Wolf E Mehling1, Mark H Ebell2, Andrew L Avins3, Frederick M Hecht4. 1. Department of Family Medicine, University of California-San Francisco, 1545 Divisadero St, San Francisco, CA 94115, USA; Osher Center for Integrative Medicine, University of California-San Francisco, 1545 Divisadero St, 4th Floor, San Francisco, CA 94115, USA. Electronic address: mehlingw@ocim.ucsf.edu. 2. Department of Epidemiology and Biostatistics, University of Georgia, 101 Buck Rd, Athens, GA 30602, USA. 3. Department of Medicine, University of California-San Francisco, 1545 Divisadero St, San Francisco, CA 94115, USA; Division of Research, Kaiser Permanente, Northern California, 2000 Broadway, Oakland, CA 94612, USA. 4. Osher Center for Integrative Medicine, University of California-San Francisco, 1545 Divisadero St, 4th Floor, San Francisco, CA 94115, USA; Department of Medicine, University of California-San Francisco, 1545 Divisadero St, San Francisco, CA 94115, USA.
Abstract
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.
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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