In the low back pain (LBP) research there has been quite an interest in recent years as to which psychosocial factors are the most predictive of a poor outcome, both in terms of activity limitations and work absence. A systematic review by Iles et al (2009) showed that recovery expectations measured within three weeks of the onset of non-specific LBP (NSLBP) are a strong predictor that the pain will become chronic. However, the question remains as to whether or not these recovery expectations in the acute or sub-acute phases of NSLBP are predictive of progressing to chronic LBP that is severe enough to cause ongoing work absence from usual work activities. This is where I hoped that a systematic review with meta-analysis by Hallegraeff et al (2012) could enlighten me.
Here’s what they did
Four electronic databases were searched: PubMed, MEDLINE, EMBASE and PEDro. Prospective cohort studies with adults with NSLBP that was less than 12 weeks from onset were included. Study participants were asked as to their expectations regarding recovery. The outcome measure was continued absence from usual work. The Agency for Healthcare Research and Quality’s (AHRQ) checklist was used to appraise the methodological quality of the included studies. Odds ratios (ORs) were calculated, with ORs between 1.5 and 2.0 considered moderate, and higher ORs considered strong. ORs were considered statistically significant if the 95% confidence interval (CI) straddled 1.00.
Here’s what they found
Searches uncovered 589 publications, however, only 10 papers (representing 4683 participants) met the inclusion criteria; five studies had a low and five a moderate risk of bias. The 95% CIs of all but one of the studies, as well as that of the pooled result, lay to the right of 1.00, indicating significantly greater risk of absence from usual work among participants whose early expectations about their recovery were poor. The pooled result (OR = 2.17, 95% CI 1.61 to 2.91) indicated a strong predictive value.
The authors concluded
This well-conducted review confirmed that the recovery expectations of patients with acute or sub-acute NSLBP are a statistically significant predictor of absence from usual work due to progression to chronic LBP. The odds of remaining absent from work at a given time point beyond 12 weeks after the onset of the pain were two times higher among those with negative recovery expectations.
The authors recommend that healthcare professionals screen patients’ expectations in the acute stage of low back pain so that strategies can be targeted to those most at risk of absence from work in a given period due to progression of their LBP into the chronic phase.
The Musculoskeletal Elf’s view
Once again, research evidence is driving healthcare professionals towards a greater focus on psychosocial factors in their assessments and treatment of LBP.
One simple measurement instrument for recovery expectations suggested by Iles et al (2011) for use by healthcare professionals is “How certain are you that you will return to your all of your usual activities one month from today?” on a scale of 0 (not certain at all) to 10 (completely certain), with a score of 7 or less classified as low to moderate recovery expectation.
How many of you routinely ask your patients measurable questions regarding their recovery or return to work expectations? In what ways do you explore issues of recovery expectations? What strategies do you use with a patient who has low recovery expectations?
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Iles, R., Davidson, M., Taylor, N. & O’Halloran, P. 2009, “Systematic review of the ability of recovery expectations to predict outcomes in non-chronic non-specific low back pain”, Journal of Occupational Rehabilitation, Vol. 19, no. 1, pp. 25-40. [PubMed abstract]
Hallegraeff, J.M., Krijnen, W.P., van der Schans, C.P. & de Greef, M.H.G. 2012, “Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: A systematic review”, Journal of Physiotherapy, Vol. 58, no. 3, pp. 165-172. [PubMed abstract]
Iles, R., Taylor, N.F., Davidson, M. & O’Halloran, P. 2011, “Telephone coaching can increase activity levels for people with non-chronic low back pain: A randomised trial”, Journal of Physiotherapy, Vol. 57, no. 4, pp. 231-238. [PubMed abstract]