What Matters to Patients with Low Back Pain?What matters to patients with low back pain? Is it the activities they cannot perform? Daily activities? Walking? Sports participation? What does the patient want to achieve with treatment? Maybe treatment should be directed toward the patient's priorities, not what the health care specialist thinks is important.
In this study, researchers attempt (for the first time) to assess patients' priorities who have chronic low back pain. A total of 150 patients with chronic low back pain were part of the study. Each one filled out the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR). Although the MACTAR has been used successfully with arthritis patients, this is the first reported use of it with patients who suffer loss of function and disability from chronic low back pain.
There are plenty of other tests out there to assess people with chronic low back pain. Physicians, physical therapists, and other rehab counselors are familiar with the Roland-Morris Disability Questionnaire, the Oswestry Disability Index (ODI), and the Quebec Back Pain Disability Questionnaire (QUEBEC) for looking at disability and participation restriction. They also use tools such as the Visual Analog Scale (VAS) and the Numerical Rating Scale (NRS) to measure pain intensity.
But the MACTAR looks at what the patient would like to do -- what the patient cannot do because of pain. These are the issues that really matter to the patient. The MACTAR looks at mobility; community, social, and civic life; domestic life; work; interpersonal interactions and relationships; and self-care.
Each of those main sections has multiple subsections of activities and participation. For example, mobility looks at driving, walking, standing, running, climbing, and changing positions. Community/social/civic life includes sports, recreation, and leisure including crafts, hobbies, the arts, and culture. Domestic life ranges from shopping and doing housework to caring for plants or gardening, and preparing meals.
Besides filling out the MACTAR, the study participants also completed several other tests to measure their coping skills, level of anxiety and depression, and any fear-avoidance behavior. Fear-avoidance refers to the concept that people in pain often stop moving in ways they think might cause their back to hurt or cause another injury. The result of that behavior is more pain from the altered movement patterns or avoidance of movement.
The idea in giving patients other tests besides the MACTAR was to see how well each test correlated with the MACTAR. A test that correlates well means the two tests measure the same things. Sometimes it's important to confirm research findings about patient population groups. That's when tests that correlate well are used together. But in other cases, it's helpful to give patients more than one test that don't correlate well. That way, more information is added to help direct and guide treatment.
There wasn't one area that stood above the others as the most commonly placed patient priority among the 150 participants. But analysis of the data did show that there were three general trends: mobility, community and social life, and domestic activities. Patients chose different activities within those groups.
The top 10 activities listed as being affected the most by disability included sports, walking, working, cleaning, recreation, driving, moving around, and taking care of plants. The activities that caused the most trouble were sports, shopping, and walking.
The second arm of the study was to find out which tests correlated well with the MACTAR and which did not. The authors found that there was moderate correlation with the Visual Analog Scale (VAS) handicap score but not with the VAS pain scale. The authors propose that this shows patients can tell the difference between activities limited by pain and activities limited by disability.
There was no correlation between the MACTAR and the Fear-Avoidance Behavior test or tests for coping skills. That means the MACTAR does not measure or assess these two areas of psychologic and behavioral factors. These other tests would be needed if the examiner wants or needs this additional information when planning treatment or managing the rehab program. There was a weak correlation between the MACTAR and the QUEBEC for disability.
The authors conclude that the MACTAR is a valid measure of real-life participation limitations identified by the patient with chronic low back pain. Such information could be very useful when making clinical decisions, establishing treatment goals, and planning treatment. The questionnaire only takes the patient five minutes to fill out.
On the downside, there is a 15-minute face-to-face interview that's part of the MACTAR. That part is not so easy or inexpensive as the simple five-minute survey. And the MACTAR doesn't give a global picture of the patient's needs, wants, or desires. It's a functional scale that takes a look at patient priorities. As such, it has its own unique place in the assessment process.
Katherine Sanchez, MD, et al. Patient-Preference Disability Assessment for Disabling Chronic Low Back Pain. In Spine. May 1, 2009. Vol. 34. No. 10. Pp. 1052-1059.
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