Quebec Task Force Classification Research Articles

Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol

BackgroundChronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis.MethodsWe have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10–12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients’ intervention assignment.DiscussionBy targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem.Trial registrationClinicalTrials.gov Identifier: NCT03581123.

Distortion of the cervical spine : Pathophysiology, diagnostics, treatment and assessment

Distortion or whiplash trauma of the cervical spine is an injury pattern associated with motor vehicle collisions and typically occurs after rear impact collisions, but is not limited to this type of collision and accident. The vast majority of these injuries are low-grade injuries according to the Quebec Task Force (QTF) classification, whereby no objective morphological correlates can be determined in clinical and radiological examinations. The prognosis is predominantly favorable and the condition is self-limiting; however, care must be taken with respect to complex courses with chronic pain and the manifestation of neuropsychiatric complaints. Due to the mechanism of the accident this injury pattern is particularly frequent in accidents associated with third party liability insurance claims. The discrepancy between subjective complaints and the presence of objective findings is a particular challenge for the assessment by the medical expert.

Effectiveness of Local Cryotherapy Treatment with the Use of Carbon Dioxide and Liquid Nitrogen Among Patients with Low Back Pain Syndrome

Introduction: Low back pain syndromes (LBPS) are common. One of the methods of treating LBPS is local cryotherapy, which can be based on various cooling substances. In the available literature, it is suggested that effective cold treatment may depend on the type and temperature of the cooling substance used. Research objective: The aim of the study was to evaluate the effectiveness of 2 local cryotherapy (Carbon Dioxide and Liquid Nitrogen) types among patients with low back pain syndrome (LBPS). Materials and methods: The study included 60 patients diagnosed with chronic LBPS of discopathic origin. Patients were randomised into 2 study groups. Local cryotherapy treatment with Carbon Dioxide was used in the 1st group (G1), while in the 2nd (G2), cryotherapy treatment with applied Liquid Nitrogen. Two measurements were taken, before and after 2 weeks treatment. The following were used for assessment: centralisation of symptoms (Pain Drawings), pain intensity (Numeral Rating Scale), duration of the current pain episode (Quebec Task Force Classification), level of disability (Roland-Morris Disability Questionnaire), quality and intensity of subjective pain (McGill Pain Questionnaire), patients’ emotional state (Adjectival Scale for Testing Emotions) and self-efficacy related to pain (Pain Self-Efficacy Questionnaire). Statistical analysis was performed via the Student’s t-test for dependent and independent samples. Results: In both study groups, the perceived pain was either completely eliminated or centralised to the spine, hip joint and buttock. The level of pain, disability and pain-related self-efficacy decreased significantly, regardless of the therapy used. In terms of these variables, no greater therapeutic efficacy was demonstrated with either cryostimulation treatment. Qualitative assessment of pain and emotions (especially anxiety and anger) decreased significantly in G1 and G2. However, in the nitrogen-treated group, a significantly greater improvement was noted for WOB:OC, anger and anxiety scores (for these variables, the G2 group started from a higher level prior to therapy). Conclusions: Both analysed treatments are equally effective in terms of variables such as: centralisation of symptoms, level of pain intensity, disability, joy, self-efficacy related to pain, as well as the majority of the analysed MPQ indicators. Cryostimulation with liquid nitrogen may be more effective, but only in improving the WOB: OC index of the MPQ questionnaire and the level of anger and anxiety. Nonetheless, the obtained results do not allow for definitive confirmation of these results. The use of both cryostimulation treatment methods may assist in the treatment process of LBPS.

Психоемоційні розлади в пацієнтів із хронічними больовими синдромами попереково-крижової локалізації

Мета дослідження — вивчити особливості психоемоційних розладів у групах пацієнтів із хронічними больовими синдромами попереково-крижової локалізації згідно з Класифікацією захворювань хребта Квебекської спеціальної комісії (КЗХКСК). Матеріали і методи. Обстежені 103 пацієнти з хронічним вертеброгенним попереково-крижовим больовим синдромом (ХВПКБС) та 30 практично здорових осіб. За результатами клініко-неврологічного обстеження всі пацієнти були розподілені на групи, які відповідали першим чотирьом групам КЗХКСК. З метою дослідження психоемоційних розладів проводилося обстеження з використанням тесту Спілбергера в модифікації Ханіна та опитувальника Бека. Результати. У групі пацієнтів із ХВПКБС спостерігалися більш високі рівні реактивної та особистісної тривожності, депресії порівняно з контрольною групою. Так, середній бал реактивної тривожності становив 51 (47; 58), особистісної тривожності — 44 (41; 50), депресії — 4 (3; 7) бали. При розподілі пацієнтів на групи відповідно до КЗХКСК найвищі значення реактивної (56 (49,5; 61,5)) та особистісної (47 (41,5; 51,5)) тривожності, а також депресії (6 (4; 9)) спостерігались в групі IV. Рівні особистісної тривожності та депресії вірогідно (P < 0,05) відрізнялись в групах пацієнтів II (42 (38,75; 43,25) та 2,5 (0,75; 4) відповідно) та III (47 (41,5; 52,5) та 5 (3,5; 8,5) відповідно). Висновки. Пацієнти із ХВПКБС мають прояви тривожності і депресії різного ступеня вираженості, для виявлення яких доцільне проведення комплексного клініко-психологічного обстеження. Вивчення показників тривожності й депресії дозволить індивідуалізувати підхід до лікування, що сприятиме поліпшенню психоемоційного та соціального статусу пацієнтів.

Якість життя в пацієнтів із хронічними больовими синдромами попереково-крижової локалізації

Мета дослідження. Вивчити якість життя, особливості обмеження функції та якості сну в пацієнтів із хронічними больовими синдромами попереково-крижової локалізації відповідно до груп за Класифікацією захворювань хребта Квебекської спеціальної комісії (КЗХКСК). Матеріали і методи. Обстежено 103 пацієнти з хронічним вертеброгенним попереково-крижовим больовим синдромом (ХВПКБС) та 30 практично здорових випробуваних. За результатами клініко-неврологічного обстеження всі пацієнти були розподілені на групи, які відповідали першим чотирьом групам КЗХКСК. З метою дослідження якості життя, обмеження функції та якості сну застосовували: опитувальник якості життя EuroQol-5D, опитувальник якості сну Центру сомнології та опитувальник Освестрі. Результати. У групі пацієнтів із ХВПКБС показник якості життя був вірогідно меншим (5 (4; 6) балів із 10 максимально можливих), ніж у контрольній групі (9 (8; 10) балів). Середній ступінь обмеження функції за опитувальником Освестрі в групі пацієнтів дорівнював 30,50 ± 13,55 %. Розлади сну мали місце в 100 % досліджуваних, а середній бал за цим показником у групі пацієнтів становив 20 (18; 22). У групі пацієнтів IV (класична радикулопатія) спостерігались найнижчі показники якості життя (4 (3; 5)) та якості сну (18 (17; 20,5)) і найвищі показники ступеня обмеження функції за опитувальником Освестрі (36,63 ± 14,45). Висновки. У пацієнтів із ХВПКБС виявлено зниження рівня окремих компонентів і загальної оцінки якості життя, а також ступеня обмеження функції за опитувальником Освестрі. Усі пацієнти мали розлади сну різного ступеня вираженості. Група пацієнтів IV за КЗХКСК характеризувалась найнижчою якістю життя та сну, а також найбільшим ступенем обмеження функції за опитувальником Освестрі порівняно з іншими групами.

Impairment of Proprioception in Young Adult Nonradicular Patients with Lumbar Derangement Syndrome.

Maintaining body balance is a complex function based on the information deriving from the vestibular, visual, and proprioceptive systems. The aim of the study was to evaluate quiet single stance stability in young adults with lumbar derangement syndrome (LDS) and in the control group of the healthy subjects. The second aim of this study was to determine whether pain intensity, degree of disability, and the level of physical activity can influence postural control in patients with LDS. It is important to underline that selecting a homogeneous group of LBP patients using, for example, mechanical diagnosis and therapy method and Quebec Task Force Classification, can result in an increased sensitivity of the study. The study included 126 subjects: 70 patients with LDS (37 women, 33 men) and the control group 56 healthy volunteers (36 women, 20 men). In case of multiple group comparisons for variables with normal distribution, ANOVA post hoc test was used or, as the nonparametric equivalent, Kruskal-Wallis test. In all these calculations, the statistical significance level was set to p < 0.05. The stability index eyes open for the study group was 88.34 and for the control group 89.86. There was no significant difference in the level of postural control between the study and control groups (p > 0.05). The level of stability index eyes closed (SI EC) for the study group was 71.44 and for the control group 77.1. SI EC results showed significant differences in proprioceptive control during single leg stance between the study and control groups (p < 0.05). The level of pain intensity, the degree of disability, and physical activity level did not influence postural control in the study group with LDS. In summary, patients with LDS showed significantly worse proprioceptive control.

Development of selective criteria for the verification of whiplash-associated disorders.

Whiplash injury (distortion of the cervical spine) is the most commonly diagnosed type of injury sustained in car accidents, and it ranks first in the structure of compensation claims for personal injury resulting from traffic incidents. The verification of whiplash-associated disorders (WADs) continues to be agreat problem in the formulation of medico- legal expert opinions, as injuries of this type, cannot, by definition, be captured using available imaging methods ("radiologically negative effects of acceleration/deceleration mechanism with awide variety of clinical manifestations"). The present study aims to define aset of criteria that might represent threshold conditions for WAD verification, enabling preliminary cohorting (preselection) of evaluated cases and facilitating the adoption of legal decisions. The available scientific literature addressing problems relating to WAD verification was reviewed to identify factors that differentiate an extremely broad spectrum and varying severity of symptoms depending on the circumstances of incidents, the results of physical evaluation of patients and additional instrumental examinations, as well as technical indicators. Based on the literature search, arange of criteria with the highest potential significance for application in routine medical and forensic expert practice were selected (with afocus on aspects related to verification, quantification and outcomes). The primary prerequisite for recognising the presence of moderate impairment to health (according to the Polish penal code) due to distortion of the cervical spine should involve confirmation of grade 3 WAD according to the Quebec Task Force (QTF) classification, and exceeding the threshold values of Δv (> 15 km/h), acceleration of the victim's vehicle centre of gravity (> 4 g), and NIC criterion (> 15 m2/s2). Additional criteria used by experts should include the verification of the correct head restraint position as well as results of biomechanical examinations evaluating the level of safety of agiven vehicle, and epidemiological data retrieved from databases including the statistics for claims filed by victims of real-life accidents.

High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1° and 2° grade of the Quebec Task Force classification) involving muscles and ligaments

High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1° and 2° grade of the Quebec Task Force classification) involving muscles and ligaments

A predictive model to analyze factors affecting the presence of mild whiplash-associated disorders in minor motor vehicle crashes based on the Korean In-Depth Accidents Study (KIDAS) Database

Objectives: We aimed to analyze factors affecting the severity of mild whiplash-associated disorders (WADs) and to develop a predictive model to evaluate the presence of mild WAD in minor motor vehicle crashes (MVCs).Methods: We used the Korean In-Depth Accident Study (KIDAS) database, which collects data from 4 regional emergency centers, to obtain data from 2011 to 2017. The Collision Deformation Classification code was obtained as vehicle’s damage information, and Abbreviated Injury Scale (AIS), Maximum Abbreviated Injury Scale (MAIS), and Injury Severity Score (ISS) were used as occupant’s injury information. The degree of WAD was determined using the Quebec Task Force (QTF) classification, comprised of 5 stages (QTF 0–4), depending on the occupant’s pain and the physician’s findings. QTF 1 was defined as mild WAD, and we used QTF 0 to define those who were uninjured. For KIDAS data between 2011 and 2016, a logistic regression model was used to identify factors affecting the occurrence of mild WAD and a predictive model was constructed. Internal validity was estimated using random bootstrapping, and external validity was evaluated by applying 2017 KIDAS data. Of the 2,629 occupants in the KIDAS database from 2011 to 2016, after applying several exclusion conditions, 459 occupants were used to develop the predictive model. The external validity of the derived predictive model was assessed using the 13 MVC occupants from the 2017 KIDAS database meeting our inclusion criteria. Among the 137 MVC occupants from the 2017 KIDAS database for analysis of the external validity of the derived predictive model, the predictive model was verified for 13 MVC occupants.Results: Logistic regression analysis was used to derive a predictive model based on sex, age, body mass index, type of vehicle, belt status, seating row, crush type, and crush extent. This predictive model had an explanatory power of 65.5% to determine an actual QTF of 0 and 1 (c-statistics: 0.655). As a result of the external validity analysis of the predictive model using data from the 2017 KIDAS database (N = 13), sensitivity, specificity, and accuracy were 0.500, 0.857, and 0.692, respectively.Conclusions: Using the predictive model, the results of the external validity analysis showed low sensitivity but high specificity. This predictive model provided meaningful results, with a high success rate for determining no injury to an occupant. Given our study results, future research is needed to create a more accurate predictive model that includes relevant technical and sociological factors.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia

BackgroundIn Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence.MethodsThis was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis.ResultsMedian time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9–12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01).ConclusionThere is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

The Associated Factors of Neuropathic Pain Among Chronic Low Back Pain Patients in South Korea: Findings from the NLBP OR

Low back pain (LBP) patients with neuropathic pain (NP) had substantially impaired quality of life. We investigated possible factors associated with NP in chronic LBP patients. Data were extracted from the NLBP OR [the NP in chronic LBP patients; Korean epidemiological study]. It was a multicenter and cross-sectional study where 1,200 patients older than 20 years of age with chronic LBP longer than 3 months, with a visual analog scale (VAS) pain score higher than 4, and with pain medication at least 4 weeks prior to enrollment were recruited at 27 general hospitals from December 2014 to May 2015. Potential factors related to NP were age, sex, LBP duration from diagnosis, Quebec Task Force Classification for Spinal Disorders (QTFC-SD), comorbidities, and pain VAS and were collected by medical chart review. Douleur Neuropathique 4 (DN4) was used for diagnosis of NP (DN4≥4). Analysis was performed on 880 patients (mean age 64 years, male 34%) who had complete data of all measured variables. 362 (41%; mean age 63 years, male 40%) patients were classified as NP. In multiple logistic regression analysis, independently associated factors of NP prevalence were male (adjusted odds ratio, 1.7; 95% Confidence Interval, 1.2-2.3) and having pain of severe intensity compared to moderate pain (1.8; 1.4-2.4). In addition, compared to pain without radiation, pain with proximal extremity radiation (3.5; 1.8-6.8), pain with distal extremity radiation (7.4; 4.1-13.6), pain with radiation and neurologic finding (7.6; 3.6-16.3), spinal nerve root compression (5.9; 2.8-12.4), and spinal stenosis (4.6; 2.3-9.2) were respectively associated with NP prevalence. When physicians treat chronic LBP, more attention should be given to those patients with related factors of NP.

Latent class analysis derived subgroups of low back pain patients \u2013 do they have prognostic capacity?

BackgroundHeterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the ‘comparator variables’).MethodsThis was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above.ResultsThe two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants’ recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%–6.9% for pain intensity and from 6.8%–20.3% for disability, and highest at the 2 weeks follow-up.ConclusionsLatent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

Isometric muscle fatigue of the paravertebral and upper extremity muscles after whiplash injury.

BACKGROUNDWhiplash-associated disorders (WAD) result from injury of neck structures that most often occur during traffic accidents as a result of rapid acceleration-deceleration. The dominant symptoms manifest in the musculoskeletal system and include increased fatigue. Because of the frequency of whiplash injuries, a simple, cheap and useful diagnostic tool is needed to differentiate whiplash injury from healthy patients or those faking symptoms.OBJECTIVESTo determine muscle fatigue in patients with whiplash injury in six body positions.DESIGNAnalytical cross-sectional study.SETTINGEmergency center, university hospital.PATIENTS AND METHODSWe studied patients with whiplash injury from vehicular traffic accidents who presented to the emergency center within 6 hours of sustaining the injury. We determined whiplash injury grade according to the Quebec Task Force (QTF) classification and measured isometric muscle endurance in six different body positions. Control subjects for each patient were matched by age, gender and anthropomorphic characteristics. Cut-off values were determined to distinguish patients with whiplash injury from controls and for determination of injury grade.MAIN OUTCOME MEASURE(S)QTF grade, time to muscle fatigue in seconds.RESULTSFrom September 2013 to September 2016, we enrolled 75 patients with whiplash injury and 75 matching control subjects. In all six positions, the patients with whiplash injury felt muscle fatigue faster than equivalent controls (P<.05) and the time to onset of muscle fatigue decreased with increasing injury grades in all six positions. Assignment to the patient or control group and to injury grade could be predicted with more than 90% accuracy on the basis of time to muscle fatigue. The most efficient position was the highest injury grade, by which 99.9% of the patients were accurately categorized. Isometric muscle endurance correlated with whiplash injury grade in all six positions (P<.01).CONCLUSIONUnder clinical conditions, muscle endurance and the appearance of isometric muscle fatigue during testing can be a useful indicator of whiplash injury and grade.LIMITATIONSThe size of the sample was small. An objective parameter such as electromyography is needed to confirm isometric muscle fatigue.

An Integrated Model of Chronic Whiplash-Associated Disorder.

Synopsis The development of persistent symptoms following whiplash injury from a motor vehicle collision is common and contributes substantially to societal and personal costs. The popular Quebec Task Force classification system of whiplash-associated disorders (WADs) was meant to function as a prognostic and intervention decision aid, but its usefulness has been questioned. Emerging evidence highlights the heterogeneity of WAD by demonstrating physical and psychological impairments that are unique to those who develop persistent symptoms. These impairments are not recognized in the Quebec Task Force classification system. The purpose of this clinical commentary is to describe an integrated model that focuses on how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic WAD. The model has been developed through more than 20 years of work in the field, consultation with experts, in-depth synthesis of existing evidence, and new evidence from the authors' own research programs. A subtheme is that a point of convergence currently exists between the psychological, physiological, and social determinants of health literature that can further explain the complex presentation of WAD. The new model is proposed to orient future research toward more interdisciplinary efforts across nontraditional fields, including data scientists and consumers, to clarify the WAD condition. J Orthop Sports Phys Ther 2017;47(7):462-471. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7455.

Significance of sub grouping patients with chronic low back pain in management decisions: A prospective study

Background: The Quebec Task Force classification (QTF) was originally designed to help in making a clinical decision and to aid in determining the prognosis. However, the predictive validity and prognostic significance of the classification was debated. We conducted the study to determine the discriminative and prognostic significance of the modified Quebec Task Force classification in chronic low back pain patientsMaterials & Methods: 183 consecutive chronic low back pain(>7 weeks of continuous pain) patients in the age groups of 18-65 years who presented to a tertiary care centre in South India and followed up for a minimum of 6 months were included in the study. Patients were assigned to one of the four QTF categories after a detailed history and examination. Pain severity and functional disability were assessed using LBPRS and RMDQ respectively. The patients were then put on the common specific rehabilitation protocol and analgesics, and followed up every six weeks to look for compliance with the treatment. The scores (LBPRS, RMDQ) were noted again at 3 and 6 months. The comparison of scores was done among the 4 QTF categories at the time of presentation, at 3 months and at 6 months Result: There were no significant differences in the distribution of age, sex, occupation or educational status among different QTF categories. Non-parametric tests using Wilcoxon Signed Rank test showed significant improvement in LBPRS and RMDQ scores with time in each category(p value

A Study of the Modified Quebec Task Force Classification of Chronic Low Back Pain with Regards to Activity Limitation, Global Percieved Effect, Sick Leave, and its Prognostic Implications

Introduction The Quebec Task Force(QTF) on activity related spinal disorders was a group of experts in various fields brought together by the Quebec Worker's Health and Safety Commission. It formally recognized that clinicians couldnot reliably differentiate between different patho anatomic causes of low back pain(LBP). Classifying patients as described by the QTF has shown associated differences on several characteristics which showed increasing severity from category 1(local LBP) across the categories of LBP+radiation above knee (category 2), LBP+radiation below knee (category 3) to LBP+neurological signs (category 4). The objective of the study is to determine the prognostic significance of the QTF classification in patients with chronic LBP and to compare the efficacy of the chronic LBP rehabilitation protocol among various categories of QTF. Material and Methods Routine data was collected at the time of presentation to an outpatient department of a tertiary care center in India. After taking a detailed history and clinical examination, the pain severity is assessed by Low Back Pain Rating scale (LBPRS) and the activity limitation is assessed by Roland Morris Disability Questionnaire (RMDQ). The patients were advised treatment according to the common standard rehabilitation protocol. The patients were followed up every 6 weeks to check for the progression of symptoms clinically and for the compliance with the rehabilitation protocol. The patients were evaluated at 3 months and again at 6 months for Global Perceived Effect (GPE), activity limitation (RMDQ questionnaire) and sick leave status along with LBPRS. Results A total of 188 patients were included with 75% 3 month and 70% 6 month follow up.category 1 had the least and category 4 had the most severe activity limitation at all time points.Patients in category 4 improved the most at the end of 6 months with the common rahabilitation protocol.Patients in category 4 landed up more frequently in surgery compared with others. There were no significant differences in comparisions between category 2 and category 3 Conclusion Categorizing patients based on QTF classification has shown significant association with activity limitation. Prognosis of the patient's condition based on the symptoms at presentation can be roughly estimated using the QTF classification. However, differentiating patients based on radiating pain above or below the knee has no significant prognostic implications. It was found difficult to establish a diagnosis based on symptoms alone. Hence, targeted treatment based on the QTF classification may have a potential role in better management of patients with chronic LBP.

The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy

Objective: To determine the correlation between the Quebec Task Force Classification (QTFC) system and outcome in patients with non-specific low back pain (LBP).Methods: Forty-nine patients who were treated in outpatient physical therapy clinics of Catholic Health System (CHS) of Western New York (WNY) were classified according to the QTFC at the initial examination by physical therapists (PTs) with training in Mechanical Diagnosis and Therapy (MDT). The patient’s perceived level of function was assessed with the Focus On Therapeutic Outcomes (FOTO) tool at the initial examination, 2 weeks following the initiation of physical therapy and again at discharge.Results: A linear regression model between acuity and change in FOTO score was performed and demonstrated statistical significance (P<0·05) as the more favorable outcome was found with the more acute patients. Spearman correlations between change in FOTO score and QTFC, duration of treatment and acuity of condition, and number of visits and change in FOTO score were not found to be statistically significant.Conclusions: The patients treated in this study demonstrated functional improvement in an average of eight visits, indicating efficacious care. Future research is needed to determine prioritized intervention strategies for designated LBP classifications.

Mid-term follow-up of whiplash with Bournemouth Questionnaire: The significance of the initial depression to pain ratio

The Bournemouth Questionnaire (BQ) was used to report the short to mid-term outcome of a prospective cohort of patients who had sustained Whiplash Associated Disorder (WAD), and establish whether outcome could be predicted on initial assessment. One hundred patients with WAD grades I-III on the Quebec Task Force Classification were referred for physiotherapy (neck posture advice, initially practised under the direct supervision of a therapist). BQ scores were recorded on the first visit, at six weeks, then at final follow-up. Seventy-six percent of patients were available at final follow-up, 58% women. The mean age was 43.2 years old and follow-up time 38 months (28-48). Symptoms plateaued after six weeks in the majority and improved gradually thereafter. When the individual BQ components on initial presentation were reassessed, patients who score disproportionately highly in BQ Question 5 (Depression) had a worse outcome. To quantify this, the ratio of BQ Questions 5 (Depression)/1 (Pain) was calculated. BQ5/1 ratio greater than 1 on initial presentation had an odds ratio of 2 for poor outcome (p= 0.02). The BQ can therefore be used to identify patients with a disproportionately high depression score (BQ5) who are highly likely to clinically deteriorate in the medium term.

In a secondary care setting, differences between neck pain subgroups classified using the Quebec task force classification system were typically small - a longitudinal study.

BackgroundThe component of the Quebec Task Force Classification System that subgroups patients based on the extent of their radiating pain and neurological signs has been demonstrated to have prognostic implications for patients with low back pain but has not been tested on patients with neck pain (NP).The main aim of this study was to examine the association between these subgroups, their baseline characteristics and outcome in chronic NP patients referred to an outpatient hospital department.MethodsThis was an observational study of longitudinal data extracted from systematically collected, routine clinical data. Patients were classified into Local NP only, NP + arm pain above the elbow, NP + arm pain below the elbow, and NP with signs of nerve root involvement (NP + NRI). Outcome was pain intensity and activity limitation. Associations were tested in longitudinal linear mixed models.ResultsA total of 1,852 people were classified into subgroups (64 % females, mean age 49 years). Follow ups after 3, 6 and 12 months were available for 45 %, 32 % and 40 % of those invited to participate at each time point.A small improvement in pain was observed over time in all subgroups. There was a significant interaction between subgroups and time, but effect sizes were small. The local NP subgroup improved slightly less after 3 months as compared with all other groups, but continued to have the lowest level of pain. After 6 and 12 months, those with NP + pain above the elbow had improved the least and patients with NP + NRI had experienced the largest improvements in pain intensity. Similar results were obtained for activity limitation.ConclusionsThis study found baseline and outcome differences between neck pain subgroups classified using the Quebec Task Force Classification System. However, differences in outcome were typically small in size and mostly differentiated the local NP subgroup from the other subgroups. A caveat to these results is that they were obtained in a cohort of chronic neck pain patients who only displayed small improvements over time and the results may not apply to other cohorts, such as people at earlier stages of their clinical course and in other clinical settings.

Study protocol for patient response to spinal manipulation - a prospective observational clinical trial on physiological and patient-centered outcomes in patients with chronic low back pain.

BackgroundLow back pain (LBP) is a major health issue due to its high prevalence rate and socioeconomic cost. While spinal manipulation (SM) is recommended for LBP treatment by recently published clinical guidelines, the underlying therapeutic mechanisms remain unclear. Spinal stiffness is routinely examined and used in clinical decisions for SM delivery. It has also been explored as a predictor for clinical improvement. Flexion-relaxation phenomenon has been demonstrated to distinguish between LBP and healthy populations. The primary objective of the current study is to collect preliminary estimates of variability and effect size for the associations of these two physiological measures with patient-centered outcomes in chronic LBP patients. Additionally biomechanical characteristics of SM delivery are collected with the intention to explore the potential dose–response relationship between SM and LBP improvement.Methods/DesignThis is a prospective, observational study applying side-lying, high velocity, low amplitude SM as treatment for patients with LBP over a course of 6 weeks. Approximately 80 participants will be enrolled if they present with chronic LBP of 1, 2 or 3 in Quebec Task Force Classification for spinal disorders, a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 6, and persistent LBP ≥ 2 with a maximum ≥ 4 using numerical rating scale. Patient-centered outcomes include LBP using visual analog scale, RMDQ, and PROMIS-29. Lumbar spine stiffness is assessed using palpation, a hand-held instrumented device, and an automated device. Flexion-relaxation is assessed using surface electromyography at the third level of the lumbar spine. Biomechanical characteristics of SM are assessed using a self-reported, itemized description system, as well as advanced kinetic measures that will be applied to estimate forces and moments at the lumbar segment level targeted by SM.DiscussionBeside alterations in material properties of the passive components of the spine, increased neuromuscular activity may also contribute to a stiffened spine. Examining changes in both spinal stiffness and flexion-relaxation along the course of the treatment provides an opportunity to understand if the therapeutic effect of SM is associated with its action on active and/or passive components of the spine.Trial registrationNCT01670292 on clinicaltrials.gov.