Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain
Open accessAbstract
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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The items used for impact stratification (pain intensity, pain interference, and functional status) have substantial research support for their discriminatory and prognostic importance.
“These items have substantial research support to validate their discriminatory and prognostic importance. 13, 19, 31, 38, 39, 43, 47–49, 53, 54, 57–60, 66–68, 73, 76, 80, 82, 85, 86, 97, 106, 108, 110, 112–116, 122”
From Report of the NIH Task Force on research standards for chronic low back pain. (2014) · cites this paper as [48]
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- Authors
- Friedman, B. W., Mulvey, L., Davitt, M., Choi, H., Esses, D., Bijur, P. E., & Gallagher, E. J.
- Affiliations
- Albert Einstein College of Medicine (US)
- Corresponding author
- Friedman, Benjamin W.
- Venue
- The American Journal of Emergency Medicine
- Publisher
- Elsevier BV
- Published
- 2012-11
- Volume
- 30
- Issue
- 9
- Pages
- 1852-1859
- ISSN
- 0735-6757 (ISSN-L)
- PMC
- PMC3434270
- OpenAlex
- W1977811440
- Cited by
- 28
- References
- 18
- Citations by year
- 2026: 1 · 2024: 1 · 2023: 1 · 2021: 2 · 2020: 4 · 2018: 2 · 2017: 1 · 2016: 3 · 2015: 5 · 2014: 8
- FWCI
- 3.05
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Licence
- Locations
- The American Journal of Emergency Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (5k23ns051409-02)
- National Institute of Neurological Disorders and Stroke (K23 NS051409)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Keywords
- acute low back pain, functional disability, emergency department, predictors of poor outcome, chronic low back pain, depression, occupational injuries, Roland-Morris Disability Questionnaire, post-discharge follow-up, risk stratification, telephone follow-up
- MeSH terms
- Activities of Daily Living, Adult, Emergency Service, Hospital, Female, Humans, Interviews as Topic, Male, Risk Factors, Time Factors, Treatment Outcome, Low Back Pain, Acute Pain
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