Spine (Phila Pa 1976). 2014 (Jan 1); 39 (1): 81–90 ~ FULL TEXT
Alice Kongsted, PhD, Werner Vach, PhD, Marie Ax0, MSc(Clin Biomech),
Rasmus Norgaard Bech, MSc(Clin Biomech), and Lise Hestbaek, PhD
Nordic Institute of Chiropractic and Clinical Biomechanics,
part of Clinical Locomotion Network,
STUDY DESIGN: A prospective cohort study conducted in general practice (GP) and chiropractic practice (CP).
OBJECTIVE: To explore which patient characteristics were associated with recovery expectations in patients with low back pain (LBP), whether expectations predicted 3-month outcome, and to what extent expectations were associated with empirical prognostic factors.
SUMMARY OF BACKGROUND DATA: Patients' recovery expectations have been associated with prognosis, but it is largely unknown why patients expect what they do, and how expectations relate to other prognostic factors.
METHODS: A total of 1169 participants completed questionnaires at their first consultation due to LBP, and 78% were followed for 3 months. At baseline, recovery expectations were measured on a 0 to 10 scale. Outcome measures were LBP intensity and global perceived effect. Associations were tested in regression models, and the predictive capacity of expectations described in terms of adjusted R and area under the receiver operating characteristic curve. Correlations between predicted expectations and prognosis were quantified by the Spearman rho.
RESULTS: Expectations were associated with known prognostic factors, mainly LBP history, but were only partly explained by measured factors (adjusted R, 35% [CP]/55% [GP]). Expectations had statistically significant associations with both outcomes after adjusting for other baseline factors, but explained only a little of the variance in LBP (adjusted R: 0.11 CP/0.32 GP) and did not add to the explained variance. The prediction of global perceived effect was limited in CP (area under the receiver operating characteristics curve, 0.59), but more substantial in GP (area under the receiver operating characteristics curve, 0.77) patients. Correlations between predicted expectations and predicted outcome were strong.
CONCLUSION: Patients' recovery expectations were associated mainly with LBP history and were generally, but not consistently, similar to an empirically predicted prognosis. Expectations were significantly associated with outcome, and may, at least for some outcomes, be a relevant proxy for more complex models. Future studies should explore the effect of addressing negative recovery expectations.
LEVEL OF EVIDENCE: 2.
From the FULL TEXT Article:
Low back pain (LBP) is an extremely common and burdensome
condition  for which there are no truly effective
treatments. Identification of potentially modifiable
prognostic factors may assist in improving care,  and patients'
expectations of recovery or return to work have been shown
to be prognostic factors with relatively strong and very consistent
associations with outcome in LBP [3-8] as well as in a
number of other conditions. [9, 10]
However, it is not clear whether recovery expectations are
associated with outcome because they reflect other prognostic
factors, or if recovery expectations have a causal relationship
with outcome, acting in a self-fulfilling manner. To explore
causality and to improve our understanding of the potential
for modifying expectations, it is essential to know which
patient characteristics are associated with expectations.
Although the construct of expectations has been investigated, [6, 11, 12]
little is known about the factors that form the
expectations of patients with LBP. Moreover, the construct of
expectations in an episodic and idiopathic condition such as
LBP is likely to differ from conditions such as the Alzheimer
disease  or after a traumatic injury. 
In LBP, a cohort study has demonstrated associations
between return-to-work expectations in work-related LBP
and pain, mood, prior back pain, job demands, functional
limitation, and marital status.  In a qualitative study, multiple
factors also emerged as important for expectations of patients
with LBP,  but associations between patient characteristics
and recovery expectations in those seeking care for their LBP
The objectives of this study were to explore which baseline
characteristics were associated with LBP patients' expectations
of recovery, whether recovery expectations predicted
outcome after 3 months, and whether these expectations were
similar to a prognosis predicted from other known prognostic
These objectives were explored in a sample of Danish
patients consulting for LBP in primary care. In Denmark,
general practice (GP) and chiropractic practice (CP) are the
means by which patients with LBP first gain access to the public
health care system, and thus a combination of the 2 settings
would represent first-line LBP care. There are several significant
differences between patients in the 2 settings and therefore
the objectives are explored separately in the 2 cohorts.
MATERIALS AND METHODS
Participants were recruited between September 2010 and
January 2012 from 17 CP clinics in the research network of
the Nordic Institute for Chiropractic and Clinical Biomechanics
in Denmark, and from Eebruary to May 2011 from GPs in
the Region of Southern Denmark who accepted an invitation to
participate in a quality assurance program.  Baseline questionnaires
were completed in the reception area before the initial
consultation in CPs, whereas in GPs, patients were handed a
questionnaire and a prepaid envelope and asked to complete the
survey at home. A follow-up questionnaire was mailed after 3
months, and nonresponders were reminded by phone.
Treatment was not affected by participation in the study, and
the local ethics committee determined that the study did not
need ethical approval according to Danish rules.'^ The study
was conducted in agreement with the Declaration of Helsinki.
Clinicians at the recruiting practices were asked to invite consecutive
patients to participate who were aged 18 to 65 years,
attending the CP or GP for the first time because of their current
episode of LBP, and who could read Danish. Exclusion
criteria were nonresponse on the expectations question, suspicion
of inflammatory or pathological pain, and nerve root
involvement requiring acute referral to surgery. In CP, additional
exclusion criteria were pregnancy and having had more
than 1 health care consultation due to LBP within the previous
At baseline, participants were asked: "How likely do you
think it is that you will be fully recovered in 3 months?"
The response was on a 0 to 10 numeric rating scale (0 =
not at all likely; 10 = very likely). A time-based single-item
tool specifically asking about expectations of return to work
was previously found to be the optimal measure of recovery
expectations.  Eor this study, a time-based, single-item question
was used but not related to return to work because only
a small proportion of participants were expected to be sick
listed at the time of inclusion.
Other Baseline Characteristics
The baseline characteristics investigated as potentially related
to a patient's expectations were from the domains of LBP history,
pain, activity limitation, psychology, general health, and
social factors. The following variable definitions were used:
previous LBP episodes (0,1-2,3 or more), LBP last year (^30
d, >30 d), duration (0-2 wk, 2-4 wk, 1-3 mo, or >3 mo),
LBP intensity last week (0-10 numeric rating scale, 0 = no
pain; 10 = worst imaginable pain [16, 17]), leg pain intensity (as
for LBP), activity limitation (proportional score Roland-Morris
Disability Questionnaires 0-100 ), depressive symptoms
(sum score Major Depression Inventory 0-50 ), fear avoidance
(Eear Avoidance Beliefs Questionnaire physical activity
scale [0-24] ), self-rated general health (EQ5D VAS scale
0 = worst imaginable health state; 100 = best imaginable
health state ) education (no qualification, vocational training,
higher education <3 yr, higher education 3-4 yr, higher
education >4 yr), heavy physical work (heavy physical work
vs. nonheavy [sitting, sitting/walking, and light physical]
work), and age (yr). The work scale of the Eear Avoidance
Beliefs Questionnaire was not included because it also measures
The outcome measures were LBP intensity (0-10 numeric rating
scale) and improvement ("much better" or "better" on a
7-point Global Perceived Effect Likert scale ) after 3 months.
Data were entered twice in EpiData.  Analyses were performed
in STATA/SE 12.1 (STATA Corp, College Station, TX). GP
and CP patients were analyzed separately because they differed
on many factors, with GP patients having generally lower
expectations and more complex profiles than CP patients.
Multiple imputations based on fully conditional specifications
were used with 5 chained iterations to impute missing
values.  Eor each analysis, the imputations were based on a
model that included all variables, but without replacing missing
values on outcome measures. All baseline variables except
for age, sex, and expectations were affected by missing values,
with a maximum prevalence of 7%.
To explore the associations between expectations and other
baseline characteristics, univariate linear regression analyses
were initially performed of all baseline measures, followed by
multivariable linear regression. We also investigated whether
the factors most strongly associated with expectations had
that effect moderated by other characteristics using tests of
interactions between the factor and the potential moderator.
Associations between expectations and outcome were tested
by means of linear regression (for the outcome LBP intensity)
and logistic regression (outcome improvement) and presented
as β-coefficients and odds ratios with 95% confidence intervals
(CIs), respectively. In addition, predictive models without
the expectation variable were formed, that included all
other baseline values, to investigate if adding recovery expectations
substantially increased the explanatory power of the
model in terms of
(1) adjusted R- for LBP change and
(2) area under the receiver operating characteristics curve (AUC) for improvement.
AUC was validated by means of a leave-oneout
cross validation. Joint models for both cohorts with interaction
terms between care setting and covariates were used to
assess differences between settings.
Correlations (Spearman rho [p]) between observed recovery
expectations, as well as expectations predicted from all
other baseline characteristics, and the predicted 3-month outcomes
from models also including all other baseline variables
(hereafter denoted empirical prognosis) were calculated to
investigate the degree to which patients' expectations were
driven by the empirical prognosis.
Potential dependency between observations from the same
clinics was taken into account using the STATA cluster option
for robust variance estimation with clinics (CP) or clinicians
(GP) as cluster level in all regression analyses.
In total, 1,169 participants were included, 928 from CP and
241 from CP (Figure 1). The baseline characteristics of the
cohorts are summarized in Table 1. The response rates at follow-
up were 76% from CP and 83% from GP. At baseline,
the nonresponders had on average 0.7 points lower expectations
(F = 0.001), slightly higher leg pain intensity (β =
0.05, P = 0.01), and depression scores (β = 1.7, P = 0.01),
more frequently an episode duration more than 3 months
(odds ratio = 1.7, P = 0.01), and were on average 5.1 years
younger (P < 0.01) compared with the responders. The association
between baseline characteristics and expectations did
not differ between responders and nonresponders.
The median expectations score was 9 (interquartile range
[IQR], 7-10) in CP and 6 (IQR, 3-9) in GP. In CP patients,
48% (95% CI, 45%-51%) had maxtmal recovery expectations
(expectations score =10), whereas this was the case in
22% (95% CI, 16%-27%) of GP patients (Figure 2).
Baseline Characteristics Associated With Recovery Expectations
Expectations were univariately associated with education,
previous LBP episodes, LBP days last year, episode duration,
leg pain intensity, depressive symptoms, and self-rated health
in both cohorts (Tables 2, 3). In CP patients, age, sex, and
heavy work were also associated with recovery expectations.
Multivariable Baseline Analyses
Previous episodes and duration were the only significant associations
with recovery expectations in both cohorts in the
multivariable models (Tables 2, 3). We tested if the effects
of these factors were moderated by education, depression,
LBP, or leg pain intensity. In CP patients, they were not. In
GP patients, depression added to the negative effect of duration
(0.1 additional decrease in expectations for each point
on the depression scale in patients with a duration >1 mo,
P = 0.03).
In the CP cohort, associations were also significant for age
and LBP days last year (Table 2), whereas sex, education, and
leg pain intensity were significantly associated with recovery
expectations in GP patients (Table 3).
Measured parameters explained 35% (adjusted R2) of the
variance in the recovery expectations measure in CP patients
and 55% in GP patients.
Expectations as Predictors of Outcome
After 3 months, median LBP intensity was 1 (IQR, 0-2) in
CP and 2 (IQR, 1-5) in GP patients. Higher expectations at
baseline were univariately associated with lower LBP intensity
3 months later (Table 4), with a stronger association in
GP patients than in CP patients (interaction term P < 0.001)
(Figure 3). Including all other baseline parameters in the
model, associations were reduced but still statistically significant
for both cohorts. The adjusted R- values were largely
unaltered by adding expectations to a model consisting of all
other predictors (Table 4).
In the CP cohort, 83% (95% CI, 80%-86%) were improved
at 3-month follow-up compared with 60% (95% CI, 53%-
67%) in the GP cohort. Higher baseline recovery expectations
were associated with a higher probability of improvement
in univariate (Figure 3, Table 4), and multivariable models
(Table 4). Odds ratios differed between settings with stronger
associations in GP patients (P = 0.02 crude and adjusted
In GP patients, a model consisting of all other baseline factors
had higher predictive capacity for improvement (AUG =
0.71) than expectations alone (AUG = 0.59). Expectations
alone (AUG = 0.77) predicted as well as the more complex
model (AUG = 0.75) in GP patients. Adding recovery expectations
to a model containing other baseline measures did
not increase AUG values considerably in any of the cohorts
Correlations Between Recovery Expectations and Empirical Prognosis
Taking the predicted outcomes from a model including all
other prognostic factors except for expectations as an empirical
measure for the prognosis, we could observe moderate correlations
between prognosis and expectations: for LBP intensity
p = -0.49 (P < 0.001) in the GP and p = -0.67 (P < 0.001)
in the GP cohort, and correspondingly, for improvement, p =
0.47(P < 0.001) and p = 0.60 (P < 0.001). These moderate
correlations suggest variability between empirical prognosis
and expectations in individuals (Figure 4). To get some insight
into a possible general difference between expectations and
prognosis, we calculated the correlation between expectations
predicted from other prognostic factors and the empirical
prognosis, and found strong correlations for both LBP intensity
(GP: p = -0.78, P < 0.001. GP: p = -0.87, P < 0.001)
and improvement (GP: p = 0.64, P < 0.001, GP: p = 0.78,
P < 0.001). This illustrated that, in general, the measured
predictors affected patients' expectations and the empirical
prediction in similar ways (Figure 4). Flowever, the correlations
were below one, indicating the predictive model and
patients' expectations weighted these factors differently.
Our main findings were:
(1) that patients' recovery expectations
were related to previous LBP experience more than to
symptom severity or to the considered psychological factors,
(2) that recovery expectations were associated with outcome
independently of other measured factors,
(3) that expectations
were generally a good proxy for other measured prognostic
factors but did not add predictive accuracy to that of
the other factors, and
(4) that patients' expectations generally
were similar to an empirically derived prognosis. However, it
should be recognized that the empirical model did not predict
outcomes very accurately.
This means that patients generally had realistic expectations,
although some considered their prognosis to be different
from that which we would predict from known prognostic
factors. It also means that in primary care, clinicians
should pay attention to previous experience in patients with
low expectations rather than focusing on psychological factors
such as depressive symptoms and fear avoidance beliefs.
However, factors measured in the study only explained part
of the variance in expectations, suggesting that recovery
expectations result from a more complex individual process
and although we included factors covering a wide range of
health domains, other measurable factors may better explain
those aspects that inform expectations. Self-efficacy and illness
beliefs are potentially relevant factors which theoretically
relate to recovery expectations  and should be investigated as
mediators of the association between recovery expectations
It remains somewhat unclear if expectations are useful as a
substitute for other known prognostic factors. In the prediction
of improvement in GP patients expectations predicted
outcome as well as a model with many other baseline factors,
whereas this was not the case in CP patients or in relation to
Associations with outcome were stronger in the GP than the
CP cohort. This may be influenced by the GP patients having
more previous episodes and a longer duration of LBP. In other
words, GP patients' more profound experience with LBP may
help them make a better prediction of their prognosis, and it
may be that expectations are more important in more severely
affected patients, who were more numerous in the GP cohort.
Alternatively, the different effects of expectations may be a
result of the interventions offered that could moderate the
effects of expectations in different ways.
We did not investigate
the possible effects of the interventions and cannot tell
to what extent that played a role. Finally, the observed differences
between settings could have been an effect of different
timing of the expectations question. CP patients were asked
about expectations prior to the first consultation whereas
GP patients completed the questionnaire at home after the
consultation. Having negative expectations after, rather than
prior to, a consultation may be more important. This makes
sense if clinicians generally are able to reassure patients during
the consultation. Unfortunately, effects of setting and timing
cannot be separated in this study.
Other limitations were that although the practices were
instructed to include patients consecutively, the actual source
population is unknown. Also, drop out may have introduced
bias, but response rates were acceptable and baseline factors
associated with expectations did not differ between responders
and nonresponders. Finally, the reliability and validity of
the expectations question was not established. It was deemed
necessary to use a single-item question because the cohorts
were asked a very high number of questions, and the wording
of the recovery question was based on previous studies. 
The main strength of this study was the adequate sample
size with complete data and enrollment from 2 settings. In an
explorative study like this, we also considered the variability
in duration a strength, as it allowed us to study the importance
of symptom duration. Moreover, the choice of investigated
patient characteristics was not restricted by a theoretical
framework about the construct of expectations. This is
needed to explore whether our thinking of recovery expectations
should be broadened to encompass other elements. Conversely,
as mentioned earlier important aspects may have been
missed using this approach.
Recovery expectations were associated mainly with LBP
history and were more complex than that which could be
explained by other measured factors. Patients' expectations
reflected that most patients assessed known prognostic factors
in an empirically "reasonable" way. Nevertheless, some had
expectations that seemed unrealistically low or high, although
this could only be judged against a rather inaccurate model.
Expectations were significandy associated with outcome, but
causal pathways between expectations and outcomes are still
to be explored. Given that other measured factors seemed to
relate more strongly to prognosis than expectations, there is
good justification for attempting to increase expectations in
patients who have a good predicted prognosis but low expectations.
Euture studies should explore the implications of having
expectations that seem unrealistic, whether expectations
can be modified, and if that alters outcome.
Recovery expectations of patients witb LBP are
a complex construct and associated mostly with
Patients' expectations were generally similarto
an empirically predicted prognosis.
Recovery expectations were associated witb outcome
independently of other measured factors.
Expectations did not increase tbe predictive accuracy
when added to a model consisting of known
prognostic factors, but they were a relevant proxy
for some outcome measures.
It may be useful to investigate if expectations can
be modified and if so, whether that would affect
The authors thank the chiropractors in the KIP research network
and the participating general practitioners for their participation
in data collection. They also thank APO Odense for establishing the contact with general practitioners. Lastly, they
thank the research assistants Jytte Johannesen and Orla Lund
Nielsen for taking care of all the logistics.
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