Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy



      To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs).


      Prospective inception cohort study.


      Primary care private physiotherapy clinics in Melbourne, Australia.


      Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration.


      Not applicable.

      Main Outcome Measures

      Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale.


      Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome.


      This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.


      List of abbreviations:

      GEE (generalized estimating equation), GLMM (generalized linear mixed model), LBD (low back disorder)
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        • Vasseljen O.
        • Woodhouse A.
        • Bjorngaard J.H.
        • Leivseth L.
        Natural course of acute neck and low back pain in the general population: the HUNT study.
        Pain. 2013; 154: 1237-1244
        • Verkerk K.
        • Luijsterburg P.A.
        • Miedema H.S.
        • Pool-Goudzwaard A.
        • Koes B.W.
        Prognostic factors for recovery in chronic nonspecific low back pain: a systematic review.
        Phys Ther. 2012; 92: 1093-1108
        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Field A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine. 2002; 27: E109-E120
        • Ashworth J.
        • Konstantinou K.
        • Dunn K.M.
        Prognostic factors in non-surgically treated sciatica: a systematic review.
        BMC Musculoskelet Disord. 2011; 12: 208
        • Hayden J.A.
        • Chou R.
        • Hogg-Johnson S.
        • Bombardier C.
        Systematic reviews of low back pain prognosis had variable methods and results: guidance for future prognosis reviews.
        J Clin Epidemiol. 2009; 62: 781-796
        • Kent P.M.
        • Keating J.L.
        Can we predict poor recovery from recent-onset nonspecific low back pain? A systematic review.
        Man Ther. 2008; 13: 12-28
        • Ramond A.
        • Bouton C.
        • Richard I.
        • et al.
        Psychosocial risk factors for chronic low back pain in primary care: a systematic review.
        Fam Pract. 2011; 28: 12-21
        • Gray H.
        • Adefolarin A.T.
        • Howe T.E.
        A systematic review of instruments for the assessment of work-related psychosocial factors (Blue Flags) in individuals with non-specific low back pain.
        Man Ther. 2011; 16: 531-543
        • Iles R.A.
        • Davidson M.
        • Taylor N.F.
        Psychosocial predictors of failure to return to work in nonchronic nonspecific low back pain: a systematic review.
        Occup Environ Med. 2008; 65: 507-517
        • Hartvigsen J.
        • Lings S.
        • Leboeuf-Yde C.
        • Bakketeig L.
        Psychosocial factors at work in relation to low back pain and consequences of low back pain; a systematic, critical review of prospective cohort studies.
        Occup Environ Med. 2004; 61: e2
        • Wong A.Y.
        • Parent E.C.
        • Funabashi M.
        • Stanton T.R.
        • Kawchuk G.N.
        Do various baseline characteristics of transversus abdominis and lumbar multifidus predict clinical outcomes in non-specific low back pain? A systematic review.
        Pain. 2013; 154: 2589-2602
        • Konstantinou K.
        • Hider S.L.
        • Jordan J.L.
        • Lewis M.
        • Dunn K.M.
        • Hay E.M.
        The impact of low back-related leg pain on outcomes as compared with low back pain alone: a systematic review of the literature.
        Clin J Pain. 2013; 29: 644-654
        • Chorti A.
        • Chortis A.G.
        • Strimpakos N.
        • McCarthy C.J.
        • Lamb S.E.
        The prognostic value of symptom responses in the conservative management of spinal pain: a systematic review.
        Spine. 2009; 34: 2686-2699
        • Borge J.A.
        • Leboeuf-Yde C.
        • Lothe J.
        Prognostic values of physical examination findings in patients with chronic low back pain treated conservatively: a systematic literature review.
        J Manipulative Physiol Ther. 2001; 24: 292-295
        • Hendrick P.
        • Milosavljevic S.
        • Hale L.
        • et al.
        The relationship between physical activity and low back pain outcomes: a systematic review of observational studies.
        Eur Spine J. 2011; 20: 464-474
        • Kent P.
        • Keating J.L.
        Classification in nonspecific low back pain: what methods do primary care clinicians currently use?.
        Spine. 2005; 30: 1433-1440
      1. Maitland G. Hengeveld E. Banks K. English K. Maitland's vertebral manipulation. 7th ed. Elsevier, Philadelphia2005
        • van Oort L.
        • van den Berg T.
        • Koes B.W.
        • et al.
        Preliminary state of development of prediction models for primary care physical therapy: a systematic review.
        J Clin Epidemiol. 2012; 65: 1257-1266
        • Hilfiker R.
        • Bachmann L.M.
        • Heitz C.A.
        • Lorenz T.
        • Joronen H.
        • Klipstein A.
        Value of predictive instruments to determine persisting restriction of function in patients with subacute non-specific low back pain. Systematic review.
        Eur Spine J. 2007; 16: 1755-1775
        • Ford J.J.
        • Hahne A.J.
        • Surkitt L.D.
        • et al.
        Individualized physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial.
        Br J Sports Med. 2016; 50: 237-245
        • Hahne A.J.
        • Ford J.J.
        • Surkitt L.D.
        • et al.
        Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders.
        BMC Musculoskelet Disord. 2011; 12: 104
        • Ford J.J.
        • Hahne A.J.
        Pathoanatomy and classification of low back disorders.
        Man Ther. 2013; 18: 165-168
        • Ford J.J.
        • Hahne A.J.
        Complexity in the physiotherapy management of low back disorders: clinical and research implications.
        Man Ther. 2013; 18: 438-442
        • Indahl A.
        • Velund L.
        • Reikeraas O.
        Good prognosis for low back pain when left untampered. A randomized clinical trial.
        Spine. 1995; 20: 473-477
        • Ford J.J.
        • Hahne A.J.
        • Chan A.Y.P.
        • Surkitt L.D.
        A classification and treatment protocol for low back disorders. Part 3: functional restoration for intervertebral disc related disorders.
        Phys Ther Rev. 2012; 17: 55-75
        • Ford J.J.
        • Richards M.J.
        • Hahne A.J.
        A classification and treatment protocol for low back disorders. Part 4: functional restoration for low back disorders associated with multifactorial persistent pain.
        Phys Ther Rev. 2012; 17: 322-334
        • Ford J.J.
        • Surkitt L.D.
        • Hahne A.J.
        A classification and treatment protocol for low back disorders. Part 2: directional preference management for reducible discogenic pain.
        Phys Ther Rev. 2011; 16: 423-437
        • Ford J.J.
        • Thompson S.L.
        • Hahne A.J.
        A classification and treatment protocol for low back disorders. Part 1: specific manual therapy.
        Phys Ther Rev. 2011; 16: 168-177
        • Ford J.J.
        • Story I.
        • McMeeken J.
        The test-retest reliability and concurrent validity of the Subjective Complaints Questionnaire for low back pain.
        Man Ther. 2009; 14: 283-291
      2. Australian Bureau of Statistics. Socio-Economic Indexes for Areas (SEIFA) 2016.
        (Available at:)
        • Dollman J.
        • Lewis N.R.
        The impact of socioeconomic position on sport participation among South Australian youth.
        J Sci Med Sport. 2010; 13: 318-322
        • Walker A.E.
        • Becker N.G.
        Health inequalities across socio-economic groups: comparing geographic-area–based and individual-based indicators.
        Public Health. 2005; 119: 1097-1104
        • Rudwaleit M.
        • Metter A.
        • Listing J.
        • Sieper J.
        • Braun J.
        Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria.
        Arthritis Rheum. 2006; 54: 569-578
        • Walker B.F.
        • Williamson O.D.
        Mechanical or inflammatory low back pain. What are the potential signs and symptoms?.
        Man Ther. 2009; 14: 314-320
        • Calin A.
        • Porta J.
        • Fries J.F.
        • Schurman D.J.
        Clinical history as a screening test for ankylosing spondylitis.
        JAMA. 1977; 237: 2613-2614
        • Malaviya A.P.
        • Ostor A.J.
        Early diagnosis crucial in ankylosing spondylitis.
        Practitioner. 2011; 255 (2): 21-24
        • Chan A.Y.
        • Ford J.J.
        • McMeeken J.M.
        • Wilde V.E.
        Preliminary evidence for the features of nonreducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique.
        Physiotherapy. 2013; 99: 212-220
        • Jarvik J.G.
        • Haynor D.R.
        • Koepsell T.D.
        • Bronstein A.
        • Ashley D.
        • Deyo R.A.
        Interreader reliability for a new classification of lumbar disk disease.
        Acad Radiol. 1996; 3: 537-544
        • Patrick D.L.
        • Deyo R.A.
        • Atlas S.J.
        • Singer D.E.
        • Chapin A.
        • Keller R.B.
        Assessing health-related quality of life in patients with sciatica.
        Spine. 1995; 20: 1899-1908
        • Grotle M.
        • Vollestad N.K.
        • Brox J.I.
        Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire.
        Clin J Pain. 2006; 22: 458-467
        • Linde L.
        • Sorensen J.
        • Ostergaard M.
        • Horslev-Petersen K.
        • Hetland M.L.
        Health-related quality of life: validity, reliability, and responsiveness of SF-36, 15D, EQ-5D (corrected) RAQoL, and HAQ in patients with rheumatoid arthritis.
        J Rheumatol. 2008; 35: 1528-1537
        • Westman A.
        • Linton S.J.
        • Ohrvik J.
        • Wahlen P.
        • Leppert J.
        Do psychosocial factors predict disability and health at a 3-year follow-up for patients with nonacute musculoskeletal pain? A validation of the Orebro Musculoskeletal Pain Screening Questionnaire.
        Eur J Pain. 2008; 12: 641-649
        • Frost H.
        • Lamb S.E.
        • Stewart-Brown S.
        Responsiveness of a patient specific outcome measure compared with the Oswestry Disability Index v2.1 and Roland and Morris Disability Questionnaire for patients with subacute and chronic low back pain.
        Spine. 2008; 33: 2450-2457
        • Ostelo R.W.
        • de Vet H.C.
        Clinically important outcomes in low back pain.
        Best Pract Res Clin Rheumatol. 2005; 19: 593-607
        • Childs J.D.
        • Piva S.R.
        • Fritz J.M.
        Responsiveness of the numeric pain rating scale in patients with low back pain.
        Spine. 2005; 30: 1331-1334
        • George S.L.
        Identification and assessment of prognostic factors.
        Semin Oncol. 1988; 15: 462-471
        • Cort N.A.
        • Gamble S.A.
        • Smith P.N.
        • et al.
        Predictors of treatment outcomes among depressed women with childhood sexual abuse histories.
        Depress Anxiety. 2012; 29: 479-486
        • Dranitsaris G.
        • Vincent M.D.
        • Yu J.
        • Huang L.
        • Fang F.
        • Lacouture M.E.
        Development and validation of a prediction index for hand–foot skin reaction in cancer patients receiving sorafenib.
        Ann Oncol. 2012; 23: 2103-2108
        • Boyle R.
        Path analysis and ordinal data.
        Am J Sociol. 1970; 75: 461-480
        • Kongsted A.
        • Kent P.
        • Jensen T.S.
        • Albert H.
        • Manniche C.
        Prognostic implications of the Quebec Task Force classification of back-related leg pain: an analysis of longitudinal routine clinical data.
        BMC Musculoskelet Disord. 2013; 14: 171
        • Smeets R.J.
        • Maher C.G.
        • Nicholas M.K.
        • Refshauge K.M.
        • Herbert R.D.
        Do psychological characteristics predict response to exercise and advice for subacute low back pain?.
        Arthritis Rheum. 2009; 61: 1202-1209
        • Cassidy E.L.
        • Atherton R.J.
        • Robertson N.
        • Walsh D.A.
        • Gillett R.
        Mindfulness, functioning, and catastrophizing after multidisciplinary pain management for chronic low back pain.
        Pain. 2012; 153: 644-650
        • Foster N.E.
        • Thomas E.
        • Bishop A.
        • Dunn K.M.
        • Main C.J.
        Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care.
        Pain. 2010; 148: 398-406
        • Hendrick P.
        • Milosavljevic S.
        • Hale L.
        • et al.
        Does a patient's physical activity predict recovery from an episode of acute low back pain? A prospective cohort study.
        BMC Musculoskelet Disord. 2013; 14: 126
        • Vittinghoff E.
        • McCulloch C.E.
        Relaxing the rule of ten events per variable in logistic and Cox regression.
        Am J Epidemiol. 2007; 165: 710-718
        • Costello A.B.
        • Osborne J.W.
        Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Practical Assessment.
        Research & Evaluation. 2005; 10: 1-9
        • Katz M.
        Multivariable analysis: a practical guide for clinicians and public health researchers.
        2nd ed. Cambridge University Press, Cambridge2006
        • Haugen A.J.
        • Brox J.I.
        • Grovle L.
        • et al.
        Prognostic factors for non-success in patients with sciatica and disc herniation.
        BMC Musculoskelet Disord. 2012; 13: 183
        • Campbell P.
        • Bishop A.
        • Dunn K.M.
        • Main C.J.
        • Thomas E.
        • Foster N.E.
        Conceptual overlap of psychological constructs in low back pain.
        Pain. 2013; 154: 1783-1791
        • Liang K.
        • Zeger S.
        Longitudinal data analysis using generalized linear models.
        Biometrika. 1986; 73: 13-22
        • Cook C.E.
        • Learman K.E.
        • O'Halloran B.J.
        • et al.
        Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?.
        Phys Ther. 2013; 93: 32-40
        • Skargren E.I.
        • Oberg B.E.
        Predictive factors for 1-year outcome of low-back and neck pain in patients treated in primary care: comparison between the treatment strategies chiropractic and physiotherapy.
        Pain. 1998; 77: 201-207
        • Gwilliam B.
        • Keeley V.
        • Todd C.
        • et al.
        Development of Prognosis in Palliative care Study (PiPS) predictor models to improve prognostication in advanced cancer: prospective cohort study.
        BMJ Support Palliat Care. 2012; 2: 63-71
        • Pinto A.M.
        • Subak L.L.
        • Nakagawa S.
        • et al.
        The effect of weight loss on changes in health-related quality of life among overweight and obese women with urinary incontinence.
        Qual Life Res. 2012; 21: 1685-1694
        • Sterne J.A.
        • White I.R.
        • Carlin J.B.
        • et al.
        Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.
        BMJ. 2009; 338: b2393
        • Schafer J.L.
        • Graham J.W.
        Missing data: our view of the state of the art.
        Psychol Methods. 2002; 7: 147-177
        • Mackinnon A.
        The use and reporting of multiple imputation in medical research-a review.
        J Intern Med. 2010; 268: 586-593
        • Childs J.D.
        • Teyhen D.S.
        • Van Wyngaarden J.J.
        • et al.
        Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM).
        BMC Musculoskelet Disord. 2011; 12: 132
        • Menzies N.A.
        • Berruti A.A.
        • Blandford J.M.
        The determinants of HIV treatment costs in resource limited settings.
        PLoS One. 2012; 7: e48726
        • Breslow N.
        • Clayton D.
        Approximate inference in generalized linear mixed models.
        Journal of the American Statistical Association. 1993; 88: 9-25
        • Kovacs F.M.
        • Seco J.
        • Royuela A.
        • Corcoll Reixach J.
        • Abraira V.
        • Spanish Back Pain Research Network
        Predicting the evolution of low back pain patients in routine clinical practice: results from a registry within the Spanish National Health Service.
        Spine J. 2012; 12: 1008-1020
        • Dagenais S.
        • Tricco A.C.
        • Haldeman S.
        Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.
        Spine J. 2010; 10: 514-529
        • Hayden J.A.
        • Dunn K.M.
        • van der Windt D.A.
        • Shaw W.S.
        What is the prognosis of back pain?.
        Best Pract Res Clin Rheumatol. 2010; 24: 167-179
        • McKenzie R.
        The lumbar spine: mechanical diagnosis and therapy.
        Spinal Publication, Waikanae1981
        • May S.
        • Aina A.
        Centralization and directional preference: a systematic review.
        Man Ther. 2012; 17: 497-506
        • Adams M.A.
        • Stefanakis M.
        • Dolan P.
        Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain.
        Clin Biomech. 2010; 25: 961-971
        • Keeling S.O.
        • Majumdar S.R.
        • Conner-Spady B.
        • Battie M.C.
        • Carroll L.J.
        • Maksymowych W.P.
        Preliminary validation of a self-reported screening questionnaire for inflammatory back pain.
        J Rheumatol. 2012; 39: 822-829
        • Ulrich J.A.
        • Liebenberg E.C.
        • Thuillier D.U.
        • Lotz J.C.
        ISSLS prize winner: repeated disc injury causes persistent inflammation.
        Spine (Phila Pa 1976). 2007; 32: 2812-2819
        • Unsgaard-Tondel M.
        • Lund Nilsen T.I.
        • Magnussen J.
        • Vasseljen O.
        Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up.
        Br J Sports Med. 2012; 46: 729-734
        • Ferreira P.H.
        • Ferreira M.L.
        • Maher C.G.
        • Refshauge K.
        • Herbert R.D.
        • Hodges P.W.
        Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain.
        Br J Sports Med. 2010; 44: 1166-1172
        • Hodges P.
        Spinal control: the rehabilitation of back pain.
        1st ed. Churchill Livingston, Edinburgh2013
        • McBeth J.
        • Macfarlane G.J.
        • Hunt I.M.
        • Silman A.J.
        Risk factors for persistent chronic widespread pain: a community-based study.
        Rheumatology (Oxford). 2001; 40: 95-101
        • Hagg O.
        • Fritzell P.
        • Hedlund R.
        • et al.
        Pain-drawing does not predict the outcome of fusion surgery for chronic low-back pain: a report from the Swedish Lumbar Spine Study.
        Eur Spine J. 2003; 12: 2-11
        • Guilmatre A.
        • Sharp A.J.
        Parent of origin effects.
        Clin Genet. 2012; 81: 201-209
        • Hayden J.A.
        • Cote P.
        • Bombardier C.
        Evaluation of the quality of prognosis studies in systematic reviews.
        Ann Intern Med. 2006; 144: 427-437
        • Collins G.S.
        • Reitsma J.B.
        • Altman D.G.
        • Moons K.G.
        Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement.
        BMJ. 2015; 350: g7594
        • Linton S.
        • Hallden K.
        Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain.
        Clin J Pain. 1998; 14: 209-215