ORIGINAL ARTICLE

Predicting rapid recovery from acute low back pain based on

the intensity, duration and history of pain: A validation study
C.M. Williams
1,2
, M.J. Hancock
3
, C.G. Maher
1
, J.H. McAuley
4
, C.W.C. Lin
1
, J. Latimer
1
1 The George Institute for Global Health, University of Sydney, NSW, Australia
2 Hunter Medical Research Institute and School of Medicine and Public Health, University of Newcastle, NSW, Australia
3 Faculty of Human Sciences, Macquarie University, Australia
4 Neuroscience Research Australia, Randwick, NSW, Australia
Correspondence
Christopher M. Williams
E-mail: cwilliams@georgeinstitute.org.au
Funding sources
Drs Maher, Hancock and Latimer are
investigators on a clinical trial evaluating the
efcacy of paracetamol for acute low back
pain (ACTRN126090000966291). This is an
investigator initiated trial funded by
Australias National Health and Medical
Research Council (NHMRC). The trial
medicines and supplementary funding are
provided by GlaxoSmithKline. Drs Maher and
Latimer hold research fellowships funded by
the Australian Research Council.
Conicts of interest
There are no other conicts of interests.
Accepted for publication
24 January 2014
doi:10.1002/j.1532-2149.2014.00467.x
Abstract
Background: Clinical prediction rules can assist clinicians to identify
patients with low back pain (LBP) who are likely to recover quickly with
minimal treatment; however, there is a paucity of validated instruments to
assist with this task.
Method: We performed a pre-planned external validation study to assess
the generalizability of a simple 3-item clinical prediction rule developed to
estimate the probability of recovery from acute LBP at certain time points.
The accuracy of the rule (calibration and discrimination) was determined
in a sample of 956 participants enrolled in a randomized controlled trial.
Results: The calibration of the rule was reasonable in the new sample
with predictions of recovery typically within 510% of observed recovery.
Discriminative performance of the rule was poor to moderate and similar
to that found in the development sample.
Conclusions: The results suggest that the rule can be used to provide
accurate information about expected recovery from acute LBP, within the
rst few weeks of patients presenting to primary care. Impact analysis to
determine if the rule inuences clinical behaviours and patient outcomes
is required.
1. Introduction
The prognosis of acute low back pain (LBP) is gener-
ally regarded as favourable with simple treatments
recommended as rst-line care (Koes et al., 2010).
However, many patients presenting to care receive
additional complex or expensive interventions initially
(Chenot et al., 2008; Williams et al., 2010a), which
provide little or no added benet (Hancock et al.,
2007). This pattern of care is concerning as it results in
increased costs of care and exposes patients to unnec-
essary risks of adverse events (McGuirk et al., 2001;
Minal et al., 2011).
A challenge for clinicians treating patients with
acute LBP is that while most recover quickly, some do
not, and go on to develop persistent LBP (Menezes
Costa et al., 2012; Itz et al., 2013). This uncertain
prognosis may be a reason why many clinicians do not
provide simple minimal care initially as recommended
in international guidelines (Koes et al., 2010). If clini-
cians were able to easily identify patients who are
likely to recover rapidly, it may assist them to recom-
mend simple minimal care with greater condence.
Accurate information about the chance of recovery by
certain time points may also help patients make
informed choices.
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1182 Eur J Pain 18 (2014) 11821189

Clinical prediction rules (CPRs) can assist clinicians
identify patients with a more or less favourable prog-
nosis. In the LBP eld, most CPRs focus on predicting
persistent pain (i.e. greater than 3 months) rather than
rapid recovery (Hayden et al., 2010). Regardless of
their scope, most of the CPRs for LBP have not under-
gone external validation testing (Kent and Keating,
2008; Chouand Shekelle, 2010), whichis animportant
prerequisite for their use in clinical practice. External
validation testing assesses the accuracy of a CPR in
different settings and patient populations to those in
which it was developed (Altman and Royston, 2000).
In external validation studies, the accuracy of a CPR
should be measured in terms of calibration and dis-
crimination (Altman and Royston, 2000). Calibration
refers to how close the predicted probabilities or risks
are to that observed, and discrimination refers to how
well the CPRclassies those at high risk of the outcome
compared with those at lower risk (Toll et al., 2008).
One simple CPR developed by Hancock et al. (2009)
aims to identify patients likely to recover rapidly from
acute LBP. The original study assessed a range of base-
line predictor variables including patient characteristics
(e.g. gender, catastrophizing, fear-avoidance beliefs),
features of the episode (e.g. duration, intensity) and
clinical ndings (area of symptoms and lumbar seg-
mental mobility) as predictors of rapid recovery. The
results showed patients with lower than average initial
pain intensity, shorter duration of symptoms and fewer
previous episodes recovered more quickly than
patients without these characteristics. For instance, in
patients who had all three characteristics, the model
predicted 53% probability of recovery at 1 week, 78%
by 2 weeks and 98%by 4 weeks. Such information has
the potential to help clinicians more condently rec-
ommend simple minimal care as per guideline recom-
mendations, in patients very likely to recover rapidly.
However, to date, no external validation has been
performed on the Hancock CPR. The aim of this pro-
spective external validation study was to assess the
generalizability of the Hancock CPR.
2. Methods
2.1 Study design
This study uses data from a consecutive subset of participants
enrolled in the paracetamol for low back pain (PACE) study
(Williams et al., 2010b), which is a randomized controlled
trial investigating the effectiveness of paracetamol for acute
LBP. The validation study is based on the outcomes of par-
ticipants from all groups enrolled in the trial between
November 2009 and December 2011. The full trial methods
have been published (Williams et al., 2010b). Ethical
approval for the trial was granted by the University of
Sydney Human Research Ethics Committee. The trial was
prospectively registered on the Australian New Zealand
Clinical Trials Registry (ACTN 12609000966291).
2.2 Setting and participants
The methods of the development study (Hancock et al.,
2009) and recruitment of the development sample (Hancock
et al., 2007) have been published. In brief, the development
sample is composed of 239 participants recruited by 19
general practitioners from 14 practices in Central West
Sydney, Australia. These patients were enrolled in a random-
ized controlled trial of diclofenac and/or spinal manipulation
for acute LBP conducted in 20052006. The validation
sample consisted of consecutive LBP patients recruited by
207 primary care clinicians (general practitioner, pharmacist
or physiotherapist) in Greater Metropolitan Sydney, Austra-
lia, to participate in the PACE study, a randomized controlled
trial comparing paracetamol to placebo for acute LBP. Table 1
Whats already known about this topic?
External validation testing of clinical prediction
rules is an important prerequisite to recommending
them for use in clinical practice. However, few pre-
diction rules developed for low back pain have
undergone this process.
What does this study add?
The prospective external validation study found a
simple prediction rule was accurate to predict
short-term recovery (within 4 weeks) from low
back pain. Longer predictions (412 weeks) were
less precise.
Table 1 Key differences between development and validation studies.
Study characteristic Development sample Validation sample
Recruitment
Setting GP (19) GP (157), Pharmacist
(46) Physiotherapist
(4)
Geographic Central-West Sydney Greater Metropolitan
Sydney
Inclusion criteria
Sciatica Excluded Included
Regular paracetamol Included Excluded
>moderate disability Included Not considered
Treatments NSAIDs or manipulation Advice/paracetamol
Data collection Face-to-face; phone
interview
Online survey; phone
interview
Time period 20052007 20092012
GP, general practitioner; NSAIDs, non-steroidal anti-inammatory drug.
C.M. Williams et al. Validation of a prediction rule for low back pain
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Eur J Pain 18 (2014) 11821189 1183

details key methodological differences between the develop-
ment and validation studies. Participants for each trial were
consenting patients with a primary complaint of LBP less
than 6 weeks in duration, with or without leg pain; with at
least moderate intensity pain during the preceding 24 h
(measured by an adaptation of item 7 of the Short Form-36);
and who were pain free for at least 1 month before the onset
of the current LBP episode. Patients were excluded if they
were suspected of having a serious spinal pathology; were
taking regular recommended doses of an analgesic; were
pregnant or planning pregnancy during the treatment period
(4 weeks); or had a contraindication paracetamol. Patients
with a clinical diagnosis of sciatica were excluded from the
study in which the development sample was drawn, whereas
this criterion was not applied to the validation sample.
For this validation study, all participants from the PACE
cohort that had past the nal follow-up time point (12
weeks) at the time of analysis were included. No adjustment
was made for treatment group as the primary trial was not
completed and investigators remained blind to treatment
allocation. Given the randomized design, equal numbers of
participants from each treatment group are expected to be
classied across the levels of the rule and therefore treatment
effect consistent across the levels of the rule.
2.3 Outcomes and data collection
The primary outcome sustained recovery from LBP was
dened as a score of 0 or 1 out of 10 on a numerical pain
rating scale for 7 consecutive days. Participants recorded pain
scores in a daily pain diary until recovery, or for a maximum
of 12 weeks. Outcome data were collected over the phone by
a researcher blind to status on the prediction rule or tran-
scribed directly by the participant into an online database.
As the validation study was pre-planned in the design of
the PACE study (Williams et al., 2010b) the prognostic vari-
ables that comprised the prediction rule were the same as
those used in the Hancock et al. study: baseline pain (7/10;
numerical pain rating scale), duration of current symptoms
(5 days), number of previous episodes of LBP (1). These
variables and descriptive baseline data were collected during
a telephone interview with each participant prior to random-
ization, usually within 24 h following their initial consulta-
tion with the recruiting clinician. This method of data
collection was comparable with the development study.
2.4 Determining status on the prediction rule
Status on the prediction rule was determined for each par-
ticipant by calculating the number of predictors of recovery
present. Participants were thus grouped into one of four
strata representing their status on the prediction rule (0, 1, 2
or 3 features positive). No weighting of predictors was per-
formed. This method of classication was retained from the
development study whereby weighting of features did not
add predictive value and simplicity of the rule was preferred
for usability.
2.5 Statistical analysis and assessment of
predictive accuracy
The performance of the prediction rule was assessed by mea-
suring the calibration and discrimination of the developed
model at 1, 2, 4 and 12 weeks post randomization. Methods
used for the model development have been published else-
where and were not assessed in the current study (Hancock
et al., 2009). Multivariate Cox regression was used to identify
the nal variables included in the CPR. The development of
the model was internally validated with re-sampling methods
(Altman and Andersen, 1989; Hancock et al., 2009).
Calibration of the rule was considered the most relevant
measure of accuracy because the rules main aim was to
provide information about the probability of recovery, based
on a patients status on the rule. Calibration was assessed by
comparing the proportion of participants predicted to
recover (for each status level of the rule) to the observed
(actual) proportion who recovered, at 1, 2, 4 and 12 weeks in
the validation sample. Predicted recovery was based on sur-
vival curves of the four strata produced after Cox regression.
Observed recovery was calculated for each strata using the
KaplanMeier procedure. We considered absolute differ-
ences between predicted and actual probabilities of recovery
of less than 5% to represent very good calibration, 510%
moderate calibration and greater than 10% poor calibration.
The discriminative ability of the prediction rule was evalu-
ated by calculating the c-index (Harrell et al., 1984). A
c-index of 1 represents a perfect model, were 0.5 indicates an
uninformative model with discrimination no better than
chance. We calculated the c-index for recovery at four time
points; 1, 2, 4 and 12 weeks post randomization. Kaplan
Meier survival curves were produced along with median
recovery times for eachstratum. We also constructed stratum-
specic likelihood ratios (LRs) to assess discrimination at each
level of the rule. LRs were calculated for the outcome recov-
ery at each time point. LRs were calculated by dividing the
probability that a recovered patient has a score on the rule
(e.g. three predictors present) by the probability that a non-
recovered patient has the same score on the rule.
Completeness of survival data was calculated using the
completeness index (Clark et al., 2002). In the case of incom-
plete data, censoring occurred at the last completed follow
up if recovery had not been established. All analyses were
performed in STATA version 12 (StataCorp, 2011).
3. Results
3.1 Study population
Characteristics of patients in the validation and devel-
opment samples were similar at baseline (Table 2)
except patients in the validation sample were slightly
older and had a greater number of previous episodes
of LBP. Of the 956 participants included in the valida-
tion study, 937 (99%) were followed until they had
Validation of a prediction rule for low back pain C.M. Williams et al.
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1184 Eur J Pain 18 (2014) 11821189

recovered (82%) or were censored at the end of week
12 (Fig. 1). Completeness of survival data was esti-
mated as 98.7%. Five participants were lost to follow
up from day 1 and were censored at day 1. Another 14
participants had incomplete outcome data and were
censored before week 2 (three participants) or week
12 (11 participants). Seven participants (0.7%) were
excluded from the analyses because of missing predic-
tors at baseline.
Overall, there were 68 participants who had 0 pre-
dictors, 348 had one predictor, 419 had two predictors,
and 114 had three predictors. Of the 348 participants
with one predictor and the 419 with two predictors
present, the most common feature was pain (7/10;
n = 238 and 357, respectively).
3.2 Accuracy of the rule
Overall the calibration was very good to moderate as
shown in Table 3 and Fig. 1. At week 1 observed prob-
abilities of recovery were within 5% of predicted
values for three of the four strata and within 10% for
the other strata. At week 2, observed probabilities of
recovery were within 5% of predicted values for one
of the four strata and within 10% for the other three
strata. At longer-term follow ups of 4 and 12 weeks,
predicted and actual rates of recovery were less well
Table 2 Baseline characteristics and predictors of development and vali-
dation samples.
Characteristic
Development
sample
Validation
sample
Age (years) 40.7 (15.6) 44.5 (16.0)
Female gender 105 (44%) 457 (46%)
Disability (RM 24) 13.1 (5.4) 13.0 (5.5)
Pain referral distal to knee 26 (11%) 206, (22%)
Pain (010 NRS) 6.5 (1.7) 6.2 (1.9)
Number of previous episodes 3.7 (6.4) 11.5 (79.1)
Duration of current episode (days) 9.13 (9.31) 10.1 (10.0)
Continuous variables are mean (standard deviation), categorical variables
are n (%). RM24, 24 item Roland Morris Disability Questionnaire; NRS,
numerical rating scale.
Figure 1 Calibration plots for (A) weeks 1, (B)
2, (C) 4 and (D) 12 predicted versus observed
recovery by number of predictors. Predicted
and observed recoveries were within 510%
difference for weeks 1 and 2, with slightly
larger differences in weeks 4 and 12. 0 predic-
tor is no predictor present; 1 predictor is any
one of three predictors; 2 predictors is any two
of three predictors; 3 predictors is all three
predictors present. Predictors are: 7/10
(numerical pain rating scale), 5-day duration
of current symptoms, number of previous epi-
sodes of low back pain (LBP) 1. Recovery
dened as 0 or 1 out of 10 on a pain rating
scale for 7 consecutive days.
Table 3 Calibration performance of the clinical prediction rule for each time point.
Predictors present
% recovered
Week1 Week 2 Week 4 Week 12
Predicted Observed Predicted Observed Predicted Observed Predicted Observed
0 12.7 13.5 24.5 33.2 53.5 52.9 74.7 68.1
1 18.9 25.9 34.8 44.6 68.9 61.7 87.7 78.2
2 30 30.1 51.2 54 85.4 71.7 97.2 84.7
3 52.6 54.4 77.9 69.6 97.9 85.7 99.9 91.1
Number of patients at each level of the rule: 0 predictors (68), 1 predictor (348), 2 predictors (419), 3 predictors (114).
C.M. Williams et al. Validation of a prediction rule for low back pain
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Eur J Pain 18 (2014) 11821189 1185

calibrated with observed rates being typically about
10% less than predicted rates (Fig. 1).
There was a small reduction in the discriminative
ability of the rule (e.g. at week 1 the discrimination
reduced from 0.66 in the development sample to 0.65
in the validation sample). The c-index values for the
rule in the validation sample are presented in Table 4.
Stratum-specic LRs for each of the four time points
presented in Table 4, and the survival curves with
median survival times detailed in Fig. 2 demonstrate
reasonable discriminative ability of the prediction rule
in the validation sample.
4. Discussion
4.1 Principal ndings
The performance of the prediction rule, when evalu-
ated in a new independent patient dataset was reason-
able, but this depended on the time frame for
recovery. Calibration in the rst 2 weeks was very
good or moderate with half of the observed values
being within 5% of the predicted values, and the other
half within 10%. At 4 and 12 weeks, calibration was
less precise with observed values being typically about
10% less than predicted values. The discriminative
ability of the rule, measured with the c-index, did not
reduce signicantly in the validation sample; however,
the overall discrimination was poor to moderate (e.g.
at week 1, c-index = 0.65; LR3 = 2.74; differences in
survival curves).
4.2 Strengths and limitations
This study is of high quality and one of very few
pre-planned validation studies to assess the accuracy
of a previously developed clinical prediction rule for
LBP in an external dataset (Kent and Keating, 2008).
The intention to conduct the validation study has been
published a priori (Williams et al., 2010b). We mea-
sured critical aspects of accuracy (calibration and dis-
crimination) and highlighted the relative importance
of these measures based on how the rule would be
used in clinical practice. The large data sample
(n = 956) were captured prospectively during a high-
quality multicentre trial and had a high rate of com-
pleteness of follow up (99%). These data provide
precise estimates from which to assess the perfor-
mance of the prediction rule, and with only three
predictor variables in the prediction rule, the study
was sufciently powered for this purpose. These quali-
ties are atypical in validation studies (Toll et al., 2008).
There are some potential limitations to this study.
First, we did not use a formal statistical test to assess
the calibration of the observed and predicted values.
Statistical tests such as the HosmerLemeshow test can
be used for this purpose; however, in a large sample,
Table 4 Discriminative performance of the clinical prediction rule for each time point.
Predictors present
LR (95%CI)
Week 1 Week 2 Week 4 Week 12
0 0.36 (0.180.71) 0.48 (0.290.79) 0.52 (0.330.82) 0.48 (0.290.79)
1 0.80 (0.660.98) 0.77 (0.650.92) 0.74 (0.630.88) 0.77 (0.650.96)
2 0.99 (0.851.16) 1.13 (0.981.31) 1.18 (1.001.39) 1.21 (0.981.51)
3 2.74 (1.953.86) 2.24 (1.533.27) 2.77 (1.664.62) 2.43 (1.264.71)
c-index 0.65 (0.60 0.70) 0.63 (0.580.67) 0.61 (0.570.64) 0.60 (0.560.64)
Number of patients at each level of the rule: 0 predictors (68), 1 predictor (348), 2 predictors (419), 3 predictors (114).
Figure 2 KaplanMeier recovery curves for each level of the clinical pre-
diction rule (CPR) and median recovery time [number of days and 95%
condence interval (CI) ]. Non-overlapping 95% CIs indicate signicant dif-
ferences between strata. A logrank test for trend conrmed time to
recovery was signicantly different and ordered by status on the CPR
(p < 0.0001). 0 predictor is no predictor present; 1 predictor is any one of
three predictors; 2 predictors is any two of three predictors; and 3 pre-
dictors is all three predictors present. Predictors are: 7/10 (numerical
pain rating scale), 5 days duration of current symptoms, number of
previous episodes of low back pain (LBP) 1. Recovery dened as 0 or 1
out of 10 on a pain rating scale for 7 consecutive days.
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1186 Eur J Pain 18 (2014) 11821189

this test will detect even small clinically insignicant
differences between predicted and observed events.
(McGeechan et al., 2008) Rather, we used arbitrary
cut-offs of <5%, and less than 10% to describe our
ndings as we considered the absolute difference
between predicted and observed events to be more
important than statistical signicance. Second, despite
many key differences from the development study,
this validation study is not a true independent valida-
tion as some investigators were involved in the devel-
opment study. Third, a clinically relevant comparison
of predictive utility would be to compare the predic-
tive ability of the rule to a clinicians subjective judge-
ment of prognosis. While the development study
found results in favour of the rule, the available data
did not allow this comparison in the validation study.
Finally, while in the development study, a wide
range of potential psychosocial predictors were evalu-
ated, none remained in the nal model. While the
current study did not assess the validity of this nding
from the development study, it is possible that psycho-
social inuences on predicting rapid recovery are far
less important than for predicting chronicity. Impor-
tantly the current study aimed to validate the rule
exactly as developed in the original study.
4.3 Comparison with previous research
An initial step to comparing our results with previous
studies is to assess the overall recovery rates across the
whole sample. We observed a faster rate of recovery
compared with other studies, and overall recovery by
12 weeks was higher. In our sample, 50% of partici-
pants had recovered by 2 weeks, 65% by 4 weeks and
80% by 12 weeks. Others have typically found a
median recovery time of 612 weeks and fewer
patients recover overall (Menezes Costa et al., 2012).
A possible reason for this is that unlike our study, it is
unclear if participants of these studies received
guideline-recommended treatments. The speed of
recovery in our sample is similar to that of the devel-
opment study, which also applied guideline-
recommended rst-line care to all participants. This
suggests the prediction rule would be ideally applied to
patients provided with care in that context.
To our knowledge, the Hancock prediction rule is
the only instrument that provides probability for
recovery from acute LBP at different time points
within 12 weeks of symptom onset; and so, comparing
the performance of calibration is not possible. Our
nding of only poor to moderate discriminative per-
formance at 12 weeks, however, is comparable with or
slightly inferior to the few other prognostic rules for
LBP that have undergone validation. The area under
the curve (AUC) of the Orebro Musculoskeletal Pain
Screening Questionnaire (Maher and Grotle, 2009)
ranges from 0.62 to 0.75 for persistent pain and from
0.68 to 0.83 for persistent disability. (Hockings et al.,
2008) A recent meta-analysis of the Orebro Question-
naire revealed high heterogeneity and consequently
weak to moderate predictive value (sensitivity 0.59,
specicity 0.77 and AUC 0.64; Sattelmayer et al.,
2012). Early validation of the STarT Back Screening
Tool revealed that at 6 months, the tool predicts well
between patients at low/medium risk of disability and
high risk of disability (+LR 5.51, 95% condence
interval 3.309.28; Hill et al., 2008). However, a rea-
sonable predictive performance was not replicated in a
broader validation sample (Fritz et al., 2011). A key
difference between these instruments and the
Hancock rule is that the other rules aim to identify risk
of persistent symptoms, rather than likely rapid recov-
ery. While the ability of these instruments to classify
patients into different risk proles is comparable or
slightly superior, the other instruments are typically
much longer to complete and aim to predict non-
recovery post 3 months rather than provide estimates
of time to recovery within 3 months. Probability of
outcome has been suggested as the more useful prog-
nostic information for clinicians and their patients
(Toll et al., 2008), and is arguably the case for acute
LBP.
4.4 Interpretation of ndings
The key aim of the prediction rule investigated was to
provide clinicians and patients with additional infor-
mation about a patient recovery from acute LBP. The
rule may help in shared decision making about the
need for (or to withhold) additional interventions
beyond simple cheap rst-line care of advice and
simple analgesics for acute LBP. The prognosis of LBP
is widely reported to be favourable, yet many patients
continue to receive complex and expensive interven-
tions. The data from this study may help increase the
number of patients who elect for minimal care, when
presented with the probability of rapid recovery
within the rst 4 weeks. For example, patients with
three positive features on the CPR can be advised that
with simple recommended treatments using the
more conservative estimates from the validation study
7 in 10 people with these characteristics recover in 2
weeks (i.e. 70% chance of recovery within 2 weeks)
and nearly 9 in 10 people (85%) recover by 4 weeks
(Table 2). In our opinion, there is no threshold value
(probability of recovery) at which minimal care is
C.M. Williams et al. Validation of a prediction rule for low back pain
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Eur J Pain 18 (2014) 11821189 1187

clearly indicated; however, we believe data presented
in this manner can be used easily by individual
patients and clinicians to make more informed deci-
sions about the required care for an episode of acute
back pain.
The current study demonstrates that the simple pre-
diction rule generalized reasonably well to a new
population. This validation study utilized different cli-
nicians from a wider primary care setting (e.g. general
practice, physiotherapy and pharmacy), and the trial
interventions were different. In the development
sample, patients with sciatica or radicular symptoms
were excluded, whereas in the validation sample they
were not. Consequently, there was a higher preva-
lence of leg pain in the validation sample. As both
studies recruited people with acute LBP who were
seeking care, the prediction rule should only be con-
sidered validated in this population. In contrast,
patients with chronic LBP have been shown to have
different predictors of prognosis, and for these
patients, the rule may not be useful.
4.5 Future direction
The presented clinical prediction rule will only be be
valuable if shown to help in treatment decision
making between patients and clinicians. Future
studies should evaluate the impact of the prediction
rule; to determine the utility of the rule, if it changes
the number of patients who receive interventions
beyond those recommended for rst-line care, and
whether it inuences clinical outcomes or patient sat-
isfaction with the process and outcome of care. Con-
tinued validation in other geographical areas should
also be considered where updating the rule with the
addition of other variables may prove benecial in
other countries with different health-care processes.
For instance others have suggested psychological
factors play an important role in predicting outcomes
in similar cohorts (Grotle et al., 2005, 2007).
4.6 Conclusion
We assessed the generalizability of a simple prediction
rule that aimed to identify recovery in patients with
acute LBP. The performance of the prediction rule,
when evaluated in a new independent patient dataset,
was found to be acceptable for predicting recovery.
The prediction rule may help clinicians and patients
make informed decisions about treatment with greater
condence about the likely prognosis.
Author contributions
All authors made substantial contributions to conception and
design, acquisition of data. C.W., M.H. and C.M. lead data
analysis and interpretation of data. All authors were
involved in drafting the paper or its critical appraisal for
important content. All authors approved the nal the
version to be published.
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