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Boyd, Kelly (2014). Chronic Low Back Pain: Exploring Trends and Potential Predictors. McGill Family Medicine Studies Online, 09: e01.


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Context: Hundreds of thousands of Quebec residents suffer from chronic pain, for which
treatment is far from optimal. Chronic pain is recognized as a major health problem, not
only because of its frequency, but also the devastating effects it has on physical,
emotional, and social aspects of life. Despite low back pain being the second most
common reason to visit a primary care physician, management remains challenging.
Additionally, chronic low back pain (CLBP) has been found to be the most common
reason for patients to be referred to tertiary pain centers. Recently, there has been an
increasing acceptance that bio-psycho-social factors play a crucial role the clinical course
of CLBP, yet limited research concerning CLBP has been completed beyond one year.


Objectives: The purpose of this study was to identify subgroups of CLBP patients treated
in tertiary care, as defined by their changes in pain and disability over time, and to
explore possible characteristics associated with these changes. Specific objectives were:
1) to establish whether there are distinct subgroups of patients with CLBP with different
characteristics associated with change in pain and disability at 6, 12, and 24 months
following an initial visit in a tertiary pain clinic; and 2) to identify potential social,
psychological, biological, and environmental factors that may predict their responses in
pain intensity and disability in accordance with the Revised Wilson and Cleary Model for
Health-Related Quality of Life. Design: Observational prospective design to follow a
cohort of patients who were enrolled in the web-based Quebec Pain Registry. Setting:
The Quebec Pain Registry, a research database comprised of close to 5000 chronic pain
patients from tertiary pain centers associated with Université de Montréal, Université de
Sherbrooke, and McGill University Health Centre. Participants: Adults diagnosed with
CLBP who are registered in the Quebec Pain Registry. Eligible participants included all
patients who 1) have been diagnosed with lumber without radicular pain, LBP (diagnostic
code 3.1), lumbar & radicular pain, LRP (diagnostic code 3.2), or diffuse lumbar pain,
DLP (diagnostic code 3.4), 2) who provided written consent for their data to be used for
research purposes, and 3) have completed their initial visit to the pain clinic by May 31,


Intervention: The data required for this project had previously been collected and
entered in the Quebec Pain Registry. Basic descriptive results were produced using
SAS® software 9.2. This analysis described the characteristics of the 917 patients
included in the study at baseline. Additional data were explored to examine patterns of
changes over two years for certain characteristics. A generalized estimating equations
model (GEE) was used to analyze data at 6, 12, and 24 months after the initial visit.


Results: 299 (32.6%) patients were diagnosed LBP, 522 (56.9%) with LRP, and 96
(10.4%) with DLP. In general, all patients were relatively comparable in terms of their
characteristics with the exception of DLP, where proportions were noticeably different.
Patients diagnosed with DLP had a higher pain duration median (6.0 years) and the most
frequently current employment status was permanent disability (both in regards to
proportions). The most common ethnicity was Caucasian among all diagnoses. Income
was similarly distributed among all groups and secondary school was the highest level of
education completed for all. The top three medical conditions reported other than CLBP
were rheumatoid arthritis/osteoarthritis, hypertension, and depressive disorders. DLP
patients reported “accident at work” as the most common circumstance surrounding their
onset of pain. DLP also had noticeably different mean scores for average pain, worst
pain, depression, catastrophizing, disability, mental and physical summary scores on the
health-related quality of life questionnaire at baseline, 6, 12, and 24 months (in regards to
proportions). Patients with higher worst pain scores, longer pain duration, and lower
physical summary scores at the initial visit were significantly less likely to show
improvements in pain intensity and disability at six and 12 months. Conclusions:
Although modifying the analysis prohibited conclusions for a two-year follow to be
made, characteristics, such as worst pain, pain duration, and lower physical summary
scores at both six and 12 months were discovered, thus providing insight into the clinical
evolution of CLBP from baseline to 12 months by determining what characteristics
predict worse pain and disability outcomes. While it is apparent from this study that DLP
patients have noticeably different characteristics compared to other pain CLBP
diagnoses, it is recommended that DLP patients be explored in more depth over a longer
period of time. The overall findings of this project indicate there is still much needed
research in the area of CLBP.


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