Clinical indicators for recommending continued care to patients with neck pain in chiropractic practice: a cohort study.

BACKGROUND: Chiropractors' clinical indicators for recommending preventive continued care to patients with low back pain include previous pain episodes, a history of long pain duration and improvement after initial treatment. Our objectives were, in a cohort of patients with neck pain, to examine whether these clinical indicators were associated with being recommended continued care beyond 4 weeks, and if so whether this recommendation was dependent of chiropractor characteristics, as well as if the number of clinical indicators influenced this recommendation. METHODS: In this multi-center observational study, 172 patients seeking care for a new episode of neck pain in chiropractic practice in Norway were included between September 2015 and May 2016. The chiropractors treated their patients as per usual, and for this study, baseline data and 4-week follow-up data were used. Patient data included the clinical indicators (1) previous episodes of neck pain, (2) a history of long duration neck pain and (3) improvement four weeks after initial treatment. The recruiting chiropractors were asked at 4-week follow-up if each patient was recommended continued care, defined as care planned beyond the first 4 weeks. Univariate and multivariable logistic regression models investigated the association between clinical indicators and the continued care recommendation, as well as the influence of chiropractor characteristics on this recommendation. Cross tabulations investigated the relationship between the number of indicators present and recommendation of continued care. RESULTS: Long duration of neck pain was the strongest clinical indicator for being recommended continued care 4 weeks after the initial treatment. Chiropractor characteristics were not associated with this recommendation. In patients with all three clinical indicators present, 39% were recommended continued care. When two and one indicators were present, the percentages of those recommended continued care were 25% and 10%, respectively. CONCLUSION: Chiropractors recommended continued care for patients experiencing neck pain based on their history of long pain duration, and this was not influenced by characteristics of the chiropractor. This differs from previous studies of indicators for maintenance care in patients with low back pain.

Exploring visual pain trajectories in neck pain patients, using clinical course, SMS-based patterns, and patient characteristics: a cohort study.

BACKGROUND: The dynamic nature of neck pain has so far been identified through longitudinal studies with frequent measures, a method which is time-consuming and impractical. Pictures illustrating different courses of pain may be an alternative solution, usable in both clinical work and research, but it is unknown how well they capture the clinical course. The aim of this study was to explore and describe self-reported visual trajectories in terms of details of patients' prospectively reported clinical course, their SMS-based pattern classification of neck pain, and patient's characteristics. METHODS: Prospective cohort study including 888 neck pain patients from chiropractic practice, responding to weekly SMS-questions about pain intensity for 1 year from 2015 to 2017. Patients were classified into one of three clinical course patterns using definitions based on previously published descriptors. At 1-year follow-up, patients selected a visual trajectory that best represented their retrospective 1-year course of pain: single episode, episodic, mild ongoing, fluctuating and severe ongoing. RESULTS: The visual trajectories generally resembled the 1-year clinical course characteristics on group level, but there were large individual variations. Patients selecting Episodic and Mild ongoing visual trajectories were similar on most parameters. The visual trajectories generally resembled more the clinical course of the last quarter. DISCUSSION: The visual trajectories reflected the descriptors of the clinical course of pain captured by weekly SMS measures on a group level and formed groups of patients that differed on symptoms and characteristics. However, there were large variations in symptoms and characteristics within, as well as overlap between, each visual trajectory. In particular, patients with mild pain seemed predisposed to recall bias. Although the visual trajectories and SMS-based classifications appear related, visual trajectories likely capture more elements of the pain experience than just the course of pain. Therefore, they cannot be seen as a proxy for SMS-tracking of pain over 1 year.

The clinical course of neck pain: Are trajectory patterns stable over a 1-year period?

BACKGROUND: Recent studies with data-driven approaches have established common pain trajectories. It is uncertain whether these trajectory patterns are consistent over time, and if a shorter measurement period will provide accurate trajectories. METHODS: We included 1,124 patients with non-specific neck pain in chiropractic practice. We classified patients into pre-defined trajectory patterns in each of four quarters of the follow-up year (persistent, episodic, and recovery) based on measures of pain intensity and frequency from weekly SMS. We explored the shifts between patterns and compared patients with stable and shifting patterns on baseline characteristics and clinical findings. RESULTS: 785 (70%) patients were in the same pattern in 1st and 4th quarters. Patients with episodic pattern in the 1st quarter shifted to other patterns more frequently than patients in the other patterns. A stable persistent pattern was associated with reduced function and higher scores on psychosocial factors. There was a decreased frequency of patients classified as persistent pattern (75% to 63%) and an increase of patients in recovery pattern (4% to 15%) throughout the four quarters. The frequency of patients classified as episodic remained relatively stable (21% to 24%). CONCLUSIONS: We found an overall stability of the persistent pattern, and that episodic patterns have more potential for shifts. Shifts mostly occurred between patterns closest in pain variation. The deviation in pattern distribution compared with previous studies suggests that the duration of measurement periods has an impact on the results of the classification. SIGNIFICANCE: Having persistent pain and having very minor pain is relatively stable over one year, while episodic pain has more potential for shifts. The duration of measurement periods appears to have an impact on the results of the classification. The given criteria resulted in a reduced frequency of episodic pattern due to shorter measurement periods. Our findings contribute to improved understanding and predicting NP using a combination of patient characteristics and trajectory patterns.

Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks.

STUDY DESIGN: A prospective observational study. OBJECTIVE: To externally validate the prediction model developed by Schellingerhout and colleagues predicting global perceived effect at 12 weeks in patients with neck pain and to update and internally validate the updated model. SUMMARY OF BACKGROUND DATA: Only one prediction model for neck pain has undergone some external validation with good promise. However, the model needs testing in other populations before implementation in clinical practice. METHODS: Patients with neck pain (n = 773) consulting Norwegian chiropractors were followed for 12 weeks. Parameters from the original prediction model were applied to this sample for external validation. Subsequently, two random samples were drawn from the full study sample. One sample (n = 436) was used to update the model; by recalibration, removing noninformative covariates, and adding new possible predictors. The updated model was tested in the other sample (n = 303) using stepwise logistic regression analysis. Main outcomes for performance of models were discrimination and calibration plots. RESULTS: Three hundred seventy patients (47%) in the full study sample reported persistent pain at 12 weeks. The performance of the original model was poor, area under the receiver operating characteristics curve was 0.55 with a Confidence Interval of 0.51-0.59. The updated model included Radiating pain to shoulder and/or elbow, education level, physical activity, consultation-type (first- time, follow-up or maintenance consultation), expected course of neck pain, previous course of neck pain, number of pain sites, and the interaction term Physical activity##Number of pain sites. The area under the receiver operating characteristics curve was 0.65 with a 95% Confidence Interval of 0.58-0.71 for the updated model. CONCLUSION: The predictive accuracy of the original model performed insufficiently in the sample of patients from Norwegian chiropractors and the model is therefore not recommended for that setting. Only one predictor from the original model was retained in the updated model, which demonstrated reasonable good performance predicting outcome at 12 weeks. Before considering clinical use, a new external validation is required. LEVEL OF EVIDENCE: 3.

Do the key prognostic factors for non-specific neck pain have moderation effects? - A study protocol.

Neck pain is one of the common musculoskeletal conditions prevalent in the general population in Norway. Patients with neck pain, seek treatment from different health professionals such as general practitioners, physiotherapists, chiropractors and alternative medicine practitioners. The interventions for neck pain are typically provided in a primary care or specialised healthcare setting depending on the general practitioners' referral patterns. Clinicians are interested to know the various prognostic factors that can explain the recovery from neck pain. In order to know this, studies have explored and reported on a range of prognostic factors that contribute to the outcomes in patients with neck pain. This information is currently available only for neck pain following whiplash injury that has a traumatic origin. There is limited information on the role of prognostic factors specifically for non-specific neck pain without a traumatic episode. Moreover, there is a lack of data on whether there are interactions (moderation effects) between the prognostic factors. Therefore, we propose a hypothesis to elucidate whether the same set of prognostic factors found in neck pain associated with whiplash injuries are also identified in patients with neck pain without trauma. Additionally, we hypothesize that the association between a prognostic factor and the outcome variable (s) would be dependent on the third variable, thereby confirming the moderation effects. Clinicians could make informed decisions in the clinical management of neck pain with the knowledge of prognostic factors that explain the outcomes. It could also be used for the development of new interventions or for modifying the existing ones.