Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

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SOURCE:   PLoS Med. 2016 (May 17); 13 (5): e1002019

Adrian C. Traeger, Nicholas Henschke, Markus Hübscher,
Christopher M. Williams, Steven J. Kamper,
Christopher G. Maher, G. Lorimer Moseley,
James H. McAuley

Prince of Wales Clinical School,
University of New South Wales,
Sydney, New South Wales, Australia

BACKGROUND:   Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP.

METHODS AND FINDINGS:   We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a “treat all” approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings.

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CONCLUSIONS:   Based on its performance in these cohorts, this five-item prognostic model for patients with acute LBP may be a useful tool for estimating risk of chronic LBP. Further validation is required to determine whether screening with this model leads to a net reduction in unnecessary interventions provided to low-risk patients.

From the FULL TEXT Article:

Author Summary

      Why Was This Study Done?

  • A minority of patients who experience an episode of low back pain develop persistent (chronic) pain.

  • Offering tests and treatments to all these patients exposes high numbers of low-risk patients to unnecessary intervention, which is very costly and potentially harmful.

  • A tool to help healthcare practitioners accurately predict whether a patient with a recent episode of low back pain will develop persistent pain stands to greatly reduce the burden of low back pain on the health system and on patients.

      What Did the Researchers Do and Find?

  • We developed a five-item screening questionnaire using study data from 1,230 patients with a recent episode of low back pain.

  • We tested how well this screening questionnaire could predict the onset of persistent pain in a separate sample of 1,528 patients.

  • We found that the screening questionnaire could predict the onset of persistent pain with acceptable levels accuracy (area under the receiver operating characteristic curve = 0.66 [95% CI 0.63 to 0.69]; intercept = 0.55, slope = 0.89).

      What Do These Findings Mean?

  • This brief, easy-to-use screening questionnaire could help healthcare practitioners and researchers make an early estimate of a patient’s risk of persistent low back pain.

  • The screening questionnaire predicted outcome more accurately in patients with low risk scores than in those with high risk scores.

  • Screening patients with a recent episode of low back pain could reduce the number of unnecessary interventions provided to low-risk patients.


Low back pain (LBP) is a major global health problem that, compared to all other diseases and health conditions, is responsible for the most years lived with disability, an estimated 80 million years lived with disability in 2010. [1] The costs of care, investigations, and lost productivity associated with LBP are a significant economic burden for industrialized nations. [2] For example, estimates for treatments alone are US$50 billion per annum in the United States [3] and US$4 billion in the United Kingdom. [4] The impact of LBP can be profound; in Australia, LBP is the leading cause of early retirement [5] and of income poverty in older adults. [6]

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