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31-08-2014 | Rheumatology | Article

Decision tool set to improve management of low back pain


Free abstract

medwireNews: Experts have developed an evidence-based tool to help doctors in secondary and tertiary care decide how best to manage patients with chronic low back pain (CLBP), a condition with the highest societal burden in Western Europe.

The new Nijmegen Decision Tool, which is based on current scientific evidence and formal multidisciplinary consensus, aims to identify which patients should be referred to a spine surgeon and which patients should be seen by a non-surgical spine care specialist.

The experts who developed the tool, led by Miranda van Hooff (Sint Maartenskliniek, Nijmegen, the Netherlands), say they expect it to improve clinical decision-making by selecting the right patients for the right interventions, thereby improving outcomes.

The tool should also lead to a reduction in healthcare costs by reducing inappropriate referrals, “thereby improving efficient use of scarce sources,” van Hooff et al suggest in PLoS One.

To develop the tool, the researchers first conducted a literature review and identified eight systematic reviews, four narrative reviews, three randomised trials and eighteen observational studies that were suitable for inclusion.

They then undertook a three-round Delphi study to extract evidence from the studies and arrive at a consensus on indicators to be included in the tool.

The final version of the Nijmegen Decision Tool includes a web-based screening questionnaire with 47 clinical indicators grouped into five domains: sociodemographic, pain, somatic, psychological, and functioning and quality of life.

There is conclusive evidence to support 36 of the indicators in having predictive value for treatment outcomes in CLBP patients, say the authors. Evidence for the other 11 indicators is inconclusive, however the expert panel considered that they should nevertheless be included.

The tool also features a provisional decision algorithm that uses a diagnostic triage based on “red flags” – ie, features potentially indicative of serious underlying pathology such as infection, inflammatory disease, cancer or fracture – together with clinical signs and symptoms. The presence of one or more red flags is indicative of the need for a consultation with a spinal surgeon.

The tool now needs to be tested for feasibility and validity in large prospective studies, say van Hooff and co-authors. “[A]fter refinement of the decision algorithm, and after validation of the tool in other settings, we expect that the Nijmegen Decision Tool for CLBP could be used in general secondary and tertiary spine care,” they write.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2014

By Joanna Lyford, Senior medwireNews Reporter