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 (LBP). 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 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.
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References
- National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary.Adv Data. 2006; : 1-29
- One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain.Ann Emerg Med. 2012; 59: 128-133 e3
- Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.BMJ. 1994; 308: 577-580
- Predicting poor outcomes for back pain seen in primary care using patients' own criteria.Spine. 1996; 21: 2900-2907
- Predicting who develops chronic low back pain in primary care: a prospective study.BMJ. 1999; 318: 1662-1667
- 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: 145-150
- Identification of depression in an inner-city population using a simple screen.Acad Emerg Med. 2005; 12: 1221-1226
- Case-finding instruments for depression. Two questions are as good as many.J Gen Intern Med. 1997; 12: 439-445
- Parenteral corticosteroids for emergency department patients with non-radicular low back pain.J Emerg Med. 2006; 31: 365-370
- Predicting persistent disabling low back pain in general practice: a prospective cohort study.Br J Gen Pract. 2006; 56: 334-341
- Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study.BMJ. 2008; 337: a171
- 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: 1717-1724
- Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.Cochrane Database Syst Rev. 2010; : CD007431
- Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time.Spine. 2005; 30: 976-982
Article Info
Publication History
Published online: May 25, 2012
Accepted:
March 29,
2012
Received:
February 11,
2012
Identification
Copyright
© 2012 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
