Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study.

ABSTRACT: Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

Natural History of Back Pain in Older Adults over Five Years.

INTRODUCTION: Back pain is a prevalent health problem. Research often focuses on adults. Evidence on the long-term course of back pain in older patients is limited. A prospective cohort study (BACE) was conducted in a primary care setting in the Netherlands. We aim to investigate the 5-year course and medical consumption of older adults (>55 years) presenting with back pain in general practice. METHODS: Patients aged >55 years, consulting their general practitioner with a new back pain episode, were included between 2009 to 2011. Follow-up questionnaires included, for example, pain severity, disability, quality of life, recovery, and medical consumption. RESULTS: A total of 675 patients (mean age ± SD, 66.4 ± 7.6 years) participated, showing a mean (± SD) back pain reduction from 5.2 (± 2.7) to 3.6 (± 2.8) (numeric rating scale, 0 to 10) at 3 months follow-up; disability decreased from 9.8 (± 5.8) to 7.8 (± 6.2) (Roland-Morris Disability Questionnaire, 0 to 24). After 6 months, this remained practically constant over time. Medical consumption was highest in the first months; medication was used by 72% at baseline and approximately one-third (25% to 39%) during follow-up. At 5-year follow-up (response rate 58%; n = 392), 43% had recovered; a majority reported persistent or recurrent back pain. CONCLUSION: Clinically relevant improvements in back pain intensity and disability were seen in the first 3 to 6 months of follow-up. A majority of patients does not become pain free within 3 months; this does not improve over 5 years. However, most patients stop consulting health care professionals during follow-up. Current medical strategies may not be sufficient in older back pain patients, where back pain becomes a recurrent or chronic condition in the majority of patients.

Effects of health care interventions on quality of life among frail elderly: a systematized review.

INTRODUCTION: Many health care interventions have been developed that aim to improve or maintain the quality of life for frail elderly. A clear overview of these health care interventions for frail elderly and their effects on quality of life is missing. PURPOSE: To provide a systematic overview of the effect of health care interventions on quality of life of frail elderly. METHODS: A systematic search was conducted in Embase, Medline (OvidSP), Cochrane Central, Cinahl, PsycInfo and Web of Science, up to and including November 2017. Studies describing health care interventions for frail elderly were included if the effect of the intervention on quality of life was described. The effects of the interventions on quality of life were described in an overview of the included studies. RESULTS: In total 4,853 potentially relevant articles were screened for relevance, of which 19 intervention studies met the inclusion criteria. The studies were very heterogeneous in the design: measurement of frailty, health care intervention and outcome measurement differ. Health care interventions described were: multidisciplinary treatment, exercise programs, testosterone gel, nurse home visits and acupuncture. Seven of the nineteen intervention studies, describing different health care interventions, reported a statistically significant effect on subdomains of quality of life, two studies reported a statistically significant effect of the intervention on the overall quality of life score. Ten studies reported no statistically significant difference between the intervention and control groups. CONCLUSION: Reported effects of health care interventions on frail elderly persons' quality of life are inconsistent, with most of the studies reporting no differences between the intervention and control groups. As the number of frail elderly persons in the population will continue to grow, it will be important to continue the search for effective health care interventions. Alignment of studies in design and outcome measurements is needed.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice.

BACKGROUND: In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present. OBJECTIVE: The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain. METHODS: The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry. RESULTS: Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values. LIMITATIONS: Low prevalence of vertebral fractures could have led to findings by chance. CONCLUSIONS: In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

Analgesic use in older adults with back pain: the BACE study.

BACKGROUND: Older patients with back pain are more likely to visit their general practitioner (GP) and are more likely to be prescribed analgesics. OBJECTIVE: To assess analgesic use in older adults with back pain in general practice. METHODS: The BACE study in the Netherlands is a prospective cohort study. Patients (aged >55 years) with back complaints were recruited when consulting their GP or shortly thereafter. Measurements took place at baseline and at 3- and 6-month follow-up. For medication use, patients were asked if they had used any medication for their back pain in the previous 3 months and, if so, to specify the medication name, dosage used, frequency of usage, and whether the medication was prescribed or purchased over the counter. RESULTS: Of the 1,402 patients who were approached to enter the study, 675 were included. Of these patients, 484 (72%) reported medication use at baseline. Nonsteroidal anti-inflammatory drugs (NSAIDs) (57%) were more often used than paracetamol (49%). Paracetamol was mostly obtained over the counter (69%), and NSAIDs were mostly obtained by prescription (85%). At baseline, patients with severe pain (numerical rating scale score ≥7) used more paracetamol, opioids, and muscle relaxants. Patients with chronic pain (back pain >3 months) used more paracetamol, while patients with a shorter duration of pain used more NSAIDs. During follow-up there was an overall decline in medication use; however, at 3- and 6-month follow-up, 36% and 30% of the patients, respectively, still used analgesics. CONCLUSIONS: In these older adults consulting their GP with back pain, 72% used analgesics at baseline. Despite a decrease in medication use during follow-up, at 3 and 6 months a considerable proportion still used analgesics.

Direct access to physical therapy for patients with low back pain in the Netherlands: prevalence and predictors.

BACKGROUND: In the Netherlands, direct access to physical therapy was introduced in 2006. Although many patients with back pain visit physical therapists through direct access, the frequency and characteristics of episodes of care are unknown. OBJECTIVE: The purposes of this study were: (1) to investigate the prevalence of direct access to physical therapy for patients with low back pain in the Netherlands from 2006 to 2009, (2) to examine associations between mode of access (direct versus referral) and patient characteristics, and (3) to describe the severity of the back complaints at the beginning and end of treatment for direct access and referral-based physical therapy. DESIGN: A cross-sectional study was conducted using registration data of physical therapists obtained from a longitudinal study. METHOD: Data were used from the National Information Service for Allied Health Care, a registration network of Dutch physical therapists. Mode of access (direct or referral) was registered for each episode of physical therapy care due to back pain from 2006 to 2009. Logistic regression analysis was used to explore associations between mode of access and patient/clinical characteristics. RESULTS: The percentage of episodes of care for which patients with back pain directly accessed a physical therapist increased from 28.9% in 2006 to 52.1% in 2009. Characteristics associated with direct access were: middle or higher education level (odds ratio [OR]=1.3 and 2.0, respectively), previous physical therapy care (OR=1.7), recurrent back pain (OR=1.7), duration of back pain <7 days (OR=4.2), and age >55 years (OR=0.6). LIMITATIONS: The study could not compare outcomes of physical therapy care by mode of access because this information was not registered from the beginning of data collection and, therefore, was missing for too many cases. CONCLUSIONS: Direct access was used for an increasing percentage of episodes of physical therapy care in the years 2006 to 2009. Patient/clinical characteristics associated with the mode of access were education level, recurrent back pain, previous physical therapy sessions, and age.

Back complaints in older adults: prevalence of neuropathic pain and its characteristics.

OBJECTIVE: Neuropathic symptoms are reported in 16-55.6% of patients with back pain. Studies were performed in various populations; however, none focused on older adults. The aim of the study was to assess prevalence of neuropathic pain in older adults with back pain. METHODS: Prevalence of neuropathic pain, measured with the Dolour Neuropathique en 4 questions (DN4), was assessed in the Back Complaints in the Elders study (Netherlands). Patients (>55 years) consulting their general practitioner with a new episode of back complaints were included. Two DN4-versions were used: one based on interview plus physical examination, the other based on interview alone. In the interview plus physical examination version, patients' and complaint characteristics were compared between groups with different scores (0, 1, 2, 3, and ≥4). The DN4 interview-version compared patients with negative and positive scores. RESULTS: Of the 261 included patients available for analysis were 250 patients (95.8%) with the DN4 interview plus physical examination, and 259 patients (99.2%) with the DN4 interview. In DN4 interview plus physical examination (N = 250), five patients (2%) scored positive (score ≥4). Higher score was associated with pain radiating below the knee (P < 0.001) and use of paracetamol (P = 0.02). In DN4 interview (N = 259), 29 (11.2%) patients scored positive (score ≥3). Positive score was associated with higher body mass index (P = 0.01), pain radiating below the knee (P = 0.001), and use of paracetamol (P = 0.002). CONCLUSIONS: In older adults with back pain presenting with a new episode in primary care, prevalence of neuropathic pain is low and seems to be associated with pain radiating below the knee, use of paracetamol, and higher body mass index.

Course and prognosis of older back pain patients in general practice: a prospective cohort study.

The aim of the current study was to determine the course of back pain in older patients and identify prognostic factors for non-recovery at 3 months' follow-up. We conducted a prospective cohort study (the BACE study) of patients aged >55 years visiting a general practitioner (GP) with a new episode of back pain in the Netherlands. The course of back pain was described in terms of self-perceived recovery, pain severity, disability, pain medication, and GP visits at 6 weeks' and 3 months' follow-up. Prognostic factors for non-recovery at 3 months' follow-up were derived from the baseline questionnaire and physical examination. Variables with a prognostic value were identified with multivariable logistic regression analysis (method backward), and an area under the receiver operating curve (AUC) was calculated for the prognostic model. A total of 675 back pain patients (mean age 66.4 (SD 7.6) years) participated in the BACE cohort study. At 6 weeks' follow-up 64% of the patients reported non-recovery from back pain. At 3 months' follow-up 61% still reported non-recovery, but only 26% of these patients had revisited the GP. Longer duration of the back pain, severity of back pain, history of back pain, absence of radiating pain in the leg below the knee, number of comorbidities, patients' expectation of non-recovery, and a longer duration of the timed 'Up and Go' test were significantly associated with non-recovery in a multiple regression model (AUC 0.79). This information can help GPs identify older back pain patients at risk for non-recovery.

Back complaints in the elders (BACE); design of cohort studies in primary care: an international consortium.

BACKGROUND: Although back complaints are common among older people, limited information is available in the literature about the clinical course of back pain in older people and the identification of older persons at risk for the transition from acute back complaints to chronic back pain. The aim of this study is to assess the course of back complaints and identify prognostic factors for the transition from acute back complaints to chronic back complaints in older people who visit a primary health care physician. METHODS/DESIGN: The design is a prospective cohort study with one-year follow-up. There will be no interference with usual care. Patients older than 55 years who consult a primary health care physician with a new episode of back complaints will be included in this study. Data will be collected using a questionnaire, physical examination and X-ray at baseline, and follow-up questionnaires after 6 weeks and 3, 6, 9 and 12 months. The study 'Back Complaints in the Elders' (BACE) will take place in different countries: starting in the Netherlands, Brazil and Australia. The research groups collaborate in the BACE consortium. The design and basic objectives of the study will be the same across the studies. DISCUSSION: This consortium is a collaboration between different research groups, aiming to provide insight into the course of back complaints in older people and to identify prognostic factors for the transition from acute back complaints to chronic back complaints in older persons. The BACE consortium allows to investigate differences between older people with back complaints and the health care systems in the different countries and to increase the statistical power by enabling meta-analyses using the individual patient data. Additional research groups worldwide are invited to join the BACE consortium.