title: Identification of patients with chronic low back pain who might benefit from additional psychological assessment.
abstract: OBJECTIVE
  To identify signs and symptoms that should alert clinicians to the need for additional psychological assessment in patients with chronic low back pain (CLBP).
  
  
  METHODS
  In this prospective cohort study, 229 consecutive patients with CLBP who attended an outpatient rehabilitation center were assessed by psychologists and physical therapists before their treatment started. The signs and symptoms assessed by the physical therapists were compared with the assessments made by the psychologists, which were considered to be the reference standard (relevant psychological disturbances, yes or no). Univariable and multivariable regression methods were applied to investigate which signs and symptoms were associated with the reference standard. A receiver operator characteristic (ROC) curve was constructed to assess the overall accuracy of the final model.
  
  
  RESULTS
  The psychologists classified 53% of the patients as having relevant psychological disturbances. Univariable analysis revealed statistically significant differences (P<0.05) between the 2 patient groups (relevant psychological disturbances, yes or no) for 10 of the 17 signs and symptoms. Multivariate analysis yielded a screening instrument consisting of the following 4 signs and symptoms: presence of Waddell signs, elevated scores on the pain drawing, absence of a directional preference, and daily use of analgesic medication for CLBP [area under the ROC curve, 0.81 (95% confidence interval: 0.75, 0.87)].
  
  
  CONCLUSIONS
  This study established a clinically useful screening instrument for the identification of patients with CLBP who might benefit from additional psychological assessment in an outpatient rehabilitation setting. Further research is needed to confirm our preliminary results.
authors.affiliation: Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands. a.apeldoorn@vumc.nl
authors.forename: Adri T
authors.initials: AT
authors.lastname: Apeldoorn
authors.forename: Henk
authors.initials: H
authors.lastname: Bosselaar
authors.forename: Raymond W
authors.initials: RW
authors.lastname: Ostelo
authors.forename: Tanja
authors.initials: T
authors.lastname: Blom-Luberti
authors.forename: Tjeerd
authors.initials: T
authors.lastname: van der Ploeg
authors.forename: Julie M
authors.initials: JM
authors.lastname: Fritz
authors.forename: Henrica C W
authors.initials: HC
authors.lastname: de Vet
authors.forename: Maurits W
authors.initials: MW
authors.lastname: van Tulder
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D002908:Chronic Disease; D015331:Cohort Studies; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000150:complications* / Q000175:diagnosis* / Q000534:rehabilitation; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D059825:Physical Therapists; D011237:Predictive Value of Tests; D011581:Psychological Tests; D011602:Psychophysiologic Disorders / Q000175:diagnosis* / Q000209:etiology* / Q000523:psychology / Q000534:rehabilitation; D012372:ROC Curve; D012016:Reference Values; D012047:Rehabilitation Centers; D012189:Retrospective Studies; D011795:Surveys and Questionnaires