[Chronic non specific spinal pain: complexity on several levels and a few paths to follow]. / Rachialgies communes chroniques : une complexité à plusieurs niveaux et quelques pistes.

For several decades now, chronic spinal pain has been one of the most prevalent health problems in virtually every country in the world. Although most scientific research has focused on the intervertebral disc, this has unfortunately not yet led to truly effective treatments. Fortunately, other groups have resolutely tackled this challenge by adopting a complexity-based perspective, paving the way for the emergence of promising new therapeutic approaches.

Depuis plusieurs décennies, les pathologies rachidiennes occupent une place prépondérante parmi les problèmes de santé les plus prévalents dans pratiquement tous les pays du monde. Bien que la majeure partie de la recherche scientifique se concentre sur le disque intervertébral, cela n'a malheureusement pas encore conduit à des traitements véritablement efficaces. Heureusement, d'autres groupes se sont résolument attaqués à ce défi en adoptant une perspective axée sur la complexité, ce qui a ouvert la voie à l'émergence de nouvelles approches thérapeutiques prometteuses.

[Rheumatology: what's new in 2023]. / Rhumatologie: ce qui a changé en 2023.

In rheumatology, this year has been characterized by a broader knowledge of the pathogenesis of rheumatoid arthritis and mechanisms involved in the onset and persistence of low back pain. Studies relevant to the management of of gout, axial spondyloarthritis, autoinflammatory diseases and systemic vasculitides were published. New data on the safety of JAK inhibitors have been published. The ASAS-EULAR recommendations for the treatment of axial spondyloarthritis were updated, and the 2023 EULAR/PReS guidelines for the diagnosis and treatment of systemic juvenile idiopathic arthritis and adult-onset Still's disease are now available. New molecules and different glucocorticoid sparing strategies were introduced for giant cell arteritis.

En 2023, en rhumatologie, une avancée des connaissances sur la pathogenèse de la polyarthrite rhumatoïde et des mécanismes impliqués dans l'apparition et la persistance des lombalgies a été notée. Des études relevantes pour le traitement de la goutte, de la spondylarthrite axiale, des maladies auto-inflammatoires et des vascularites systémiques ont été publiées. De nouvelles données concernant la sécurité des inhibiteurs de Janus kinase sont disponibles. Les directives ASAS-EULAR pour le traitement de la spondylarthrite axiale ont été actualisées et les recommandations EULAR/PReS 2023 pour le diagnostic et le traitement de l'arthrite juvénile idiopathique systémique et de la maladie de Still de l'adulte sont désormais disponibles. De nouvelles molécules et différentes stratégies d'épargne des glucocorticoïdes ont été proposées pour l'artérite à cellules géantes.

[Chronic pain : from symptom to disease]. / La douleur chronique : du symptôme à la maladie.

At last, chronic pain, with its consequences and impact for patients and society, is now considered as a disease in its own in the 11th revision of the international classification of diseases (ICD). We present here in the light of two clinical cases, why the diagnosis of chronic primary pain is useful and how to utilize these new codes. We hope to rapidly see the awaited impact on the healthcare system (from the patient care to insurance issues), as on research and teaching.

La douleur chronique avec ses conséquences et son impact pour les patients et la société est enfin considérée comme une maladie à part entière dans la 11e révision de la Classification internationale des maladies (CIM). Nous présentons ici, à l'aide de deux vignettes, l'utilité du diagnostic de douleur chronique primaire et la façon d'utiliser les nouveaux codes. Nous espérons que l'impact attendu soit rapidement visible tant sur le système de santé (de la prise en charge des patients aux questions assécurologiques), que sur la recherche et l'enseignement.

One-year persistent symptoms and functional impairment in SARS-CoV-2 positive and negative individuals.

BACKGROUND: Persistent symptoms of SARS-CoV-2 are prevalent weeks to months following the infection. To date, it is difficult to disentangle the direct from the indirect effects of SARS-CoV-2, including lockdown, social, and economic factors. OBJECTIVE: The study aims to characterize the prevalence of symptoms, functional capacity, and quality of life at 12 months in outpatient symptomatic individuals tested positive for SARS-CoV-2 compared to individuals tested negative. METHODS: From 23 April to 27 July 2021, outpatient symptomatic individuals tested for SARS-CoV-2 at the Geneva University Hospitals were followed up 12 months after their test date. RESULTS: At 12 months, out of the 1447 participants (mean age 45.2 years, 61.2% women), 33.4% reported residual mild to moderate symptoms following SARS-CoV-2 infection compared to 6.5% in the control group. Symptoms included fatigue (16% vs. 3.1%), dyspnea (8.9% vs. 1.1%), headache (9.8% vs. 1.7%), insomnia (8.9% vs. 2.7%), and difficulty concentrating (7.4% vs. 2.5%). When compared to the control group, 30.5% of SARS-CoV-2 positive individuals reported functional impairment at 12 months versus 6.6%. SARS-CoV-2 infection was associated with the persistence of symptoms (adjusted odds ratio [aOR] 4.1; 2.60-6.83) and functional impairment (aOR 3.54; 2.16-5.80) overall, and in subgroups of women, men, individuals younger than 40 years, those between 40-59 years, and in individuals with no past medical or psychiatric history. CONCLUSION: SARS-CoV-2 infection leads to persistent symptoms over several months, including in young healthy individuals, in addition to the pandemic effects, and potentially more than other common respiratory infections. Symptoms impact functional capacity up to 12 months post infection.

Effects of COVID-19 lockdown on low back pain intensity in chronic low back pain patients: results of the multicenter CONFI-LOMB study.

PURPOSE: The COVID-19 pandemic and the extended lockdown are associated with numerous changes in behavior and lifestyles. The objective was to assess the impact of the first lockdown on LBP course among chronic LBP patients. METHODS: Descriptive and analytical, cross-sectional, multicenter study, conducted by questionnaire from mid-May to end of June 2020 among patients treated for chronic LBP in 6 French and 1 Swiss center. Collected data concerned changes in LBP intensity during lockdown, lockdown experience, physical activity (PA) practice and sedentary lifestyle prior and during lockdown, recourse to care, consumption of psychoactive substances for LBP, and professional activity and its conditions during lockdown. RESULTS: 360 participants (58.6% women, 52.1 ± 13.4 years) were included of which 65% were active (63% keep on working of which 54% teleworked). LBP got worse in 41.1%, mean VAS went from 49.5 ± 21.6 before to 53.5 ± 22.4 during lockdown (p < 0.001) and needed increase of treatment by 29% but very few people increased their consumption psychoactive substances for analgesia. Half of participants had well-experienced lockdown. Findings revealed a significant decrease in PA and increase of sedentary during lockdown (p < 0.0001). Good experience of lockdown was associated with LBP improvement (OR = 0.6 [0.3-0.9]) and decrease of PA with LBP worsening (OR = 1.9 [1.1-3.2]). Teleworking was also associated with LBP worsening. Gender, age, or BMI did not influence LBP course. CONCLUSION: These findings indicate that chronic LBP people suffered from increase in self-perceived LBP during lockdown and help to better understand the factors associated with their condition.

The flexion relaxation phenomenon in nonspecific chronic low back pain: prevalence, reproducibility and flexion-extension ratios. A systematic review and meta-analysis.

PURPOSE: The flexion relaxation phenomenon (FRP) is characterized by the reduction of paraspinal muscle activity at maximum trunk flexion. The FRP is reported to be altered (persistence of spinal muscle activity) in nonspecific chronic low back pain (NSCLBP) and is considered a promising biomarker. The aim of this systematic review was to synthetize current knowledge on FRP in the NSCLBP population regarding prevalence, the reliability of FRP measurement using surface electromyography (sEMG), the average value, and variation of the relaxation ratios (RR). METHODS: Five databases were searched (PubMed, EMBASE, Web of Sciences, Cochrane Library, Pedro). A qualitative analysis was done for all included studies and meta-analysis studying prevalence, mean value of flexion relaxation ratio (FRR) and extension relaxation ratio (ERR), and difference between asymptomatic and NSCLBP FRR. RESULTS: Twenty-seven studies were included for qualitative analysis and 21 studies for meta-analysis. The prevalence of the altered FRP was 55% (95%CI [32-79%]) in the NSCLBP population. The studies on reliability reported good within-session and between-session reproducibility. In the NSLBP population, the mean FRR was 2.96 (95%CI [2.02; 3.90]) and the mean ERR was 4.07 (95%CI [2.08; 6.07]). The difference between asymptomatic and NSCLBP FRR was - 1.19 (95%CI [- 1.92, - 0.45]). In all meta-analysis, the I2 index was > 80%. CONCLUSION: An altered FRP is frequently found in NSCLBP population using sEMG and the test has a good reproducibility. The difference between asymptomatic and NSCLBP FRR was significant. Nevertheless, considering the high heterogeneity observed, additional research is required to confirm the value of RR.

[Which imaging in patients with low back pain ?] / Patient lombalgique : quel examen d'imagerie choisir ?

Low back pain is a major public health problem, with a significant physical and psychosocial impact. Inappropriate use of diagnostic imaging is one of the main factors contributing to the costs of these conditions. In addition, there is evidence to suggest that imaging and the accompanying report are risk factors for chronicity. This article reviews the main clinical situations that clinicians face and summarizes the good clinical practice recommendations for each of them.

Les lombalgies sont un véritable problème de santé publique, avec un impact physique et psychosocial important. L'utilisation inappropriée de l'imagerie fait partie des principaux facteurs qui participent aux coûts engendrés par ces pathologies. De plus, il existe des indices pour penser que la réalisation d'un examen d'imagerie et les éléments contenus dans le rapport qui l'accompagne sont des facteurs de risque de chronicité. Cet article aborde les principales situations cliniques auxquelles les cliniciens sont confrontés et résume les recommandations de bonnes pratiques pour chacune d'elles.

[Rheumatology: 2021 update]. / Rhumatologie.

In rheumatology, this year has seen an expansion of knowledge about the effects of COVID and the vaccine response in patients with autoimmune diseases, but also a re-examination of the usual doses of glucocorticoids in vasculitides and new treatments strategies for diseases such as systemic lupus erythematosus, spondylarthritis and rheumatoid arthritis. New criteria for imaging assessment in spondylarthritis and new management guidelines for patients with low back pain have also been proposed.

En rhumatologie, dans les nouveautés que nous avons choisi de mettre en avant, cette année a vu l'élargissement des connaissances sur le Covid et la réponse vaccinale chez les patients avec maladies autoimmunes, la remise en question des doses habituelles des corticostéroïdes dans les vascularites et la possibilité de nouveaux traitements ou stratégies de prise en charge, dans le lupus érythémateux systémique, les spondylarthrites et la polyarthrite rhumatoïde. De nouveaux critères pour l'évaluation de l'imagerie des spondylarthrites ont aussi été proposés et des précisions quant au type de prise en charge nécessaire pour les patients lombalgiques ont également été apportées.

[New guidelines for the management of low back pain in general practice - «Stop pain without drugs¼]. / Nouvelles recommandations de prise en charge des lombalgies communes en cabinet - «Stop pain without drugs¼.

The so-called 4P medicine, preventive, predictive, participatory, and personalized, which places the patient at the center has influenced the latest recommendations for the management of common low back pain. The management of low back pain in the acute, subacute, and chronic phase is currently based on the profile of each patient with their risk factors, their prognosis, and the respect of their preferences, promoting an integrative approach. During the first consultation, it is important to identify factors of moderate to poor prognosis, including kinesiophobia and to search for false beliefs, through a detailed medical history. The non-pharmacological approaches are more effective and have less side effects than the medications. Reassurance and therapeutic education are the first steps in good management of common low back pain.

La médecine dite des 4P, préventive, prédictive, participative et personnalisée, a influencé les dernières recommandations de prise en charge des lombalgies communes. La prise en charge de ces dernières en phases aiguë, subaiguë et chronique se base sur le profil de chaque patient avec ses facteurs de risque, son pronostic et le respect de ses préférences, en valorisant une approche intégrative. Dès la première consultation, il est important d'identifier des facteurs de pronostic moyen à mauvais dont la kinésiophobie et la recherche de fausses croyances grâce à une anamnèse détaillée. Les approches non pharmacologiques sont plus efficaces et ont moins d'effets secondaires que les médicaments. La réassurance et l'éducation thérapeutique sont les ingrédients d'une bonne prise en charge des lombalgies communes.

[Chronic low back pain and unhelpful beliefs]. / Lombalgies communes chroniques et croyances erronées.

Chronic back pain is a very frequent and highly morbid disease. Among the different factors influencing chronicization are the intensity of the initial episode, lack of physical activity and psychological factors. This paper focuses on this last point, and more specifically on the so-called unhelpful beliefs. The aim is to review the degree of evidence for some of these beliefs frequently found in patients and health professionals.

La lombalgie commune chronique est une affection fréquente et de haute morbidité. Différents éléments influencent la chronicisation, tels que l'intensité de l'épisode initial, la sédentarité et des facteurs psychologiques. Cet article se concentre sur ce dernier aspect et plus particulièrement sur les croyances dites « délétères ¼ concernant la lombalgie commune. Il propose une revue de la littérature afin de vérifier le niveau de preuve de certaines de ces croyances qui circulent fréquemment tant chez les patients que chez les médecins et autres thérapeutes.

Back pain occurrence and treatment-seeking behavior among nurses: the role of work-related emotional burden.

PURPOSE: To assess the association of back pain and treatment-seeking behavior for such pain with work-related emotional burden (regret about care), regret coping strategies, and physical burden among newly practicing nurses. METHODS: We used data from the Impact of Care-related Regret Upon Sleep (ICARUS) cohort collected between 05.2017 and 07.2018 using web-based surveys (weekly for measures of emotional burden, physical burden and coping strategies, and monthly for back pain and seeking care). We investigated immediate associations and temporal influences between burdens and back pain with linear mixed models and cross-lagged Bayesian models, respectively. Coefficients were standardized to allow comparison between burdens. Logistic regression was used to examine the association of burdens with seeking care. RESULTS: Among 105 nurses with an average follow-up of 3 months, 80 reported at least one episode of back pain. Neither physical nor emotional burdens had an immediate association with back pain. However, number of days with back pain in a given month was associated with an increase in both burdens during the previous month, with similar degrees of association (emotional: b = 0.24, physical: b = 0.21). Decision to seek treatment was associated with an increase in back pain frequency (OR 1.12, p = 0.04) and intensity (OR 1.80, p = 0.002) and a decrease in emotional burden (OR 0.95, p = 0.03). Coping strategies were associated neither with the occurrence of back pain nor with care-seeking. CONCLUSION: While both emotional and physical burdens were associated with increased frequency of back pain the following month, emotional burden additionally showed a negative association with the decision to seek care.

What low back pain is and why we need to pay attention.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Asymmetry of lumbar muscles fatigability with non-specific chronic low back pain patients.

PURPOSE: Non-specific chronic low back pain (NSCLBP) patients present with reduced back extensor muscle endurance which could be explained by the higher fatigability of their lumbar muscles. However, studies investigating lumbar muscle fatigability have shown contradictory findings. Furthermore, none investigated potential asymmetry in lumbar muscle fatigability, despite neuromuscular asymmetry being reported as a risk factor for NSCLBP. The present study's primary purpose was to determine whether NSCLBP patients presented with higher lumbar muscle fatigability and fatigability asymmetry than asymptomatic participants. METHODS: Thirty NSCLBP patients and 23 asymptomatic participants performed the Sorensen test. The median frequencies from the electromyographs of the right and left erector spinae longissimus (ESL) and lumbar multifidus (LMF) were measured during the test. A linear regression was performed on the median frequencies on each muscle. Slope and initial median frequency were extracted to characterize fatigability. Asymmetry was quantified by the absolute differences between right-side and left-side muscle pairs. RESULTS: NSCLBP patients presented significantly poorer back extensor muscle endurance than asymptomatic participants. No differences were found between NSCLBP patients and asymptomatic participants in terms of fatigability or fatigability asymmetry for either the ESL or LMF. The initial median frequency in both muscles was significantly lower among NSCLBP patients. CONCLUSIONS: The present study showed that NSCLBP patients did not present higher fatigability or higher fatigability asymmetry in lumbar muscles than asymptomatic participants. The heterogeneity of the NSCLBP population, due to the absence of any specific etiology, may explain these findings. These slides can be retrieved under Electronic Supplementary Material.

Recovering the capability to work among patients with chronic low Back pain after a four-week, multidisciplinary biopsychosocial rehabilitation program: 18-month follow-up study.

BACKGROUND: Chronic low back pain (LBP) is a leading cause of disability worldwide. Biopsychosocial rehabilitation programs have been advocated for its management, especially since the widespread acceptance of the biopsychosocial model of chronic pain. Despite extensive evidence of its short-term benefits, few studies have reported on its long-term effect and more specifically on indirect outcomes such as return to work and quality of life (QoL). The present study evaluated the long-term effect of a multidisciplinary biopsychosocial rehabilitation (MBR) program for patients with chronic LBP, for which short- and intermediate-term efficacy had been established, with an emphasis on recovering work capability. METHODS: This prospective cohort study enrolled 201 patients on a four-week MBR program incorporating physical and occupational therapies and psychological counselling. Assessments occurred at program admission and discharge and at 6 and 18 months. Work capability, Oswestry Disability Index, Tampa Scale for Kinesiophobia, Core Outcome Measures Index (COMI), and Hospital Anxiety and Depression Scale were assessed. Multiple mixed models were used to detect changes in each outcome. Logistic regressions were calculated to identify predictors of recovery of work capability. RESULTS: Of the 201 patients who fulfilled the eligibility criteria, 160 (79.8%) attended the discharge assessment, 127 (63.2%) attended the 6-month follow-up, and 107 (53.3%) continued to the 18-month follow-up. Initially, 128 patients (71.5%) had been on sick leave. At 6 and 18 months, 72 (56.7%) and 84 (78.5%) participants had recovered their work capability, respectively. There were significant improvements in pain, disability, kinesiophobia, and anxiety and depression scores over time. Patients who recovered work capability showed significantly greater improvements in their total COMI score, general QoL, and disability, which were the best three predictors of recovering work capability. CONCLUSIONS: This study extends previous results confirming the program's contribution to recovering work capability among chronic LBP patients.

[Diagnosis and prognosis of low back pain: contribution and limitations of the clinical approach]. / Diagnostic et pronostic des douleurs lombaires : apport et limites de la clinique.

The label « non-specific ¼ that applies to 85% of patients complaining of low back pain is an heterogeneous group including different phenotypes. The identification of the anatomic origin of pain is often impossible in a primary care encounter. However, the physician can identify several elements that are useful to establish some diagnosis, foresee the evolution and tailor therapeutic decisions.

Le diagnostic de lombalgie « non spécifique ¼, attribué à 85% des patients avec maux de dos, ne reflète pas une réalité homogène. Cet article passe en revue les différentes approches existantes visant à identifier des sous-groupes utiles aux cliniciens. L'accent souvent porté sur l'identification anatomique des causes de la douleur est en réalité une mission quasiment impossible et rarement utile. Par contre, le médecin de premier recours a à sa disposition des éléments susceptibles de lui permettre d'identifier certaines pathologies, d'estimer le risque de chronicité et de personnaliser les décisions thérapeutiques. Les résultats récents obtenus dans ce dernier domaine laissent présager pour l'avenir la possibilité d'un meilleur ciblage, en particulier dans le choix des traitements physiothérapeutiques, qui devrait améliorer l'efficacité thérapeutique globale.

[Spinal injection : risks and side effects]. / Complications des infiltrations rachidiennes.

The efficacy of spinal injection for chronic spinal pain is dubious for most conditions. They are however frequently prescribed. Side effects are poorly reported in the literature. In addition to benign and transient problems, serious and lethal side effects have been reported due to infection, hematoma or central and spinal cord infarctions which could be related to intravascular injection of corticoids. Although their frequency is excessively low, they should be discussed with every patient before prescription and should be mentioned in the consent form.

Malgré leur efficacité hautement contestée dans la plupart des situations, les infiltrations épidurales sont fréquemment utilisées dans le traitement des rachialgies chroniques. Les effets secondaires sont rarement considérés et la littérature à leur sujet est pauvre. Il apparaît qu'en plus des effets secondaires bénins, des complications graves et parfois létales doivent être connues des praticiens. Il s'agit principalement de complications infectieuses, hémorragiques mais aussi d'infarctus centraux ou médullaires qui pourraient être secondaires à des injections intravasculaires de corticostéroïdes. Bien qu'extrêmement rares, ils doivent être évoqués avec le patient au moment de la proposition de l'acte thérapeutique et apparaître dans le formulaire de consentement.

[A clinical tool to develop therapeutic goals with chronic low back pain patients]. / Outil clinique pour élaborer des objectifs thérapeutiques avec des patients lombalgiques chroniques.

When treating patients suffering from chronic low back pain, it is important to determine therapeutic objectives that are realistic, measurable and focused on the activities of everyday life. To help patients and therapists to elaborate these objectives, we developped a clinical tool made of a metric scale graduated from 0 to 10 and of a series of photographs. Within the framework of a semi-structured interview, this tool is a help not only in the detection of relevant activities that may induce fear avoidance behaviours but also in the determination and negotiation of objectives that can be realised in the care process and are adapted to the patient's context of living.

Il est important de déterminer avec les patients souffrant de douleurs chroniques du dos, des objectifs thérapeutiques réalistes, mesurables et qui soient centrés sur les activités de la vie quotidienne. Pour aider patients et thérapeutes dans la détermination de ces objectifs, nous avons développé un outil clinique composé d'une échelle métrique graduée de 0 à 10 et d'une série de photographies. Dans le cadre d'un entretien semi-dirigé, cet outil est non seulement une aide dans la détection des activités significatives pour lesquelles se révèle une kinésiophobie, c'est-à-dire une peur ou une appréhension du mouvement, mais également un support dans la détermination et la négociation d'objectifs adaptés au contexte de vie du patient, réalisables dans le processus de soins.

Conservative treatments for lumbar radicular pain.

Lumbar radicular pain is a frequent medical pathology and represents a significant burden on society. The diagnosis of sciatica is largely clinical, in the setting of a combination of radicular pain and neurologic deficits (motor, reflexes, and/or sensation) or a positive straight leg raise test. Imaging is generally not necessary for sciatica, except in the presence of warning signs or in the setting of persisting or worsening pain. The recommended first-line treatment has not yet been clearly established. The choice of a conservative treatment approach combined with simple analgesics in the initial stages seems to be reasonable. A detailed discussion with the patient is important to explain the fact that surgery may only be necessary in the event of pain persisting in excess of 3 months or because of the development or worsening of a neurologic deficit. More high quality studies are clearly required to assist the medical practitioner in knowing how best to treat this group of patients.

Validity of the French version of the Core Outcome Measures Index for low back pain patients: a prospective cohort study.

PURPOSE: Among the many questionnaires available to evaluate low back pain (LBP) patients, the Core Outcome Measures Index (COMI) has the unique advantage to investigate five dimensions using seven short questions. The aim of this study was to explore additional properties of the questionnaire in a French-speaking non-surgical population. METHODS: This study was conducted on 168 patients suffering from subacute or chronic LBP and followed up for 6 months in three French-speaking countries. In addition to basic psychometric properties (e.g., construct validity, floor and ceiling effect, reproducibility), internal validity was analyzed by a factor analysis using Cronbach's alpha. Responsiveness and sensitivity to change were assessed through minimal detectable change (MDC), effect size, and Minimal Clinically Important Improvement (MCII). We used an anchor-based method with receiver operating characteristic (ROC) curve analysis to assess MCII and the Patient Acceptable Symptom State. RESULTS: Construct validity, reliability (Cronbach's alpha = 0.87), reproducibility and the absence of floor and ceiling effects were confirmed. Factor analysis indicated a one-dimensional construct that validates the use of a sum score. The MDC (2.1) was inferior to the MCII (2.3). The limit below which the patient claims to be in a fair condition (Patient Acceptable Symptom State) was set at 3. CONCLUSIONS: The COMI is a self-report questionnaire with the capacity to easily and quickly explore several dimensions in patients with LBP that can be then summarized in a meaningful sum score. Additional knowledge provided by our study should encourage the widespread use of the COMI among the spine community.