Are co-morbid medical symptoms associated with poor response to sub-classification based management of chronic low back pain? A retrospective case-control study

Reference as:

Gibbons SGT (2019) Are co-morbid medical symptoms associated with poor response to sub-classification based management of chronic low back pain? A retrospective case-control study. Proceedings of: The 10^th Interdisciplinary World Congress on Low Back Pain. October 28-31, 2019; Antwerp, Brussels

Introduction:

There is a growing evidence base for sub-classification based management in chronic low back pain (CLBP). A category may be used for sub-classification if it provides: a diagnosis, prognosis, predicts response to treatment, or provides an underlying mechanism. Contemporary sub-classification categories include behavioral factors, pain mechanisms, and motor control interventions (MCI) (e.g. movement patterns, segmental spinal control). For each subgroup, evidence based recommendations exist, however these are not universally accepted. Medical co-morbidities (MC) are associated with CLBP. Some of which are known to be associated with chronic low grade systemic inflammation (CLGSI). CLGSI is now known to be an underlying mechanism for many behavioral conditions; conditions associated with non mechanical pain and other conditions known to presents with neurological symptoms. Despite this, there has yet been little effort to consider MC or CLGSI as a unique subgroup. It was hypothesized that co-morbid medical symptoms (CMS) would be present to a greater extent in non responders to patients sub-classified as being suitable for a MCI.

Purpose

The purpose of the study was to perform a retrospective case control study to assess the association of CMS to poor outcome of MCI in subjects with CLBP.

Materials and Methods:

The Neuro-Immune-Cardiometabolic-Endocrine symptoms Questionnaire (NICE-Q) consists of a 'review of systems' (19 categories and 126 items). A category is scored as 1 if any symptom was rated as being present "sometimes" or more frequent. This was given to 118 subjects (39M; 79F) with CLBP who had a poor outcome following a MCI over 12 weeks. A poor outcome was defined as not achieving the minimally detectable change in pain, disability or function outcome measures. Subjects were matched for age, sex, sub-classification status (non-mechanical pain, behavioral factors, poor motor skill learning ruled out by questionnaire), CLBP duration, to 127 subjects (42M; 85F). The NICE-Q was dichotomized into scores of > 12 or not. A standard 2 x 2 table was used to calculate odds ratios (OR).

Results:

The OR for a poor outcome to a MCI with > 12 on the NICE-Q =13.7.

Conclusion:

Moderate to high CMS have a high association with poor outcome in CLBP sub-classified as being suitable for a MCI. This provides preliminary evidence that CMS may be a unique subgroup of CLBP in that they predict a poor response to therapy. There is growing evidence that CLBP is part of a more complex health problem and CMS screening may provide insight into identifying this subgroup. The NICE-Q may be a promising screening tool to predict a poor response to motor control interventions. CMS should be assessed  prospectively and for other sub-classification categories.

Keywords: Sub-classification, low-grade inflammation, motor control