Abstract
Background: Low back pain (LBP) is a global problem affecting a large percentage of the adult population and is a leading cause of disability, making it a significant drain on resources worldwide. The targeted treatment of this condition may help reduce the drain of this epidemic on global resources. Clinical decision-making is a vital skill required when approaching a patient with LBP in chiropractic practice; however, this skill may take time to develop in the chiropractic intern and new chiropractic clinicians. The STarT Back Screening Tool (SBST) is a validated tool used to place primary health care patients with LBP into subgroups based on their risk for poor prognosis decided by using specific prognostic indicators. No such tools are available in chiropractic practice to aid in the stratification of patient care. The differences between the subgrouping capabilities of the SBST and chiropractic clinicians and student interns may be helpful in future studies indicating the usefulness of the SBST to the chiropractor.
Aim: The aims of this research are to compare the subgrouping ability of the SBST to that of the chiropractic clinicians and student interns at the University of Johannesburg (UJ), identify the incongruencies between them and explore the reasons for these incongruencies.
Method: The study was an observational study that incorporated both qualitative and quantitative principals and was designed to work in conjunction with the completion of the SBST to enable a comparative assessment of the agreement between the screening tool, chiropractic clinicians', and student interns subjective risk allocation.
Procedure: The practitioners reviewed a video-recorded clinical assessment and wrote a review describing the reasons for their subgroup allocation. From these reviews, trends were identified and analysed. An inter-rater agreeability score was also used to determine the percentage agreement between the SBST, clinicians, and student’s subgroup allocations.
Results: The chiropractic clinicians and student interns had near perfect agreement with each other with regard to their subgrouping decisions but their agreement with the SBST was poor on both accounts. The SBST was found to be consistent and reliable where the chiropractic clinicians and student interns were not, but the SBST did not account for the patient’s clinical history with LBP as well as their non-back pain related psychosocial factors, how they had responded to past treatments, and their compliance and willingness to actively participate in their recovery. The screening tool did not consider the patients diagnosis for their LBP and these factors were regarded highly by the practitioners when making their subgrouping decisions. Due to the practitioners self-rated decrease in confidence when subgrouping higher risk patients and the underdiagnosed presentation of psychosocial prognostic factors, a formalized tool, such as the SBST may be helpful in confirming the practitioner’s decision and may help to more consistently recognise these patients in the clinical setting.
Conclusions: This research was able to compare the subgrouping ability of the SBST and the chiropractic clinicians and student interns. It was found that there was poor agreeability between he SBST and the chiropractic clinicians as well as between the SBST and the student interns however, there was near perfect agreement between the clinicians and student themselves. The practitioners highlighted different patient characteristics which influenced their decisions making skills but were found to be in near perfect agreement with each other when allocating patients to the different subgroups. The main characteristics they considered were the patients treatment history, their compliance with treatment and active coping strategies, and the diagnosis given which were not considered by the SBST in its patient allocation. The practitioners reported decreasing confidence when allocating patients to the higher risk groups suggesting an area in which the SBST may be able to work in conjunction with the practitioners clinical decision-making skills to reassure the clinician of their choice of treatment.