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Title of Journal: J Occup Rehabil

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Abbravation: Journal of Occupational Rehabilitation

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Springer US

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Exploring the Contribution of Patient-Reported and Clinician Based Variables for the Prediction of Low Back Work Status

Authors: Martijn W. Heymans, Jon J. Ford, Joan M. McMeeken, Alexander Chan, Henrica C. W. de Vet, Willem van Mechelen,

Publish Date: 2007/06/15
Volume: 17, Issue:3, Pages: 383-397
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Retrospective cohort study in 194 patients who were compensated because of chronic low back pain and who were treated by a physiotherapy functional restoration program. Patient-reported and clinician based prognostic indicators were assessed at baseline before patients entered the functional restoration program. We investigated the predictive value of these indicators on work status at 6 months. Relationships were studied using logistic regression analysis in a 2-step bootstrap modelling approach and a nomogram was developed. Discrimination and calibration of the nomogram was evaluated internally and the explained variation of the nomogram calculated.Seventy percent of workers were back to work at 6 months. We found that including duration of complaints, functional disability, disc herniation and fear avoidance beliefs resulted in the “best” prognostic model. All these factors delayed work resumption. This model was used to construct a nomogram. The explained variation of the nomogram was 23.7%. Discrimination was estimated by the area under the receiver operating characteristic curve and was 0.76 and for calibration we used the slope estimate that was 0.91. The positive predictive values of the nomogram at different cut-off levels of predicted probability were good.Low back pain (LBP) is the most common and expensive musculoskeletal disorder in Western countries [1]. Although most patients recover from LBP within the first 2 months about 10% will develop chronic LBP [2]. The recovery process of persons with chronic LBP is slow, and their demands on the health care system are both large and costly. Total costs in Australia and the Netherlands were estimated yearly to be 400 million Euro in 1993–1994 and 4 billion Euro in 1991, respectively [3, 4]. Urgent identification of those patients for whom treatment is warranted is necessary to protect them from prolonged disability, sick-leave and medical over consumption.Studies evaluating the ability of single or combined criteria to predict change in work status following intervention can be useful in identifying patient subgroups that need more intensive interventions because of their poor prognosis. Evidence exists for the predictive value of patient-reported LBP indicators such as low back symptom duration, severity of pain, disability and fear avoidance beliefs on treatment outcome [5, 6, 7]. However, in general these prognostic models have only been able to explain a relatively small amount of variance in work status change [8]. Other studies have shown that patient examination findings of lumbar segmental mobility, lumbar range of motion and hip rotation can predict treatment outcome [9, 10, 11]. It is feasible that the inclusion of both patient-report and examination findings would increase the prognostic ability of existing models, and therefore increase their value for clinicians and researchers.Disc herniation with associated radiculopathy (DHR) is a category of LBP that has accepted diagnostic criteria [12]. Significant literature exists supporting the validity of criteria, particularly regarding response to repeated movements that may be indicative of discogenic pain [13]. However, mixed results exist concerning the prognostic value of the straight leg raising and Waddell’s nonorganic signs test [14, 15, 16]. There is no study that has evaluated the ability of clinician based pathonatomical subgroups in combination with existing patient-reported criteria to predict change in work status in response to conservative treatment.Systematic reviews have concluded that multi-disciplinary and physiotherapy functional restoration programs are most effective in improving pain, disability and work related outcome measures for chronic LBP [17, 18]. Identifying subgroups of patients that are more or less responsive to functional restoration can be a successful method of enhancing treatment effects and to guide clinical decision-making [19].



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