Article

Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1852-1859

Original Contribution

Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain

Benjamin W. Friedman MD, MS a,?, Laura Mulvey BS b, Michelle Davitt MD a, Hong Choi MD a, David Esses MD a, Polly E. Bijur PhD a, E. John Gallagher MD a

aDepartment of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA

bMedical College, Albert Einstein College of Medicine, Bronx, NY, USA

Received 11 February 2012; accepted 29 March 2012

Abstract

Background: Recent work has shown that two-thirds of patients report functional disability 1 week after an emergency department (ED) visit for nontraumatic musculoskeletal Low back pain . Nearly half of these patients report functional disability 3 months later. Identifying high-risk predictors of functional disability at each of these 2 time points will allow emergency clinicians to provide individual patients with an evidence-based understanding of their risk of protracted symptoms.

Object: The aim of the present study was to determine whether 5 high-risk features previously identified in various Primary care settings predict poor functional outcomes among patients in the ED. The hypothesized predictors are as follows: LBP-related functional disability at baseline, radicular signs, depression, a work-related injury, or a history of chronic or recurrent LBP before the index episode. Methods: We conducted a prospective observational cohort study of patients in the ED with a chief complaint of nontraumatic LBP, which the ED attending physician classified as musculoskeletal. We interviewed patients in the ED before discharge and performed a baseline assessment of functional disability using the 24-item Roland-Morris questionnaire. We also trichotomized the patient’s baseline history of LBP into chronic (defined as 30 straight days with continuous LBP or a history of acute exacerbations more frequently than once per week); episodic (acute exacerbations more frequently than once per year but less frequently than once per week), or rarely/never (less frequently than once per year or no history of LBP). We performed telephone follow-up 1 week and 3 months after ED discharge using a scripted closed-question data collection instrument. The primary outcome was any Functional limitation attributable to LBP at 1 week and 3 months, defined as a score greater than zero on the Roland-Morris questionnaire. We used logistic regression, adjusted for age, sex, and educational level, to assess the independent association between functional disability and each of the 5 hypothesized predictors listed above.

Results: We approached 894 patients for participation and included 556. We obtained follow-up on 97% and 92% of our sample at 1 week and 3 months, respectively. Two of the 5 hypothesized variables predicted functional disability at both time points: higher baseline Roland-Morris score (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.6-6.9) and chronic LBP (OR, 2.3; 95% CI, 1.1-4.8) were associated with 7-day functional disability. These same 2 variables predicted functional disability 3 months after ED discharge–higher baseline Roland-Morris score (OR, 2.3; 95% CI, 1.4-3.9) and

* Corresponding author. Department of Emergency Medicine, Montefiore Medical Center, Bronx, NY 10467, USA. Tel.: +1 718 920 6626.

E-mail address: [email protected] (B.W. Friedman).

0735-6757/$ – see front matter (C) 2012 http://dx.doi.org/10.1016/j.ajem.2012.03.027

chronic LBP (OR, 2.8; 95% CI, 1.5-5.2). The remaining 3 hypothesized predictors (depression, radicular signs, and on-the-job injury) did not predict functional outcome at either time point.

Conclusions: Patients in the ED with worse baseline functional impairment and a history of chronic LBP are 2 to 4 times most likely to have poor short- and longer-term outcomes.

(C) 2012

Background

low back pain is the fourth most common reason for an emergency department (ED) visit, resulting in 2.7 million visits annually [1]. In general, functional outcome over the weeks and months after an ED visit for nontraumatic musculoskeletal LBP is poor. One week after ED discharge, 70% of patients reported persistent functional disability and 59% reported moderate or severe LBP [2]. Three months after ED discharge, 48% reported functional impairment and 42% reported moderate or severe pain [2]. These findings are generally in keeping with pain and functional outcomes observed in non-ED outpatient settings, although there is some variability among studies. For example, 1 primary care-based study that enrolled patients with only a brief duration of LBP had substantially better outcomes than generally reported [3]. In addition to a longer duration of symptoms, other risk factors for poor functional outcomes identified in the outpatient setting include radicular signs apparent on physical examination, on-the-job-injury, worse functional status at baseline, and depression [4,5]. In contrast to previous work done in the primary care population, poor- Prognosis predictors for an ED population have yet to be determined. The purpose of this investigation was to iden- tify high-risk features that predict poor outcome at 1 week and 3 months after the index ED visit for LBP. Specifically, we wished to determine whether 5 high-risk features pre- viously identified in various primary care settings indepen- dently predict poor functional outcomes among patients in the ED, after controlling for age, sex, and educational level. The hypothesized predictors were as follows: baseline LBP- related functional disability, radicular signs, depression, a work-related injury, or a history of chronic or episodic LBP before the index episode. Identifying high-risk predictors of functional disability at 1 week and 3 months will allow emergency clinicians to provide individual patients with LBP with evidence-based prognostic expectations that might inftuence anticipated absence from work and duration of treatment or therapy for those in whom it is required.

Methods

Overview

This was a prospective observational cohort study of patients presenting to 1 urban ED with undifferentiated nontraumatic musculoskeletal LBP. We enrolled patients in the ED, completed a standardized 20-minute interview

before discharge, and then conducted a 10-minute follow- up interview by telephone 7 days and 3 months later. This study was reviewed and approved by the Montefiore Medical Center Institutional Review Board.

Setting

We conducted this study in the ED of Montefiore Medical Center, the academic medical center for the Albert Einstein College of Medicine in the Bronx, NY. The ED receives more than 100 000 adult visits annually. Salaried, trained, bilingual (English and Spanish) technician-level research associates collect data under the supervision of the principal investigators. During the study period, research associates staffed about 80% of all shifts.

Subject selection

We included adults if their chief concern was LBP whose etiology, in the judgment of the ED attending, was musculo- skeletal and in whom no alternative etiology of LBP was identified during the course of their workup. We defined LBP as originating below the tips of the scapulae and above the buttocks. Individuals could only be enrolled once. All parti- cipants had capacity to consent to participate. We excluded patients from this study for any history of trauma within the previous month, including Motor vehicle collisions, direct blunt trauma, or a fall from a standing position.

Measures

We collected the following data through a 20-minute structured in-person oral interview with the patient during the baseline ED visit.

      • Variables relating to LBP including duration of symptoms before ED presentation, prior episodes and chronicity of previous attacks of LBP (if any), and whether the current episode of LBP was associated with the patient’s work. In addition, we had our patients verbally complete the 24-item Roland-Morris questionnaire. The Roland-Morris ques- tionnaire is a valid and reliable standardized instrument used in LBP research [6]. It is reproduced in the Appendix. It includes 24 questions that assess the extent to which LBP impairs an individual’s ability to perform activities of daily living, such as putting on socks, climbing stairs, and getting out of a chair. A score of zero indicates no back pain- related functional disability, whereas a score of 24 indicates severe functional disability-related to back pain.
      • We asked 2 depression screening questions from the Patient Health Questionnaire depression module: (1) “Before your back pain began, were you bothered by little interest or pleasure in doing things?” (2) “Before your back pain began, were you feeling down, depressed, or hope- less?” We considered a positive response to be answers of “often” or “always” to either of these questions [7,8].
      • The ED attending physician caring for the patient provided the results of straight-leg testing and the patient’s clinical diagnosis.
      • Prior back pain. We solicited information on the chronicity and frequency of LBP, if any, before the baseline visit, defining these as follows: (1) chronic: we defined Chronic back pain to be continuous LBP for at least 30 successive days or a baseline frequency of acute episodes of back pain of at least once per week; (2) episodic: we defined episodic LBP to be acute exacerba- tions of back pain at least once per year but not as often as once per week; (3) none/rarely: we defined this category to be acute episodes of back pain less frequently than once per year.
      • We also solicited Sociodemographic variables including age, sex, Employment status, type of employment, and highest level of education completed. Education level was used as a surrogate marker of socioeconomic status. Employed patients were asked to rate their Job satisfaction on a scale from 0 to 10, with 0 signifying “I hate my job and would never go back if I did not have to” and 10 signifying “the job is as close to perfect as a job can be.”

Outcomes

We assessed outcomes by telephone 7 days and 3 months after the ED index visit. When follow-up was due, we attempted to obtain these data once every 8-hour shift and continued this for 1 week. Telephone follow-up was then attempted monthly until data collection was terminated in August of 2010.

The primary outcome measure for each time point was functional, derived from the patient’s score on the Roland- Morris LBP questionnaire. We dichotomized this ordinal scale to simplify the outcome and improve its clinical relevance. Patients received either a score greater than zero on the Roland-Morris questionnaire, indicating the presence of back pain-related functional impairment over the 24 hours before assessment, or a score of zero, indicating no low back-related functional impairment over the same timeframe. We consid- ered a score greater than zero on the Roland-Morris to constitute an unsatisfactory functional outcome.

Analysis

The bivariate relationship between the Roland-Morris score at 1 week and at 3 months and each of the 5 hypothesized predictors was plotted and examined visually

to determine whether a predictor variable would function better as a parametric, ordinal, or dichotomous variable. If continuous variables required transformation into ordinal variables, this was done at the most clinically sensible cut- point that would also yield a statistically valid analysis. For the baseline Roland-Morris score, one-third of patients reported a score of 24, the worst possible score, and two- thirds of patients reported a score of 20 or higher; therefore, this variable needed to be transformed before it could be used in a regression model. We plotted the 1-week Roland-Morris score vs the baseline Roland-Morris score and determined that using the criteria of clinical sensibility and statistical validity, it seemed most logical to dichotomize this variable between 16 and 17 because median 7-day Roland-Morris scores tended to be substantially better in patients who scored 16 and below than in those who scored 17 and above. Our overall analytic approach was to identify and quan- tify the independent associations between any of the 5 hypothesized baseline predictor variables and our primary outcome variable (ie, any back pain-related functional dis- ability) at each of 2 time points (1 week and 3 months) by building a multivariate logistic model. We included each of our hypothesized predictors in the model, as well as age, sex, and educational level, using SPSS V.13 (SPSS Inc, Chicago, IL) to conduct all analyses. We present the results of bivariate analysis and multivariate logistic models as crude and adjusted odds ratios, respectively, with 95% CIs. Rather than using arbitrary bivariate statistical cut-points for inclusion in the multivariate model, we decided a priori that the most unbiased approach would be to enter and retain all

hypothesized predictors and covariates in the model.

As described in the “Measures” section, we asked patients to rate their job satisfaction on a scale from 0 to 10. We determined the association between job satisfaction and both the 7-day and the 3-month Roland-Morris score with Spearman ?.

Sample size calculation

Using a commonly used rule of thumb for regression, 10 subjects with a bad outcome (back pain-related functional disability) were needed for every degree of freedom in the regression model. Based on other work, we estimated that 30% of subjects would have a bad outcome [9]. As detailed above in the measures section, we anticipated the need for up to 15 degrees of freedom in the model. Factoring in a 10% rate of missing data, we estimated that we would need to enroll 550 subjects.

Results

Between July 2009 and March 2010, we enrolled 5056 patients (Figure). Baseline characteristics are displayed in Table 1.

894 patients approached

556

low back pain patients enrolled

Excluded: 338

-118 trauma*

Variable n/N (%) or

median (IQR)

Age (y) 45 (35-53)

Female sex 341/556

(61%)

Race/Ethnicity

Black/African American 140 (25)

Asian/Pacific Islander 4 (1)

White 24 (4)

Hispanic/Latino 348 (63)

Biracial/Multiracial 15 (3)

Other 21 (4)

Refused 4 (1)

Education

Did not graduate high school 196 (35)

Graduated high school 248 (45)

College degree 102 (18)

Unknown 10 (2)

Type of work

Unemployed 234 (42)

Homemaker or student 22 (4)

Service worker 157 (28)

Professional/executive/manager/owner 53 (10)

Other 82 (15)

Unknown 8 (1)

Pain began at work

Yes 129 (23)

No 421 (76)

Unknown 6 (1)

Depression screen

Negative 517 (93)

Positive 34 (6)

Missing 5 (1)

Clinician’s diagnosis

Back pain/LBP 83%

Back strain 2%

Chronic back pain 3%

Lumbago 1%

Muscle spasm 1%

Musculoskeletal pain 4%

Sciatica/Herniated disk 5%

Spinal stenosis b1%

Spondylolisthesis b1%

Other 1%

Duration of back pain (h) 96 (48-258)

Baseline Roland-Morris score 22 (18-24) Straight-leg raise positive, as determined by 90/556 (16)

emergency clinician Back pain history a

Chronic LBP 104 (19)

Episodic LBP 325 (59)

New-onset or few lifetime episodes of LBP 107 (19) Missing 20 (4)

Abbreviation: IQR, interquartile range.

a Chronic LBP was defined as 30 or more consecutive days with LBP or a baseline LBP frequency of at least once per week. Episodic LBP was defined as multiple lifetime episodes of LBP that recurred at

a frequency of less than once per week but more than once per year.

-39 refused

-33 previous enrollment

-11 logistical barrier*

-17 unable to consent

-88 back pain originated outside specified area

-32 medical/ surgical etiology of back pain*

541 (97%)

1 week follow-up data

Table 1 Baseline characteristics

511 (92%)

3 month follow-up data

Figure. Study ftow diagram. *Patients were excluded for any trauma within the previous month, including motor vehicle colli- sions, falls, and direct blunt trauma to the back. Logistical barriers included patients who spoke a language other than English or Spanish or unavailability of research personnel. Medical and surgical etiologies of back pain included urinary tract infections, gynecologic pathology, Sickle cell disease, and Viral illness.

Most of our hypothesized predictors were associated with a poor 1-week outcome in bivariate models (Table 2). However, after adjusting for all other hypothesized pre- dictors, only baseline Roland-Morris score higher than 16 and chronic LBP were predictive of poor functional outcomes at 1 week. Two sociodemographic features, female sex, and lower educational level, which were not part of our hypothesis, were also associated with poor Short-term outcomes.

Similarly, many of our hypothesized predictors were associated with a poor 3-month outcome in bivariate models (Table 3). However, after adjusting for all other independent variables, as with the short-term outcome model, only baseline Roland-Morris score higher than 16 and chronic LBP were predictive of poor functional outcomes at 3 months.

Of 24 patients with no history of chronic LBP and a baseline Roland-Morris score lower than 16, 33% (95% CI, 16%-55%) had poor 7-day functional outcomes vs 77% (95% CI, 73%-81%) of patients with either 1 of these 2 poor- prognosis variables. At 3 months, 26% (95% CI, 11%-49%) of the former group had a poor functional outcome vs 53% (95% CI, 48%-57%) of the latter.

Mean (SD) job satisfaction among our patients who were employed at baseline was 7.7 (2.3). There was no correlation between job satisfaction and 7-day Roland-Morris score (? = 0.05, P = .55) or 3-month Roland-Morris score (? = 0.05, P = .51).

Variable Crude OR Adjusted OR (95% CI) (95% CI)

Age (10 y) 1.12 (0.96-1.30) 1.05 (0.88-1.26)

Sex

Male 1.0 1.0

Female 1.92 (1.32-2.80) 1.73 (1.12-2.66)

Education level

Did not graduate high 2.25 (1.32-3.85) 2.09 (1.13-3.86) school

Graduated high school 1.16 (0.71-1.88) 1.28 (0.73-2.24)

Graduated college 1.0 1.0

Back pain history a

New-onset or few 1.0 1.0

lifetime episodes of LBP

Episodic LBP 1.13 (0.71-1.81) 1.08 (0.63-1.84)

Chronic LBP 2.85 (1.46-5.56) 2.27 (1.07-4.81)

Baseline Roland-Morris score

<=16 1.0 1.0

>=17 4.87 (3.14-7.57) 4.25 (2.61-6.90)

Straight-leg raise test

Negative 1.0 1.0

Positive 2.00 (1.14-3.52) 1.67 (0.88-3.18)

Depression screen

Negative 1.0 1.0

Positive 7.35 (1.74-31.03) 6.75 (0.89-51.25)

On-the-job injury

No 1.0 1.0

Yes 0.78 (0.51-1.20) 1.18 (0.71-1.96)

On the Roland-Morris scale, 0 indicates no functional disability and 24 indicates severe impairment. Abbreviation: OR, odds ratio.

a Chronic LBP was defined as 30 or more consecutive days with LBP or baseline LBP frequency of at least once per week. Episodic back pain was defined as multiple lifetime episodes of LBP that recurred at a frequency of less than once per week but more than once

per year.

Limitations

Table 2 Baseline variables associated with functional disability 1 week after an ED visit for nontraumatic musculoskeletal LBP

– Overfitting the baseline Roland-Morris score. We had hoped to analyze the baseline Roland-Morris score as a continuous variable, but because these data were so skewed toward higher scores, this seemed methodolog- ically and statistically inappropriate. Dividing the cohort into equal tertiles or quartiles based on the initial Roland- Morris score would have required drawing important distinctions between a Roland-Morris score of 23 and 24, which would have made little clinical sense. We used the 1-week outcome data to determine how best to dichoto- mize the baseline Roland-Morris score and, thereby, artificially optimized the association between the newly dichotomized predictor variable and the 1-week outcome variable. This led to the robust association between baseline Roland-Morris score and the 1-week outcome, an

adjusted odds ratio that, therefore, must be interpreted cautiously. However, the critique of overfitting is not applicable to the 3-month model because the cut-point between 16 and 17 was not specifically chosen based on the relationship between these 2 variables.

  • Roland-Morris is an unwieldy tool. We do not imagine that emergency clinicians will take the time to ask the 24 questions of the Roland-Morris scale–this is simply not practical. It is more feasible for patients to complete the Roland-Morris questionnaire by themselves and submit this to the physician for a rapid interpretation, but this, too, is beyond the scope of a typical emergency visit. Future work can make the Roland-Morris scale more practical for an emergency visit by pruning it to the questions with the best predictive use.
  • Ideal primary outcome. We chose functional disability as the primary outcome for this analysis because it seemed

Table 3 Baseline variables associated with functional disability 3 months after an ED visit for nontraumatic musculoskeletal LBP

Variable Crude OR Adjusted OR (95% CI) (95% CI)

Age (1 y) 1.22 (1.05-1.40) 1.14 (0.97-1.35)

Sex

Male 1.0 1.0

Female 1.50 (1.04-2.16) 1.34 (0.90-2.00)

Education level

Did not graduate high 1.65 (1.00-2.72) 1.46 (0.84-2.52) school

Graduated high school 1.23 (0.76-2.00) 1.28 (0.75-2.17)

Graduated college 1.0 1.0

Back pain history a

New-onset or few lifetime 1.0 1.0

episodes of LBP

Episodic LBP 1.17 (0.73-1.85) 1.15 (0.70-1.89)

Chronic LBP 3.39 (1.88-6.11) 2.76 (1.47-5.20)

Baseline Roland-Morris score

<=16 1.0 1.0

>=17 2.36 (1.50-3.70) 2.33 (1.41-3.87)

Straight-leg raise test

Negative 1.0 1.0

Positive 1.93 (1.20-3.11) 1.59 (0.94-2.68)

Depression screen

Negative 1.0 1.0

Positive 3.84 (1.70-8.66) 2.15 (0.90-5.13)

On-the-job injury

No 1.0 1.0

Yes 0.88 (0.58-1.33) 1.01 (0.63-1.61)

On the Roland-Morris scale, 0 indicates no functional disability and 24 indicates severe impairment. Abbreviation: OR, odds ratio.

a Chronic LBP was defined as 30 or more consecutive days with LBP or a baseline LBP frequency of at least once per week. Episodic back pain was defined as multiple lifetime episodes of LBP that recurred at a frequency of less than once per week but more than once

per year.

both clinically relevant and can be accurately and reliably measured using the Roland-Morris scale. We were con- cerned that relying on pain level or use of analgesic medication was too readily confounded by other factors such as type of employment or household responsibilities.

    • Diagnosis was not considered in the modeling. We be- lieve that, in general, LBP diagnoses assigned by provi- ders are not necessarily reproducible. Therefore, we did not include them in our analysis.
    • For the purpose of our analysis, we defined chronic back pain to be continuous back pain for at least 30 straight days, rather than back pain for 3 to 6 months, the more typically encountered definition. We did this because only 6.5% of our population reported back pain duration of at least 3 months (vs 9% for 30 straight days) and because the bivariate analyses did not reveal important differences between a cut-point at 30 days vs 3 months.

Discussion

In this prospective observational cohort study, in which

556 patients who presented to an ED with LBP were followed up for 3 months after the index visit, patients in the ED with worse Baseline functional impairment and chronic LBP were the most likely to have poor functional outcomes at both 1 week and 3 months.

It is not surprising that the patients with the most func- tional disability on initial presentation and the worst LBP history were the ones most likely to have poor functional outcomes. This has been a consistent finding in primary care-based LBP cohorts [6,10,11]. Presumably, the clini- cians caring for these high-risk patients in our observational cohort understood that they were dealing with more refrac- tory patients but were, nevertheless, unable to deliver effec- tive interventions. It is not clear if more aggressive or comprehensive interventions for these patients would have had a greater impact.

Several high-risk features identified in clinic-based

studies did not prove to be predictive in this ED-based cohort. The first of these was radicular signs, which were associated with poor outcomes in our bivariate models, but not after multivariate adjustment. The lack of association may be related to variability in technique–many clinicians contributed patients to this study and no one standardized method exists for interpreting the results of the straight-leg raise test [12]. The lack of predictability of radicular signs may also be related to the very high degree of functional disability observed at baseline in this group, which may have made accurate assessments difficult. Alternatively, it may be that radicular signs are less strongly associated with poor outcomes than other more global measures of functional disability at baseline. Radicular signs, when present in patients with an appropriate history, suggest the presence of a herniated intervertebral disk. However, because radicular signs are not specific for a herniated disk [13] and because

we did not image most of our patients, our study cannot provide data as to whether the diagnosis of herniated disk connotes a worse prognosis than nonspecific LBP among patients with similar baseline functional disability scores and similar LBP histories.

On-the-job injury also was not associated with poor prognosis in this study, although this has been determined to be a high-risk feature in clinic-based LBP cohorts [11]. This finding in our work should be interpreted cautiously, given the very high rate of unemployment in this cohort and the broad economic downturn during which this study was conducted. Researchers in this field have raised the issue of secondary gain among patients who sustain LBP at work or in other situations in which considerations of economic compensation may inftuence a patient’s recovery [11]. Con- sistent with a finding that there was no association between on-the-job injury and poor outcome, we also did not iden- tify an association between job satisfaction and poor out- comes. Therefore, we have no evidence to support the contention that issues of secondary gain inftuenced out- comes in this study.

Finally, depression was not associated with poor outcome in the population we studied, which is surprising given that depression has been associated with poor outcome in mul- tiple clinic-based cohorts [4,11,14]. This may be because we used a depression screen rather than a thorough assessment for depression, which would have misclassified some pa- tients who were not truly depressed as experiencing depres- sion. Given the emphasis of any screening instrument on sensitivity, we were surprised at how few of our patients were categorized as depressed. We speculate that depression may have failed to predict poor outcomes in this cohort simply because, as reftected in the wide CIs, so few patients were categorized as depressed.

Female sex has been associated with poor outcome in primary care cohorts, although not consistently [5,6]. A pathophysiologic rationale for an association between gender and poor outcome is not readily apparent. We are not aware of data supporting an anatomical or hormonal contribution to poor prognosis. Given that this association was not an a priori hypothesis, these results should be interpreted as hypothesis generating. Lower educational level was similarly associated with poor short-term outcomes and may be a marker for inadequate access to health care or for manual labor. This finding, too, should be considered as an explo- ratory finding because it also was not hypothesis driven.

Of the poor prognostic variables we identified, only worse baseline Roland-Morris scale is a potentially modifiable risk factor. A hypothesis, to be tested in future work, is that aggressive and timely treatment of LBP-related functional disability could improve the long-term prognosis. This is an appealing hypothesis that, to the best of our knowledge, has yet to be studied.

Emergency clinicians can best use the results of this study to understand which of their patients are at greatest risk of poor outcome. This information can then be used to counsel

patients, anticipate the need for aggressive medical and integrative therapies, and plan for short-term disability.

References

  1. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Adv Data 2006(372): 1-29.
  2. Friedman BW, et al. One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain. Ann Emerg Med 2012;59(2):128-33 e3.
  3. Coste J, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994; 308(6928):577-80.
  4. Cherkin DC, et al. Predicting poor outcomes for back pain seen in primary care using patients’ own criteria. Spine 1996;21(24):2900-7.
  5. Thomas E, et al. Predicting who develops Chronic low back pain in primary care: a prospective study. BMJ 1999;318(7199):1662-7.
  6. Roland M, Morris R. A study of the natural history of low-back pain. Part II: development of guidelines for trials of treatment in primary care. Spine 1983;8(2):145-50.
  7. Haughey MT, et al. Identification of depression in an inner-city popu- lation using a simple screen. Acad Emerg Med 2005;12(12):1221-6.
  8. Whooley MA, et al. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12(7):439-45.
  9. Friedman BW, et al. parenteral corticosteroids for emergency department patients with non-radicular low back pain. J Emerg Med 2006;31(4):365-70.
  10. Jones GT, et al. Predicting persistent disabling low back pain in General practice: a prospective cohort study. Br J Gen Pract 2006; 56(526):334-41.
  11. Henschke N, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008; 337:a171.
  12. Rebain R, Baxter GD, McDonough S. The passive straight leg raising test in the diagnosis and treatment of lumbar disc herniation: a survey of United kingdom osteopathic opinion and clinical practice. Spine 2003;28(15):1717-24.
  13. van der Windt DA, et al. Physical examination for lumbar radicu- lopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 2010(2):CD007431.
  14. Grotle M, et al. Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time. Spine 2005;30(8):976-82.

Appendix. Roland-Morris LBP disability questionnaire

12. Over the last 24 hours, I found it difficult to get No0 Yes1 out of a chair because of my back pain.

  1. Over the last 24 hours, my back was painful almost all of the time.
  2. Over the last 24 hours, I found it difficult to turn over in bed because of my back pain.
  3. Over the last 24 hours, my appetite was not very good because of my back pain.
  4. Over the last 24 hours, I have had trouble putting on my socks (or stockings) because of the pain in my back or leg.

No0 Yes1

No0 Yes1

No0 Yes1 No0 Yes1

  1. Over the last 24 hours, I could only walk short No0 Yes1 distances because of my back pain.
  2. Over the last 24 hours, I slept less well because No0 Yes1 of my back.
  3. Over the last 24 hours, I got dressed with the No0 Yes1 help of someone else because of my back pain.
  4. Over the last 24 hours, I sat down for most of No0 Yes1 the day because of my back.
  5. Over the last 24 hours, I avoided heavy jobs No0 Yes1 around the house because of my back pain.
  6. Over the last 24 hours, I was more irritable and No0 Yes1 bad tempered with people than usual because

of my back pain.

  1. Over the last 24 hours, I went upstairs more slowly than usual because of my back pain.
  2. Over the last 24 hours, I stayed in bed most of the time because of my back pain.

No0 Yes1

No0 Yes1

1.

2.

3.

4.

Over the last 24 hours, I have stayed home most of the time because of my back pain. Over the last 24 hours, I changed position frequently to try to get my back comfortable. Over the last 24 hours, I walked more slowly than usual because of my back.

Over the last 24 hours, I have not been doing any jobs that I usually do around the house because of my back pain.

No0 Yes1

No0 Yes1 No0 Yes1 No0 Yes1

5.

6.

7.

Over the last 24 hours, I used a handrail to get No0 Yes1 upstairs because of my back pain.

Over the last 24 hours, I lay down to rest more No0 Yes1 often because of my back pain.

Over the last 24 hours, I have had to hold on to No0 Yes1 something to get out of an easy chair because

of my back pain.

8.

9.

Over the last 24 hours, I have tried to get other people to do things for me because of my back pain.

Over the last 24 hours, I got dressed more slowly than usual because of my back pain.

No0 Yes1

No0 Yes1

  1. Over the last 24 hours, I only stood up for short No0 Yes1 periods because of my back pain.
  2. Over the last 24 hours, I tried not to bend or No0 Yes1 kneel down because of my back pain.

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