Contrasting Real Time Quantitative Measures (Weekly SMS) to Patients’ Retrospective Appraisal of Their One-year’s Course of Low Back Pain; A Probing Mixed-methods Study

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SOURCE:   Chiropractic & Manual Therapies 2019 (Feb 26); 27: 12

Lise Hestbaek, Cornelius Myburgh, Henrik Hein Lauridsen, Eleanor Boyle, and Alice Kongsted

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark.

BACKGROUND:   Due to the recurrent nature of low back pain (LBP), the traditional concepts of cure and recovery are challenged, and investigating the course rather than status at fixed time-points may help us understand prognosis as well as treatment effect. However, methods of frequent measuring still need development and validation. Therefore, this study aims to evaluate the agreement between continuous, quantitative self-assessment (weekly SMS) of the course of LBP over a one-year period and qualitatively derived retrospective patient self-appraisal of the same time-period.

METHODS:   Participants were 32 subjects with LBP from primary care. The quantitative measures consisted of weekly SMS questions for one-year about pain intensity, days with LBP, and activity limitations for that week. For each subject, the weekly responses were graphed and categorized into categories based on intensity, variation and overall change patterns. Qualitative measures were based on semi-structured telephone interviews one-year after a consultation for LBP, where two coders independently categorized the self-appraisal of LBP course into the same predefined categories as the SMS-based trajectories. Furthermore, patients’ perceived overall recovery was related to variation patterns from SMS track.

RESULTS:   There was perfect agreement for 48% in the pain intensity domain, 53% in the variation domain and 63% in the change pattern domain. Most of the discordant cases were classified in neighboring categories with the majority relating to fluctuating patterns. The self-perceived overall recovery status seemed to be reflected quite well by the quantitative measures of pain intensity and days with pain in this study.

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Trajectories of Low Back Pain

CONCLUSION:   This study shows that a real time quantitative measure (weekly SMS) and the patient’s retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient’s ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.

KEYWORDS:   Back pain; Course; Interview; Mixed methods; Recall; SMS; Trajectories

From the FULL TEXT Article:


The assessment of patients’ outcomes is essential in all areas of health care as well as in clinical research. However, in diseases that are not life threatening it is not straight forward defining what a “successful” outcome is. In back pain, this is clearly demonstrated in two reviews of recovery definitions. [1, 2] In the latter, Kamper et al. identified 66 different outcome measures used in 82 studies related to low back pain (LBP). [2] The different measurements primarily cover various definitions of pain, disability, and to a lesser extent physical performance, overall recovery and return to work; alone or in combination [2]. It is self-evident that such absence of a clear conceptual understanding of “success” is not only a barrier for understanding the effect of interventions, but also for the development of accurate and relevant outcome measurements.

Qualitative studies have demonstrated that patients’ sense of recovery from LBP is both complex and highly individualized [3], but nevertheless the overarching themes support the constructs used in quantitative research, namely pain and disability [4–6]. However, many other factors probably influence the impact of LBP on the patients’ health, participation in society and quality of life, and thus their overall outcome [3, 7–9]. Equally important as the concept measured, is the time frame across which the concept is measured. LBP often presents as a recurrent condition characterized by fluctuating patterns rather than a finite condition-related resolution [10, 11]. Summarizing pain over time is a complex cognitive process and it seems to be influenced by both the physical and mental state of the patient on the day of questioning [12], and therefore a single measure at a predefined time-point is unlikely to capture the experience of LBP well. This introduces a large degree of uncertainty, which has not been appropriately addressed in LBP research [11]. It may also explain some of the apparent discrepancy between standard quantitative outcome measures, such as pain intensity or sick leave, and self-appraised recovery that has been reported previously [13, 14].

In attempts to more accurately reflect the course of LBP rather than using a single time-point measure, trajectories of LBP based on frequently repeated measures have been created [15–18]. These studies have demonstrated the existence of distinct clinical course patterns of LBP which would not have been revealed by measuring outcome at only one or a few points in time, by summarizing individual trajectories into a summary score, or by population means in longitudinal analyses [15]. However, descriptions of these trajectories are still being developed and the interpretation is therefore difficult. For instance, the level of details in the trajectories, and thus the number of resultant subgroups, varies from four [16] to twelve [15] distinct trajectories in LBP patients from primary care, when using different analytical strategies. Furthermore, it is unknown how large fluctuations should be, before they can be considered to be above measurement error and thereby relevant for clinical interpretation [19].

An attempt to operationalize the different trajectories has been made by Kongsted et al. by combining results from 10 different cohorts investigating data-driven SMS-based trajectories [19]. This has resulted in descriptions of trajectories that can be applied across datasets [20]. These descriptions are based on three domains: pain intensity, variation and overall change pattern across the observed period. However, these trajectories are data driven based on very simple questions, and they have not been validated against patients’ subjective experiences. Therefore, we need to understand if these categorizations reflect differences between trajectories that are important for the patients’ perception of their course of pain. To do this, we take advantage of previously collected data to compare patients’ recollections of their pain to SMS-based trajectories.

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