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Improvement in back-related leg pain negatively associated with several prognostic factors
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More than half of patients with low back-related leg pain and sciatica reported improvement within 12 months after consulting their family doctor in a study in which the patients’ belief that they would get better and not have other complaints related to their back and leg pain was identified as an independent prognostic factor associated with improvement.
“Slightly over half of all people who consult their primary care practitioner for back pain that relates to their leg, as well, … will report improvement after 12 months,” co-author Danielle Van Der Windt, PhD, said in her comments about study results published in The Spine Journal.
She told Orthopedics Today, “The other thing that came out of the analysis is the fact there are only a couple of factors that seem to be strongly associated with having either a good or poor outcome after 12 months and that has to do with … the illness perceptions of people and severity of symptoms that they feel are related to the condition.”
Prognostic factors
Kika Konstantinou, PhD, Kate M. Dunn, PhD, Van Der Windt and colleagues collected information about pain, function, psychological and clinical variables for 609 patients who presented to primary care physicians in the United Kingdom with back-related leg pain. Physiotherapists experienced in the assessment and management of low back pain and sciatica diagnosed the patients as having sciatica or referred leg pain.
Using mixed-effects logistic regression, researchers evaluated the prognostic value of leg pain duration, pain intensity, neuropathic pain, psychological factors, the clinical examination and imaging variables. They defined good outcome as 30% or more reduction in disability.
Results showed improvement in 55% of patients in both the total sample and the sciatica group at 12 months. The strongest independent prognostic factors that were negatively associated with improvement included longer leg pain duration, greater identity score and the patient’s belief the problem would last a long time, according to the results. Researchers found patients in the sciatica subgroup who had a greater identity score and believed their back or leg pain problem would last a long time also had a negative association with improvement.
Making improvements for patients
With the hope they may identify patient subgroups that were more vulnerable, Van der Windt noted she and her colleagues were surprised by how similar the findings were in the referred leg pain and sciatica subgroups.
“This may be reassuring for clinicians because these classifications can be quite difficult, and they are not without fault,” Van der Windt said. “Not all clinical assessment tests are very reliable in practice, so the fact that a patient who comes to you with leg pain or sciatica is likely to have a similar prognosis and similar risk factors for poor outcome, may help clinicians to be more confident in their decisions.”
She said she believes the prognostic factors identified in this study can be taken forward for use in identifying subgroups of vulnerable patients that may need more treatment, but new studies will need to confirm their prognostic value.
“If you then use those factors to stratify people and give these subgroups different types of treatment, for example if you focus specific interventions on those people who have more severe symptoms or who have a negative outlook on their condition, will that indeed help to improve their outcomes?” Van der Windt said. “Such studies could demonstrate whether making use of the information prognostic factors provide leads to benefit for patients. – by Casey Tingle
Reference:
Konstantinou K, et al. Spine J. 2018;doi:10.1016/j.spinee.2017.10.071.
For more information:
Danielle Van der Windt, PhD, can be reached at Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom; email: d.van.der.windt@keele.ac.uk.
Disclosure: Van der Windt reports no relevant financial disclosures.
Perspective
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Kevin Bernard, MD
Back-related leg pain is a widespread complaint that frequently presents to primary care doctors. This study aims to identify prognostic factors related to sciatica and back-related leg pain, both of which can be associated with significant disability. At 12 months, half of the participants had an improved disability score in both the sciatica and referred lower back pain subgroups. Prognostic factors related to leg pain duration, pain intensity and pain identity were associated with increased rates of disability. The findings may suggest the patient's experience with pain, the overall impact on quality of life and beliefs related to pain may play a more significant role in outcomes than previously believed. Risk stratification when selecting a treatment plan may improve outcomes when the pain is interrupting multiple areas of the patient's life. Additionally, discussing the natural history of back-related leg pain and addressing the patient's beliefs related to their pain symptoms may also improve their outcomes.
New England Baptist Hospital
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