- Title
- Clinical prediction rules for low back pain
- Creator
- Haskins, Robin
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2015
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Low back pain (LBP) is prevalent, costly and a significant contributor to societal burden. It is not a single specific condition, but instead generally considered to be comprised of smaller more homogenous subgroups of patient presentations that meaningfully differ with regard to their symptomology, prognosis and responsiveness to different interventions. The identification of subgroups of patients with LBP is a research priority and several classification mechanisms have been proposed. Traditionally, such classification approaches have been predominantly based upon expert opinion and biologic plausibility, with little concordance among them. More recently, there has been a greater focus upon empirically derived subgrouping methods, notably including the development of clinical prediction rules (CPRs). A CPR is a clinical tool designed to be used with an individual patient, and is based on the statistical identification of a parsimonious composite of variables that facilitate the prediction of a given diagnosis or outcome. The main objective of this thesis is to facilitate the development of CPRs with the greatest potential to positively influence the physiotherapy management of LBP. This was achieved through a series of five published studies and a published Clinical Commentary that together sought to address three primary research aims: 1. Identify and assess the degree to which CPRs for LBP may be confidently applied in clinical practice using a hierarchical framework for CPR development and an appraisal and synthesis of the existing evidence base. ; 2. Explore the range of factors that may influence the implementation of CPRs for LBP within Australian physiotherapy practice. ; 3. Examine the areas of perceived need for LBP CPRs and the range of characteristics such tools need to encompass to be considered clinically meaningful and useful within Australian physiotherapy practice. Three systematic reviews were conducted which sought to synthesise the available body of evidence to: (1) identify CPRs relevant to the assessment and management of LBP. ; (2) assess the degree to which such tools may be confidently applied in clinical practice. ; (3) identify opportunities to improve the methodological quality and reporting of LBP CPR development studies. The evidence considered within these reviews identified that a large number of diagnostic, prognostic and prescriptive LBP CPRs are under development, however the majority of these tools have not undergone validation and therefore cannot be recommended for direct use in clinical practice at this time. The current lack of impact analysis studies also prevents the assessment of whether the application of LBP CPRs in clinical practice results in beneficial effects on patient outcomes or resource efficiencies. A small number of LBP CPRs have undergone validation, such that clinicians may have some confidence in the predictive accuracy of these tools when applied in similar patient populations and settings. Further, several opportunities to improve the methodological rigour of future CPR development studies have been identified. Two qualitative studies using focus groups and involving a sample of Australian physiotherapists who manage patients with LBP were undertaken concurrently to address research aims 2 and 3. The findings of the first of these studies highlighted that physiotherapists’ knowledge of LBP CPRs may be quite varied and few participants in that study reported having ever used them to inform their clinical decision-making. Barriers to the use of LBP CPRs included a negative connotation associated with the term ‘rule’, a perception that CPRs are overly-complex and infrequently applicable, clinical experience obviating the need for such tools, and the potential threat to clinical autonomy and for misuse by third-party payers. Physiotherapy participants felt that LBP CPRs were best used within the suite of clinical reasoning processes physiotherapists typically employ and considered as second opinions or safety nets that were able to be overruled by the clinician. The findings of the second qualitative study indicated that prognostic forms of CPRs for LBP that function to predict future meaningful outcomes may be welcomed by practising physiotherapists. CPRs that identify likely responders to interventions are likely to be considered useful, as well as diagnostic forms of CPRs that function to identify serious causes of LBP such as fracture and cancer. CPRs that identify which patients are more likely to experience an adverse outcome or to not require physiotherapy intervention may also be welcomed by clinicians. Participants thought that LBP CPRs should be uncomplicated, easy to remember, easy to apply, accurate and precise, and well-supported by research evidence. It was believed that LBP CPRs should not contain an excessive number of variables, use complicated statistics, or contain variables that have no clear logical relationship to the dependent outcome. It was further considered by participants that LBP CPRs need to be compatible with traditional clinical reasoning and decision-making processes, and sufficiently inclusive of a broad range of management approaches and common clinical assessment techniques. A published Clinical Commentary was produced as a resource for clinicians and researchers based on findings arising from this research indicating the potential importance of the predictive precision of CPRs. The Clinical Commentary highlights the importance of considering uncertainty in clinical prediction, and provides a technical guide to the calculation and approximation of posterior probability uncertainty intervals. This and other study findings presented in this thesis have direct immediate implications for clinicians contemplating the application of LBP CPRs in clinical practice, and for researchers involved in the development of these tools. Opportunities for further research in this area have also been identified and are presented in the final chapter of this thesis. It is anticipated that consideration of the study findings in this program of research may support the development of CPRs with the greatest capacity to benefit the physiotherapy management of patients with LBP, and also strategies and future research projects designed to facilitate the successful translation of CPR research evidence into clinical practice.
- Subject
- clinical prediction rules; low back pain; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1310330
- Identifier
- uon:22025
- Rights
- Copyright 2015 Robin Haskins
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 28 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 605 KB | Adobe Acrobat PDF | View Details Download |