance and, in conjunction with measures of depressive symptomatology and inappropriate signs and symptoms would seem to be of considerable promise in the understanding of the sequelae of backache and much more sensitive than traditional measures of personality structure.

Assessment of severity in low-back disorders.

Physical Impairment and disability are defined, simple clinical methods of assessing them in low-back disorders are described, and the relationship between them analyzed.

Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal

Originally the term “yellow flags” was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability.

Patients with psoriasis and their compliance with medication

BACKGROUND Poor compliance with treatment advice in chronic conditions, such as psoriasis, represents a major challenge to health care professionals. Previous research suggests that the rate of noncompliance in chronic conditions may be as high as 40%. OBJECTIVE This study was designed to examine self-reported compliance in patients with psoriasis. METHODS We undertook an anonymous postal survey sent to consecutive patients with psoriasis attending a tertiary psoriasis specialty clinic. RESULTS Thirty-nine percent of participants reported that they did not comply with the treatment regimen recommended. The noncompliant group had a higher self-rated severity of psoriasis (t = -2.16, P =. 03), were younger (t = 3.28, P =.001), and had a younger age at onset (t = 2.35, P =.02) than those who were compliant. The noncompliant group reported that psoriasis had a greater impact on daily life (t = -2.23, P =.028), but general well-being was not significantly different from those who complied (t =.47, P = not significant). CONCLUSION Patients who reported intentional noncompliance with treatment advice were more likely to believe that both psoriasis and its treatment interfered with their quality of life but not overall well-being. The impact of treatment on daily life highlights the importance of joint decision making in planning treatment.

Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome?

&NA; We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ‐R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ‐R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.

The contribution of perceptions of stigmatisation to disability in patients with psoriasis

OBJECTIVE The aim of the present study was to assess the significance of general and psoriasis specific psychological variables in patients with psoriasis and to examine the relative importance of disease status and these psychological variables in predicting psoriasis-related disability. METHOD A total of 115 patients with psoriasis underwent clinical assessment and completed a number of psychological and psoriasis specific questionnaires. RESULTS High levels of self-reported distress were identified with 43% and 10% of patients scoring as probable cases on the Hospital Anxiety and Depression Scale (HADS) subscales of anxiety (mean 9.3+/-4.9) and depression (mean 4.8+/-3.7), respectively. Multiple regression analysis indicated that clinical severity of psoriasis and anatomical area of involvement had no impact on psychological distress and disability. Perceptions of stigmatisation were significantly related to both psychological distress and degree of disability (Ps<.001) and accounted for a significant amount of the variance in disability over and above general psychological distress (F change=11.03; P<.001). CONCLUSION Psychological factors were much stronger determinants of disability in patients with psoriasis than disease severity, location or duration. This has important implications in relation to the clinical management of psoriasis.