The Value of Prognostic Screening for Patients With Low Back Pain in Secondary Care.
Prognostic screening in patients with low back pain (LBP) offers a practical approach to guiding clinical decisions. Whether screening is helpful in secondary care is unclear. This prospective cohort study in adults with LBP placed on outpatient clinic waiting lists, compared the performance of the short-form Orebro Musculoskeletal Pain Screening Questionnaire, the Predicting the Inception of Chronic Pain Tool, and the STarT Back Tool. We assessed predictive validity for outcome at 4-month follow-up, by calculating estimates of discrimination, calibration, and overall performance. We applied a decision curve analysis approach to describe the clinical value of screening in this setting via comparison with a 'treat-all' strategy. Complete data were available for 89% of enrolled participants (n = 195). Eighty-four percent reported 'poor outcome' at follow-up. The area under the receiver operating characteristic curve (95% confidence interval) was .66 (.54-.78) for the Orebro Musculoskeletal Pain Screening Questionnaire, .61 (.49-.73) for the Predicting the Inception of Chronic Pain Tool, and .69 (.51-.80) for the STarT Back Tool. All instruments were miscalibrated and underestimated risk. The decision curve analysis indicated that, in this setting, prognostic screening does not add value over and above a treat-all approach. The potential for LBP patients to be misclassified using screening and the high incidence of nonrecovery indicate that care decisions should be made with the assumption that all patients are 'at risk.'



This article presents a head-to-head comparison of 3 LBP screening instruments in a secondary care setting. Early patient screening is likely to hold little clinical value in this setting and care pathways that consider all patients at risk of a poor outcome are suggested to be most appropriate.
Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Royal Adelaide Hospital, Adelaide, Australia.
Emma L
EL
Karran
Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
Adrian C
AC
Traeger
Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
James H
JH
McAuley
Sansom Institute for Health Research, University of South Australia, Adelaide, Australia.
Susan L
SL
Hillier
Royal Adelaide Hospital, Adelaide, Australia; University of Adelaide, Adelaide, Australia.
Yun-Hom
YH
Yau
Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Neuroscience Research Australia, Sydney, Australia. Electronic address: Lorimer.Moseley@unisa.edu.au.
G Lorimer
GL
Moseley
D019540:Area Under Curve; D002138:Calibration; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D017116:Low Back Pain / Q000175:diagnosis* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D063127:Secondary Health Care / Q000379:methods; D011795:Surveys and Questionnaires
Low back pain; predictive validity; prognostic screening