A Definition of "Flare" in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus

Nathalia Costa; Manuela L Ferreira; Jenny Setchell; Joanna Makovey; Tanya Dekroo; Aron Downie; Ashish Diwan; Bart Koes; Bard Natvig; Bill Vicenzino; David Hunter; Eric J Roseen; Eva Rasmussen-Barr; Francis Guillemin; Jan Hartvigsen; Kim Bennell; Leonardo Costa; Luciana Macedo; Marina Pinheiro; Martin Underwood; Mauritus Van Tulder; Melker Johansson; Paul Enthoven; Peter Kent; Peter O'Sullivan; Pradeep Suri; Stephane Genevay; Paul W Hodges

doi:10.1016/j.jpain.2019.03.009

A Definition of "Flare" in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus

J Pain. 2019 Nov;20(11):1267-1275. doi: 10.1016/j.jpain.2019.03.009. Epub 2019 Mar 21.

Authors

Nathalia Costa¹, Manuela L Ferreira², Jenny Setchell¹, Joanna Makovey², Tanya Dekroo¹, Aron Downie³, Ashish Diwan⁴, Bart Koes⁵, Bard Natvig⁶, Bill Vicenzino¹, David Hunter⁷, Eric J Roseen⁸, Eva Rasmussen-Barr⁹, Francis Guillemin¹⁰, Jan Hartvigsen¹¹, Kim Bennell¹², Leonardo Costa¹³, Luciana Macedo¹⁴, Marina Pinheiro¹⁵, Martin Underwood¹⁶, Mauritus Van Tulder¹⁷, Melker Johansson¹⁸, Paul Enthoven¹⁹, Peter Kent²⁰, Peter O'Sullivan²⁰, Pradeep Suri²¹, Stephane Genevay²², Paul W Hodges²³

Affiliations

¹ The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia.
² The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia.
³ Musculoskeletal Health Sydney, University of Sydney, Sydney, Australia; Department of Chiropractic, Macquarie University, Sydney, Australia.
⁴ Spine Service, Department of Orthopaedic Surgery, St. George & Sutherland Clinical School, University of New South Wales Australia, Kogarah, Sydney, Australia.
⁵ Department of General Practice, Erasmus MC, Rotterdam, the Netherlands; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.
⁶ Institute for Health and Society, Department of General Practice, University of Oslo, Oslo, Norway.
⁷ The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia.
⁸ Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts.
⁹ Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Stockholm, Sweden.
¹⁰ Universite de Lorraine, CHRU Nancy, Inserm, CIC1433-Epidemiologie Clinique, Nancy, France.
¹¹ Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.
¹² Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, Melbourne, The University of Melbourne, Victoria, Australia.
¹³ Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil.
¹⁴ McMaster University School of Rehabilitation Science Hamilton, Ontario, Canada.
¹⁵ Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
¹⁶ Warwick Medical School, University of Warwick, Coventry, United Kingdom.
¹⁷ Department of Health Sciences, Faculty of Science, Vrije Universiteit, Amsterdam Movement Science research institute, Amsterdam, the Netherlands.
¹⁸ Warwick Medical School, University of Warwick, Coventry, United Kingdom; Musculoskeletal Disorders and Physical Workload, National Research Centre for the Working Environment, Copenhagen, Denmark.
¹⁹ Department of Medical and Health Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.
²⁰ Department of Physiotherapy and Exercise Science, Curtin University, Perth, Australia.
²¹ Seattle Epidemiologic Research and Information Center (ERIC) and Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; New England Baptist Hospital, Boston, Massachusetts; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts.
²² Division of Rheumatology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland.
²³ The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia. Electronic address: [email protected].

PMID: 30904517
DOI: 10.1016/j.jpain.2019.03.009

Abstract

Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although "flare" is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers' views, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions." Perspective: A multiphase process, incorporating consumers' views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.

Keywords: Low back pain; consensus; definition; flare; flare-up.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Consensus
Delphi Technique
Humans
Low Back Pain / diagnosis*
Pain Measurement / methods
Pain Measurement / standards
Symptom Flare Up*