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Systematic Review of the Ability of Recovery Expectations to Predict Outcomes in Non-Chronic Non-Specific Low Back Pain

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Abstract

Objective The aim of the current review was to determine the predictive strength of low recovery expectations for activity limitation outcomes in people with non-chronic NSLBP. Methods A systematic review of prognostic studies was performed. Included studies took baseline measures in the non-chronic phase of NSLBP, included at least one baseline measure of recovery expectation, defined as a prediction or judgement made by the person with NSLBP regarding any aspect of prognosis, and studied a sample with at least 75% of participants with NSLBP. Results Recovery expectations measured using a time-based, specific single-item tool produced a strong prediction of work outcome. Recovery expectations measured within 3 weeks of NSLBP onset provide a strong prediction of outcome. It is not clear whether predictive strength of recovery expectations is affected by the length of time between the expectation measure and outcome measure. Conclusion Recovery expectations when measured using a specific, time-based measure within the first 3 weeks of NSLBP can identify people at risk of poor outcome.

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Authors

Corresponding author

Correspondence to Ross A. Iles.

Additional information

Mr. Ross Iles is supported by an Australian Postgraduate Award and is a participant in the Work Disability Prevention CIHR Strategic Training Programme at the Universite de Sherbrooke, Canada.

Appendices

Appendix 1

Medline Search Strategy

  1. 1.

    low back pain.mp. or exp Low Back Pain

  2. 2.

    back pain.mp. or exp Back Pain

  3. 3.

    sciatica.mp. or SCIATICA

  4. 4.

    backache.mp.

  5. 5.

    Spinal Stenosis/or back ache.mp.

  6. 6.

    lumbar pain.mp.

  7. 7.

    1 or 2 or 3 or 4 or 5 or 6

  8. 8.

    Functional Status/or activity limitation$.mp. or Disability Evaluation/

  9. 9.

    disability.mp. or “SEVERITY OF DISABILITY”/

  10. 10.

    oswestry.mp

  11. 11.

    participation restriction.mp.

  12. 12.

    roland morris disability questionnaire.mp.

  13. 13.

    RMDQ.mp.

  14. 14.

    8 or 9 or 10 or 11 or 12 or 13

  15. 15.

    (recover$ adj2 expect$).mp. [mp = title, original title, abstract, name of substance word, subject heading word]

  16. 16.

    (predict$ adj2 recover$).mp. [mp = title, original title, abstract, name of substance word, subject heading word]

  17. 17.

    (recover$ adj2 belief$).mp. [mp = title, original title, abstract, name of substance word, subject heading word]

  18. 18.

    expectation$.mp.

  19. 19.

    15 or 16 or 17

  20. 20.

    7 and 14 and 19

  21. 21.

    (outcome$ adj2 expect$).mp. [mp = title, original title, abstract, name of substance word, subject heading word]

  22. 22.

    18 or 19 or 21

  23. 23.

    7 and 14 and 22

Appendix 2

Criteria Required to Satisfy Quality Ratings and Justification of Criteria

S1: Study provided clearly defined inclusion and exclusion criteria

Defining inclusion criteria is important as it may determine the external validity of the study [8, 11]. This criterion was satisfied if inclusion or exclusion criteria were stated.

S2: The stage when initial measures were applied is clearly stated

Due to the natural progression and recurrent nature of LBP, the stage when baseline measures were taken is of importance when determining prognosis [4, 8, 48]. Stating that all measures were taken during the subacute phase was not sufficient to satisfy the criterion, as a person with limitation for 4 weeks has a better prognosis than a person with limitation after 12 weeks despite both fitting the description of sub acute phase. The criterion was satisfied when a time period was stated or mean/median time after injury baseline measures were taken was provided.

S3: The study used representative sampling techniques

In order to determine whether selection bias existed, a clear description of the sampling strategy and referral process should be given [9, 48]. To satisfy this criterion it was determined the study had to clearly describe that either random allocation or consecutive cases were selected in order to eliminate bias.

S4: Important characteristics of the sample were described

To adequately describe sample characteristics, a minimum of mean age and proportion of either sex was required as well as the distribution of all measures taken at baseline.

S5: The setting and study site were clearly described

To satisfy the last sampling criterion, the study had to give a description of the study setting, including the referral process, as this information is also necessary to determine the internal validity of the study [9, 49].

PI1: Clearly defined constructs of what is measured was provided

In order to eliminate bias when selecting potential prognostic indicators, the variables chosen should have a clear, sensible and reproducible definition [9, 10]. This criterion was satisfied if suitable definitions were provided.

PI2: Justification of the measures used was given

Variables that may affect activity limitation due to NSLBP are recognised as multifactorial, spanning personal, social and environmental domains [5, 50]. Therefore to satisfy the quality criteria studies had to provide a theoretical background as justification of the selection of the prognostic indicators measured.

PI3: The study used standardised, psychometrically sound instruments for all measures taken

The method of measurement of the indicators should be reliable and valid in order to eliminate bias [810]. This criterion was satisfied if instruments with demonstrated measurement properties (reliability and validity) were used. If a new tool was used the study provided information regarding the tested measurement properties of the tool.

A1: Multivariate techniques were used to adjust for potential confounding variables

Activity limitation due to NSLBP is a multifactorial process and a result of interactions between multiple variables. The aim of multivariate techniques in prognosis is to produce an equation that arrives at a predicted outcome that is as close as possible to the measured outcome [16]. Therefore a study satisfied this criterion if it employed a multivariate analysis such as multiple linear regression or Cox hazard ratios.

A2: The analysis avoided over fitting the data

In order to perform multivariate analysis there must be a high enough ratio of participants to variables measured, otherwise the derived equation will match every case and yield no useful information on prognosis [16]. Over fitting (entering too many variables compared to participants) will reduce the validity of a predictive model. Babyak [12] recommends a ratio of at least 15 participants to each variable entered into the equation and this rule of thumb was used to determine whether a study satisfied the second criterion.

A3: Prospective validation in another cohort was performed

The development of a prognostic model based on a particular sample may only be applicable to, or ‘fit’ the sample it was derived from. Prospective validation on a group of participants different to the group used to establish the model is essential to determine if it is generalisable to all people from the same population [9].

FU1: The duration of follow up was greater than or equal to 6 months

The longer activity limitation continues the more likely it is to persist [3]. Even though the likelihood of activity limitation decreasing after 3 months is similar to the likelihood of a decrease after 6 months, the longer time period was chosen as a quality criterion to allow greater opportunity to predict a positive outcome.

FU2: The data was complete for at least 80% of the sample measured at baseline

The third follow up criterion required complete data for at least 80% of the sample measured at baseline, as complete data is important in determining the validity of results [9, 10, 48, 49].

FU3: Outcome measurements were blinded

To avoid bias in assessing outcomes, blinded assessment (determining outcomes unaware of group allocation or predictor variables) should be used [9, 10, 48, 49]. This criterion was satisfied if it was clear from the study that the assessment of outcome was performed without knowledge of baseline variables of participants.

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Iles, R.A., Davidson, M., Taylor, N.F. et al. Systematic Review of the Ability of Recovery Expectations to Predict Outcomes in Non-Chronic Non-Specific Low Back Pain. J Occup Rehabil 19, 25–40 (2009). https://doi.org/10.1007/s10926-008-9161-0

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