Clinical Instrument to Identify Appropriate Patients for Low Back Pain Maintenance Care
Low back pain (LBP) affects a large portion of the adult population worldwide. In about 80-85% of individuals, LBP episodes are often short lived but recurrent throughout one’s life. As a result, research has looked at strategies of preventing recurrences in people recovered from a previous episode of LBP (termed secondary prevention) and preventing the progression and consequences of LBP (termed tertiary prevention).
Once the optimal treatment benefit is reached during an initial care plan, maintenance care is described as a potential long-term strategy, with treatments carried out at regular intervals regardless of symptoms. Maintenance care is aimed at preventing future episodes, progression and consequences of LBP. Maintenance care patients are commonly scheduled at a 1-3 month interval, and treatments such as manual therapy, individual exercises, and lifestyle advice are provided.
A randomized controlled trial investigating the effectiveness of maintenance care in patients with recurrent and persistent LBP found fewer days of bothersome low back pain over a year in specific subgroups of patients (we reviewed this paper!). In further studies, it was found that patients with differing psychological profiles (as identified using the West Haven-Yale Multidimensional Pain Inventory [or, MPI]) responded differently to maintenance care. Specifically, the three groups identified were:
- Adaptive Copers (AC): characterized by low pain severity, low interference with everyday life due to their pain, low life distress, and a higher activity level and perceived control.
- Interpersonally Distressed (ID): characterized by dysfunctional behaviors such as low levels of social support, low levels of solicitous and distracting responses from significant others, and high scores on punishing responses (compared to AC and DYS patients).
- Dysfunctional (DYS): characterized by higher pain severity, pain significantly interfering with their everyday activities, and low levels of life control and activity levels.
It was demonstrated that those with a less favourable psychological profile (DYS, specifically) reported better outcomes from a maintenance care approach as compared to patients categorized as adaptive copers, who did a little worse with maintenance care (more days with pain and a higher number of visits).
The West Haven-Yale Multidimensional Pain Inventory (MPI) was developed to capture the perceptions and consequences of living with chronic pain. This instrument has been shown to be valid and reliable and aimed to identify and categorize individuals into three subgroups defined above. However, this instrument was not designed to be used as a screening instrument for daily clinical practice but rather to be used as a comprehensive research tool. Therefore, the objective of this study was three-fold:
- To develop a new, brief instrument for identifying dysfunctional patients in a clinical setting with adequate sensitivity, specificity and receiver operating characteristics.
- To assess the instrument’s ability to reproduce the previously published effect estimate of maintenance care.
- To test the sensitivity, specificity and receiver operating characteristics in 3 other existing data sets to assess the external validity and utility of the model across populations.
You can download a copy of the MAINTAIN Maintenance Care Instrument HERE”
This review includes a guest commentary from lead author and maintenance-care research rock star Dr. Andreas Eklund!
This paper was published in Chiropractic & Manual Therapies (2022) and this Review is posted in Maintenance Care, Low Back Pain and the 2023 Archive.