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Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain
Journal of Orthopaedic Science xxx (2018) 1e6
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Original Article
Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain Ryoji Tominaga a, Miho Sekiguchi a, *, Koji Yonemoto b, Tatsuyuki Kakuma c, Shin-ichi Konno a a b c
Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan Advanced Medical Research Center, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, Okinawa, 903-0215, Japan Biostatistics Center, Kurume University, 67 Asahimachi, Kurume, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 July 2017 Received in revised form 20 March 2018 Accepted 29 March 2018 Available online xxx
Background: The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was developed in 2007, including the five domains of Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. It is used by physicians to evaluate treatment efficacy by comparing scores before and after treatment. However, the JOABPEQ does not allow evaluation of the severity of a patient's condition compared to the general population at a single time point. Given the unavailability of a standard measurement of back pain, we sought to establish reference scores and interquartile ranges using data obtained from a multicenter, cross-sectional survey taken in Japanese primary care settings. Methods: The Lumbar Spinal Stenosis Diagnosis Support Tool project was conducted from 2011 to 2012 in 1657 hospitals in Japan to investigate the establishment of reference scores using JOABPEQ. Patients aged 20 years undergoing medical examinations by either non-orthopaedic primary care physicians or general orthopedists were considered for enrollment. Results: A total of 10,651 consecutive low back pain patients (5331 men, 5320 women, 18 subjects with missing sex data) who had undergone a medical examination were included. Reference scores and interquartile ranges for each of the five domains of the JOABPEQ according to age and sex were recorded. The median score and interquartile range are the same in the domain of Pain-related disorder in all ages and sexes. The reference scores for Gait disturbance, Social life disturbance and Psychological disorder declined with increasing age in both age- and sex-stratified groups, while there was some different trend in Lumbar spine dysfunction between men and women. Conclusion: Reference scores and interquartile ranges for JOABPEQ were generated based on the data from the examination data. These provide a measurement standard to assess patient perceptions of low back pain at any time point during evaluation or therapy. © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was first developed in 2007 as a structured outcome measure for patients with low back pain (LBP) from lumbar spine disorders [1e4]. The JOABPEQ provides an objective reference for the evaluation of patients with LBP. The scores of the
* Corresponding author. Fax: þ81 24 548 5505. E-mail address: [email protected] (M. Sekiguchi).
JOABPEQ have five domains: Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. Scores for all domains range from 0 to 100, with a higher score indicating a better condition [4]. This has enabled physicians to measure dysfunctions, disabilities, and psychosocial problems resulting from LBP, and to evaluate therapeutic effects, by comparing scores pre- and post-treatment [4]. Previous research established reference values of the JOABPEQ in healthy volunteers reported that the scores for Pain-related disorder, Gait disturbance, and Social life disturbance significantly decrease (i.e., worsen) with
https://doi.org/10.1016/j.jos.2018.03.010 0949-2658/© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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R. Tominaga et al. / Journal of Orthopaedic Science xxx (2018) 1e6
increasing age, whereas Lumbar spine dysfunction and Psychological disorder do not change with age [5]. However, the JOABPEQ is limited by its lack of established reference scores and reference interquartile ranges of patients with LBP. In order to evaluate how serious a patient's condition compared to the symptomatic population, the reference scores of LBP patients might be useful in the clinical setting. Given the unavailability of standard measurements of low back pain, we aimed to accumulate robust and accurate reference scores and reference interquartile ranges of the JOABPEQ in patients with LBP. 2. Participants and methods 2.1. Ethics This study was approved by the ethics committees of Fukushima Medical University and the Japanese Orthopaedic Association.
Because it has been reported that there are age- and sex-related differences in JOABPEQ scores [5,8], reference values of patients with LBP in different ages and sexes were investigated. 2.6. Statistical analysis In the descriptive statistics, we calculated quartiles including median values for the distribution of the scores of each domain in JOABPEQ, stratifying the patients into 12 groups by sex and age. The functional scores were calculated according to the formulas only if all questions for each domain were answered. Domains in which there were missing or inappropriate answers due to failure to follow instructions were excluded. We also excluded participants who had skipped data about sex and age. Statistical analysis was performed using the JonckheereTerpstra trend test for each domain. A p-value less than 0.05 was considered statistically significant. All statistical analyses were performed by using SAS Ver 9.3 (SAS Institute Inc., Cary, NC, USA).
2.2. Study design 3. Results The survey was developed under a cross-sectional design using data from a multi-center investigation conducted under the guidance of the Japanese Society for Spine Surgery and Related Research. The research group consisted of project members from the development of the Lumbar Spinal Stenosis Diagnosis Support Tool (DISTO) [6]. A total of 38,577 individuals who visited the 1657 participating hospitals and general practices nationwide were consecutively recruited from 1 December 2011 to 31 December 2012. 2.3. Data collection The target population of this study was patients with LBP who had a medical examination and were aged 20 years, irrespective of reason for visiting the institution. Patients were included with or without leg symptoms, regardless of the duration of LBP. The participants were excluded if they had a history of heart failure, renal failure, respiratory failure, hepatic insufficiency, spinal surgery, reduced level of consciousness, or psychological disorders such as schizophrenia or personality disorders. The subjects were divided into groups according to sex and age (20s, 30s, 40s, 50s, 60s, and over-70s).
3.1. Patient background In total, 10,669 patients with LBP were included in the study. After 18 patients were excluded due to missing or inappropriate data, 10,651 participants were included in the sex- & age-strata analysis (Fig. 1). Table 1 shows the characteristics of participants in this study. A total of 5331 men and 5320 women participated, with the largest age group being the over-70s. A total of 255 subjects were examined by non-orthopedists, 774 by orthopedists, and 9783 by hospital-based orthopedists. The pain intensity of participants in this study by sex & age strata is shown in Table 2. 3.2. JOABPEQ scores Results of the scores for the five categories were calculated. The median of each domain ranged between 42.9 and 58.3: Painrelated disorder 42.9 (interquartile range (IR) 25%e75%: 14.3e71.4), Lumbar spine dysfunction 58.3 (33.3e83.3), Gait disturbance 50.0 (28.6e85.7), Social life disturbance 51.4 (35.1e64.9), Psychological disorder 47.6 (38.8e58.3). 3.3. Sex- & age-stratified results
2.4. Low back pain In general, LBP is defined as pain and discomfort localized between the lowest costal margin and the inferior gluteal folds [7]. The participants with LBP were examined in each institution in order to judge the precise location of their LBP.
3.3.1. Pain-related disorder For both sex and all age groups, the median score was 42.9, with first and third quartiles of 14.3 and 71.4 respectively (Fig. 2a and b).
2.5. JOABPEQ JOABPEQ includes 25 questions, 5 for each domain. The participants are asked to recall their health condition during the last week and circle the number of the answer that best applied to their condition for each question. If the condition varied depending on the day or the time, the subjects were asked to circle the answer applying to the worst condition. The functional score of each domain was calculated according to the calculating formulas and ranged from 0 to 100 points, with higher scores indicating a better condition [1e3]. The five functional scores are designed to be used independently; there is no total score. Visual analog scales (VASs) were used to evaluate the degree of LBP for supplemental use [4]. In this study, the JOABPEQ were completed by each patient independently.
Fig. 1. Description of participants.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
R. Tominaga et al. / Journal of Orthopaedic Science xxx (2018) 1e6
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Table 1 Subject characteristics.
Age Mean (SD) Pain intensity of LBP VAS (0e100) Mean (SD)
All subjects n ¼ 10,651
Men n ¼ 5331
Women n ¼ 5320
60.8 (16.9)
59.2 (17.1)
62.2 (16.6)
54.7 (28.2)
53.9 (28.0)
55.5 (28.3)
LBP ¼ low back pain, VAS ¼ visual-analog score.
Table 2 Pain intensity of participants with LBP by sex & age. Age group
20e29 30e39 40e49 50e59 60e69 70 Total
Men
Pain intensity (VAS;0e100)
Women
n
Mean (SD)
n
Mean (SD)
301 550 528 637 1,125 1,542 4,683
58.8 56.6 57.2 52.2 52.4 52.5 53.9
227 436 452 585 951 1,829 4,480
61.6 56.9 56.0 53.3 51.8 57.0 55.5
(25.7) (27.6) (27.9) (27.7) (27.8) (28.6) (28.0)
Pain intensity (VAS;0e100)
(25.1) (28.6) (29.2) (28.5) (29.0) (27.7) (28.3)
LBP ¼ low back pain, VAS ¼ visual-analog scale. 1488 participants had missing or inappropriate age data.
3.3.2. Lumbar spine dysfunction The median scores in men were 58.3, 50.0, 50.0, 58.3, 66.7, 58.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 58.3, 58.3, 58.3, 58.3, 66.7, 50.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 33.3, 33.3, 33.3, 41.7, 41.7, 33.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 33.3, 33.3, 33.3, 33.3, 33.3, 25.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 83.3 in all age strata. The third quartile in women were 91.7, 83.3, 83.3, 83.3, 83.3, 75.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores were almost constant for both sexes. The first quartile was 33.3 in individuals in their 20e40s for both sexes. However, the score rose for men in their 50s and 60s, whereas the score in women remained 33.3. In over-70s, the first quartile in both sexes declined to 33.3 in men and 25.0 in women, respectively. The third quartile remained at 83.3 for all age groups in men. In women, the third quartile in the 20s was 91.7, decreasing to 83.3 in 30se60s, and to 75.0 in over-70s (Fig. 3a and b). The score had a tendency to increase with age in men and decrease with age in women (Men: p ¼ 0.0182 Women: p < 0.0001). 3.3.3. Gait disturbance The median scores in men were 78.6, 71.4, 64.3, 64.3, 50.0, 42.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 85.7, 71.4, 64.3, 64.3, 50.0, 35.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 42.9, 42.9, 42.9, 35.7, 28.6, 14.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 64.3, 50.0, 42.9, 42.9, 28.6, 14.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 100, 100, 92.9, 92.9, 85.7, 64.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 100, 100, 100, 92.9, 85.7, 64.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores of both sexes gradually declined with increasing age. For both sexes, the first and third quartiles were also gradually declined with increasing age (Fig. 4a and b).
Fig. 2. a, b: Distribution of scores for “Pain-related disorder” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
The score had a tendency to decrease with age in both sexes (p < 0.0001). 3.3.4. Social life disturbance The median scores in men were 51.4, 51.4, 51.4, 51.4, 51.4, 48.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 56.8, 56.8, 56.8, 51.4, 51.4, 47.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 32.4, 35.1, 35.1, 37.8, 35.1, 29.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 43.2, 37.8, 40.5, 43.2, 37.8, 32.4, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 70.3, 70.3, 70.3, 67.6, 64.9, 59.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 78.4, 78.4, 73.0, 70.3, 67.6, 59.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in men were 51.4 for 20se60s, whereas the median scores in women gradually declined with increasing age. For both sexes, the same trend was observed with the median scores in the first and third quartiles. In men, each score relatively remained constant. The decline with increasing age also appeared in women (Fig. 5a and b). The score had a tendency to decrease with age in both sexes (p < 0.0001).
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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Fig. 3. a, b: Distribution of scores for “Lumbar spine dysfunction” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
Fig. 4. a, b: Distribution of scores for “Gait disturbance” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
3.3.5. Psychological disorder The median scores in men were 53.4, 53.4, 48.5, 50.5, 47.6, 47.6, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 53.4, 51.5, 48.5, 47.6, 47.6, 44.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 41.7, 42.7, 40.8, 38.8, 38.8, 38.8, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 41.7, 38.8, 38.8, 37.9, 38.8, 33.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 63.1, 62.1, 59.2, 60.2, 59.2, 60.2, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 60.2, 60.2, 58.3, 54.4, 56.3, 54.4, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores of both sexes gradually declined with increasing age. For both sexes, the first and third quartiles also gradually declined with increasing age (Fig. 6a and b). The score had a tendency to decrease with age in both sexes (p < 0.0001).
cross-sectional survey in Japanese primary care/orthopaedic orthopaedic settings. These results will provide physicians with meaningful measures in how serious a patient evaluates his condition using the reference scores and interquartile ranges of a symptomatic population. JOABPEQ has been considered useful for evaluating changes in a patient's status pre- and post-treatment. It is reported that a treatment is judged as “effective” when: (1) the patient provides answers to all the questions necessary to calculate a domain score and shows an increase of 20 points after the treatment, or (2) the functional score after treatment exceeds 90 points even if the answer for an unanswered question is assumed as the worst possible choice [4,9]. Because there were no reference values for JOABPEQ in patients with LBP, physicians could not use it to evaluate the severity of a patient's condition at a single time point, for example to determine if a patient visiting a hospital had a light or serious case of back pain. Here, we measured the scores of each domain of the JOABPEQ in patients with LBP in 1657 hospitals and general practices nationwide that represented Japanese primary care and orthopaedic settings. In addition to the reference values of the JOABPEQ in healthy volunteers in previous report, the reference scores of the JOABPEQ in patients with LBP can be useful for physicians to evaluate the status of individual patients at baseline, monitor patients and evaluate therapeutic efficacy at any time point.
4. Discussion Here, for the first time, we describe reference scores and interquartile ranges of the JOABPEQ in a Japanese population with low back pain, based on the data obtained from a multicenter,
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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Fig. 5. a, b: Distribution of scores for “Social life disturbance” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
Fig. 6. a, b: Distribution of scores for “Psychological disorder” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
JOABPEQ consists of five domains: Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. Age- and sex-related difference in the scores have been noted [5,8]. In this study, we investigated the age and sex difference in each JOABPEQ domain and revealed that there are variations in reference scores and interquartile ranges for the five domains stratified by age and sex. Interestingly, the median score and interquartile range are the same in the domain of Pain-related disorder in all ages and sexes. The reference scores for Gait disturbance, Social life disturbance and Psychological disorder declined with increasing age in both age- and sex-stratified groups, while there was some different trend in Lumbar spine dysfunction between men and women; The score had a tendency to increase with age in men and decrease with age in women. On the other hand, previous study reported that the scores for Lumbar spine dysfunction, Gait disturbance, and Social life disturbance decreased significantly with increasing age, while the influence of age was small for Pain-related disorder and Psychological disorder in the five domains of the JOABPEQ [5]. These discrepancies are considered to be due to the differences in target populations and participating institutions. The present study targeted patients with LBP regardless of the underlying causes and the data were obtained from Japanese primary care and orthopaedic settings, whereas the previous study included healthy volunteers out of clinical settings.
Another study which included patients with lumbar spinal diseases reported that Pain-related disorder and Gait disturbance scores were significantly different according to age, and that Lumbar spine dysfunction, Social life disturbance, and Psychological disorder scores were independent of age [8]. Some differences between the two studies might be due to differences in the categorization of age and sex or the severity of the underlying condition of the patients; the present study included patients with LBP in primary care settings, whereas the previous study included patients with lumbar spinal disease who visit specialist: spine surgeons. This study has a number of strengths: it is the first multi-center, nationwide study to investigate the reference scores and interquartile ranges for JOABPEQ in patients with LBP, and enrolled more than ten thousand participants. Participants with LBP were enrolled regardless of cause. We believe that establishment of the reference values of JOABPEQ in patients with LBP caused by various etiologies in primary care and orthopaedic settings is essential for evaluating dysfunctions, disabilities, and psychosocial problems at presentation as a first step. This study also has several limitations. First, the data were not acquired by random sampling from a population-based record, and therefore the reference data acquired in this study did not completely represent population-based values. Although LBP is one
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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R. Tominaga et al. / Journal of Orthopaedic Science xxx (2018) 1e6
of the most common complaints that lead to a medical examination, it is almost impossible to adopt random sampling in a nationwide setting. Consecutive sampling is the best available method to survey the reference values for this scale. Second, we did not evaluate JOABPEQ scores according to underlying disease, such as intervertebral disc herniation, lumbar spinal stenosis, spondylosis, and non-specific low back pain. It has been reported that each domain has significant differences in scores by causation [8]. Patients in this survey were included with or without leg symptoms that might affect the scores of Gait disturbance or Social life disturbance, results of this study, therefore, have to be taken with caution when using this reference scores. It will be necessary to investigate the reference values and ranges for each disease that causes LBP in future studies. Third, it should be considered that a selection bias occurred when the patients were included regardless of the duration of LBP. As the proportion of patients with chronic/acute LBP might affect values of JOABPEQ, these results should be interpreted with caution. 5. Conclusion Reference scores and interquartile ranges for JOABPEQ were established for patients with LBP in this study. Not unexpectedly, JOABPEQ scores may change by domain, sex, and age. The reference scores and interquartile ranges of symptomatic population shown in this study provide a reference standard for evaluating patients presenting with LBP at baseline or another single time point. Conflicts of interest The authors declare that they have no conflict. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jos.2018.03.010. Appendix The Lumbar Spinal Stenosis Diagnosis Support Tool (DISTO) project group consists of the following members: Chairman: Shin-ichi Kikuchi (Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine). Research members: Shin-ichi Kikuchi, Shin-ichi Konno, Miho Sekiguchi (Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine), Kazuhisa Takahashi, Seiji Ohtori (Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University), Tatsuyuki Kakuma, Koji Yonemoto (Bio-statistics Center, Kurume University), Kazuo Yonenobu (Department of Orthopaedic Surgery, Osaka Minami Medical Center), Keisuke Takahashi, Hideki Iizuka (Department of Orthopaedic Surgery, Saitama Medical University, Faculty of Medicine), Toshihiko Taguchi, Tsukasa Kanchiku (Department of Orthopaedic Surgery Yamaguchi University Faculty of Medicine and Health Sciences), Katsushi Takeshita, Nobuhiro Hara (Department of Orthopaedic Surgery, The University of Tokyo Faculty of Medicine), Toshikazu Tani, Ryuichi
Takemasa (Department of Orthopaedic Surgery, Kochi Medical School), Kazuhiro Chiba (Department of Orthopaedic Surgery, Kitasato University Kitasato Institute Hospital), Naofumi Hozogane (Department of Orthopaedic Surgery, Keio University School of Medicine), Kensei Nagata, Kimiaki Sato (Department of Orthopaedic Surgery, 308 Kurume University School of Medicine), Yutaka Nohara, 309 Hiroshi Taneichi (Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine), Yuichi Hoshino, Atsushi Seichi (Department of Orthopaedic Surgery, Jichi Medical University), Toshihiko Yamashita, Tsuneo Takebayashi (Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine), Munehito Yoshida, Hiroshi Yamada (Department of Orthopaedic Surgery, Wakayama Medical University). References [1] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Wada E, Yonenobu K, Tanaka T, Hirota Y. JOA back pain evaluation questionnaire: initial report. J Orthop Sci 2007 Sep;12(5):443e50. [2] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Wada E, Yonenobu K, Tanaka T, Hirota Y. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 3. Validity study and establishment of the measurement scale : Subcommittee on low back pain and Cervical Myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association. Jpn J Orthop Sci 2008 May;13(3):173e9. [3] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Yonenobu K, Wada E, Tanaka T, Hirota Y. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability : the Subcommittee on low back pain and Cervical Myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association. J Orthop Sci 2007 Nov;12(6):526e32. [4] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Yonenobu K, Wada E, Tanaka T, Hirota Y. JOA back pain evaluation questionnaire (JOABPEQ)/JOA Cervical Myelopathy evaluation questionnaire (JOACMEQ). The report on the development of revised versions. April 16, 2007. The Subcommittee of the clinical outcome committee of the Japanese orthopaedic association on low back pain and Cervical Myelopathy evaluation. J Orthop Sci 2009 May;14(3):348e65. [5] Hashizume H, Konno S, Takeshita K, Fukui M, Takahashi K, Chiba K, Miyamoto M, Matsumoto M, Kasai Y, Kanamori M, Matsunaga S, Hosono N, Kanchiku T, Taneichi H, Tanaka N, Kanayama M, Shimizu T, Kawakami M. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) as an outcome measure for patients with low back pain: reference values in healthy volunteers. J Orthop Sci 2015 Mar;20(2):264e80. [6] Ohtori S, Sekiguchi M, Yonemoto K, Kakuma T, Takahashi K, Konno S. Awareness and use of diagnostic support tools for lumbar spinal stenosis in Japan. J Orthop Sci 2014 May;19(3):412e7. [7] Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ. Chapter 2. European guidelines for prevention in low back pain. Eur Spine J 2006 Mar;15(Suppl. 2):S136e68. [8] Ohtori S, Ito T, Yamashita M, Murata Y, Morinaga T, Hirayama J, Kinoshita T, Ataka H, Koshi T, Sekikawa T, Miyagi M, Tanno T, Suzuki M, Aoki Y, Aihara T, Nakamura S, Yamaguchi K, Tauchi T, Hatakeyama K, Takata K, Sameda H, Ozawa T, Hanaoka E, Suzuki H, Akazawa T, Suseki K, Arai H, Kurokawa M, Eguchi Y, Suzuki M, Okamoto Y, Miyagi J, Yamagata M, Toyone T, Takahashi K. Chiba Low Back Pain Research G. Evaluation of low back pain using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire for lumbar spinal disease in a multicenter study: differences in scores based on age, sex, and type of disease. J Orthop Sci 2010 Jan;15(1):86e91. [9] Kasai Y, Fukui M, Takahashi K, Ohtori S, Takeuchi D, Hashizume H, Kanamori M, Hosono N, Kanchiku T, Wada E, Sekiguchi M, Konno S, Kawakami M. Verification of the sensitivity of functional scores for treatment results e Substantial clinical benefit thresholds for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). J Orthop Sci 2017 Jul;22(4):665e9.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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Original Article
Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain Ryoji Tominaga a, Miho Sekiguchi a, *, Koji Yonemoto b, Tatsuyuki Kakuma c, Shin-ichi Konno a a b c
Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan Advanced Medical Research Center, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, Okinawa, 903-0215, Japan Biostatistics Center, Kurume University, 67 Asahimachi, Kurume, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 July 2017 Received in revised form 20 March 2018 Accepted 29 March 2018 Available online xxx
Background: The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was developed in 2007, including the five domains of Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. It is used by physicians to evaluate treatment efficacy by comparing scores before and after treatment. However, the JOABPEQ does not allow evaluation of the severity of a patient's condition compared to the general population at a single time point. Given the unavailability of a standard measurement of back pain, we sought to establish reference scores and interquartile ranges using data obtained from a multicenter, cross-sectional survey taken in Japanese primary care settings. Methods: The Lumbar Spinal Stenosis Diagnosis Support Tool project was conducted from 2011 to 2012 in 1657 hospitals in Japan to investigate the establishment of reference scores using JOABPEQ. Patients aged 20 years undergoing medical examinations by either non-orthopaedic primary care physicians or general orthopedists were considered for enrollment. Results: A total of 10,651 consecutive low back pain patients (5331 men, 5320 women, 18 subjects with missing sex data) who had undergone a medical examination were included. Reference scores and interquartile ranges for each of the five domains of the JOABPEQ according to age and sex were recorded. The median score and interquartile range are the same in the domain of Pain-related disorder in all ages and sexes. The reference scores for Gait disturbance, Social life disturbance and Psychological disorder declined with increasing age in both age- and sex-stratified groups, while there was some different trend in Lumbar spine dysfunction between men and women. Conclusion: Reference scores and interquartile ranges for JOABPEQ were generated based on the data from the examination data. These provide a measurement standard to assess patient perceptions of low back pain at any time point during evaluation or therapy. © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was first developed in 2007 as a structured outcome measure for patients with low back pain (LBP) from lumbar spine disorders [1e4]. The JOABPEQ provides an objective reference for the evaluation of patients with LBP. The scores of the
* Corresponding author. Fax: þ81 24 548 5505. E-mail address: [email protected] (M. Sekiguchi).
JOABPEQ have five domains: Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. Scores for all domains range from 0 to 100, with a higher score indicating a better condition [4]. This has enabled physicians to measure dysfunctions, disabilities, and psychosocial problems resulting from LBP, and to evaluate therapeutic effects, by comparing scores pre- and post-treatment [4]. Previous research established reference values of the JOABPEQ in healthy volunteers reported that the scores for Pain-related disorder, Gait disturbance, and Social life disturbance significantly decrease (i.e., worsen) with
https://doi.org/10.1016/j.jos.2018.03.010 0949-2658/© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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increasing age, whereas Lumbar spine dysfunction and Psychological disorder do not change with age [5]. However, the JOABPEQ is limited by its lack of established reference scores and reference interquartile ranges of patients with LBP. In order to evaluate how serious a patient's condition compared to the symptomatic population, the reference scores of LBP patients might be useful in the clinical setting. Given the unavailability of standard measurements of low back pain, we aimed to accumulate robust and accurate reference scores and reference interquartile ranges of the JOABPEQ in patients with LBP. 2. Participants and methods 2.1. Ethics This study was approved by the ethics committees of Fukushima Medical University and the Japanese Orthopaedic Association.
Because it has been reported that there are age- and sex-related differences in JOABPEQ scores [5,8], reference values of patients with LBP in different ages and sexes were investigated. 2.6. Statistical analysis In the descriptive statistics, we calculated quartiles including median values for the distribution of the scores of each domain in JOABPEQ, stratifying the patients into 12 groups by sex and age. The functional scores were calculated according to the formulas only if all questions for each domain were answered. Domains in which there were missing or inappropriate answers due to failure to follow instructions were excluded. We also excluded participants who had skipped data about sex and age. Statistical analysis was performed using the JonckheereTerpstra trend test for each domain. A p-value less than 0.05 was considered statistically significant. All statistical analyses were performed by using SAS Ver 9.3 (SAS Institute Inc., Cary, NC, USA).
2.2. Study design 3. Results The survey was developed under a cross-sectional design using data from a multi-center investigation conducted under the guidance of the Japanese Society for Spine Surgery and Related Research. The research group consisted of project members from the development of the Lumbar Spinal Stenosis Diagnosis Support Tool (DISTO) [6]. A total of 38,577 individuals who visited the 1657 participating hospitals and general practices nationwide were consecutively recruited from 1 December 2011 to 31 December 2012. 2.3. Data collection The target population of this study was patients with LBP who had a medical examination and were aged 20 years, irrespective of reason for visiting the institution. Patients were included with or without leg symptoms, regardless of the duration of LBP. The participants were excluded if they had a history of heart failure, renal failure, respiratory failure, hepatic insufficiency, spinal surgery, reduced level of consciousness, or psychological disorders such as schizophrenia or personality disorders. The subjects were divided into groups according to sex and age (20s, 30s, 40s, 50s, 60s, and over-70s).
3.1. Patient background In total, 10,669 patients with LBP were included in the study. After 18 patients were excluded due to missing or inappropriate data, 10,651 participants were included in the sex- & age-strata analysis (Fig. 1). Table 1 shows the characteristics of participants in this study. A total of 5331 men and 5320 women participated, with the largest age group being the over-70s. A total of 255 subjects were examined by non-orthopedists, 774 by orthopedists, and 9783 by hospital-based orthopedists. The pain intensity of participants in this study by sex & age strata is shown in Table 2. 3.2. JOABPEQ scores Results of the scores for the five categories were calculated. The median of each domain ranged between 42.9 and 58.3: Painrelated disorder 42.9 (interquartile range (IR) 25%e75%: 14.3e71.4), Lumbar spine dysfunction 58.3 (33.3e83.3), Gait disturbance 50.0 (28.6e85.7), Social life disturbance 51.4 (35.1e64.9), Psychological disorder 47.6 (38.8e58.3). 3.3. Sex- & age-stratified results
2.4. Low back pain In general, LBP is defined as pain and discomfort localized between the lowest costal margin and the inferior gluteal folds [7]. The participants with LBP were examined in each institution in order to judge the precise location of their LBP.
3.3.1. Pain-related disorder For both sex and all age groups, the median score was 42.9, with first and third quartiles of 14.3 and 71.4 respectively (Fig. 2a and b).
2.5. JOABPEQ JOABPEQ includes 25 questions, 5 for each domain. The participants are asked to recall their health condition during the last week and circle the number of the answer that best applied to their condition for each question. If the condition varied depending on the day or the time, the subjects were asked to circle the answer applying to the worst condition. The functional score of each domain was calculated according to the calculating formulas and ranged from 0 to 100 points, with higher scores indicating a better condition [1e3]. The five functional scores are designed to be used independently; there is no total score. Visual analog scales (VASs) were used to evaluate the degree of LBP for supplemental use [4]. In this study, the JOABPEQ were completed by each patient independently.
Fig. 1. Description of participants.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
R. Tominaga et al. / Journal of Orthopaedic Science xxx (2018) 1e6
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Table 1 Subject characteristics.
Age Mean (SD) Pain intensity of LBP VAS (0e100) Mean (SD)
All subjects n ¼ 10,651
Men n ¼ 5331
Women n ¼ 5320
60.8 (16.9)
59.2 (17.1)
62.2 (16.6)
54.7 (28.2)
53.9 (28.0)
55.5 (28.3)
LBP ¼ low back pain, VAS ¼ visual-analog score.
Table 2 Pain intensity of participants with LBP by sex & age. Age group
20e29 30e39 40e49 50e59 60e69 70 Total
Men
Pain intensity (VAS;0e100)
Women
n
Mean (SD)
n
Mean (SD)
301 550 528 637 1,125 1,542 4,683
58.8 56.6 57.2 52.2 52.4 52.5 53.9
227 436 452 585 951 1,829 4,480
61.6 56.9 56.0 53.3 51.8 57.0 55.5
(25.7) (27.6) (27.9) (27.7) (27.8) (28.6) (28.0)
Pain intensity (VAS;0e100)
(25.1) (28.6) (29.2) (28.5) (29.0) (27.7) (28.3)
LBP ¼ low back pain, VAS ¼ visual-analog scale. 1488 participants had missing or inappropriate age data.
3.3.2. Lumbar spine dysfunction The median scores in men were 58.3, 50.0, 50.0, 58.3, 66.7, 58.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 58.3, 58.3, 58.3, 58.3, 66.7, 50.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 33.3, 33.3, 33.3, 41.7, 41.7, 33.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 33.3, 33.3, 33.3, 33.3, 33.3, 25.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 83.3 in all age strata. The third quartile in women were 91.7, 83.3, 83.3, 83.3, 83.3, 75.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores were almost constant for both sexes. The first quartile was 33.3 in individuals in their 20e40s for both sexes. However, the score rose for men in their 50s and 60s, whereas the score in women remained 33.3. In over-70s, the first quartile in both sexes declined to 33.3 in men and 25.0 in women, respectively. The third quartile remained at 83.3 for all age groups in men. In women, the third quartile in the 20s was 91.7, decreasing to 83.3 in 30se60s, and to 75.0 in over-70s (Fig. 3a and b). The score had a tendency to increase with age in men and decrease with age in women (Men: p ¼ 0.0182 Women: p < 0.0001). 3.3.3. Gait disturbance The median scores in men were 78.6, 71.4, 64.3, 64.3, 50.0, 42.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 85.7, 71.4, 64.3, 64.3, 50.0, 35.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 42.9, 42.9, 42.9, 35.7, 28.6, 14.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 64.3, 50.0, 42.9, 42.9, 28.6, 14.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 100, 100, 92.9, 92.9, 85.7, 64.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 100, 100, 100, 92.9, 85.7, 64.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores of both sexes gradually declined with increasing age. For both sexes, the first and third quartiles were also gradually declined with increasing age (Fig. 4a and b).
Fig. 2. a, b: Distribution of scores for “Pain-related disorder” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
The score had a tendency to decrease with age in both sexes (p < 0.0001). 3.3.4. Social life disturbance The median scores in men were 51.4, 51.4, 51.4, 51.4, 51.4, 48.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 56.8, 56.8, 56.8, 51.4, 51.4, 47.3, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 32.4, 35.1, 35.1, 37.8, 35.1, 29.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 43.2, 37.8, 40.5, 43.2, 37.8, 32.4, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 70.3, 70.3, 70.3, 67.6, 64.9, 59.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 78.4, 78.4, 73.0, 70.3, 67.6, 59.5, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in men were 51.4 for 20se60s, whereas the median scores in women gradually declined with increasing age. For both sexes, the same trend was observed with the median scores in the first and third quartiles. In men, each score relatively remained constant. The decline with increasing age also appeared in women (Fig. 5a and b). The score had a tendency to decrease with age in both sexes (p < 0.0001).
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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Fig. 3. a, b: Distribution of scores for “Lumbar spine dysfunction” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
Fig. 4. a, b: Distribution of scores for “Gait disturbance” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
3.3.5. Psychological disorder The median scores in men were 53.4, 53.4, 48.5, 50.5, 47.6, 47.6, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores in women were 53.4, 51.5, 48.5, 47.6, 47.6, 44.7, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in men were 41.7, 42.7, 40.8, 38.8, 38.8, 38.8, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The first quartile in women were 41.7, 38.8, 38.8, 37.9, 38.8, 33.0, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in men were 63.1, 62.1, 59.2, 60.2, 59.2, 60.2, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The third quartile in women were 60.2, 60.2, 58.3, 54.4, 56.3, 54.4, in the 20s, 30s, 40s, 50s, 60s, and over-70s, respectively. The median scores of both sexes gradually declined with increasing age. For both sexes, the first and third quartiles also gradually declined with increasing age (Fig. 6a and b). The score had a tendency to decrease with age in both sexes (p < 0.0001).
cross-sectional survey in Japanese primary care/orthopaedic orthopaedic settings. These results will provide physicians with meaningful measures in how serious a patient evaluates his condition using the reference scores and interquartile ranges of a symptomatic population. JOABPEQ has been considered useful for evaluating changes in a patient's status pre- and post-treatment. It is reported that a treatment is judged as “effective” when: (1) the patient provides answers to all the questions necessary to calculate a domain score and shows an increase of 20 points after the treatment, or (2) the functional score after treatment exceeds 90 points even if the answer for an unanswered question is assumed as the worst possible choice [4,9]. Because there were no reference values for JOABPEQ in patients with LBP, physicians could not use it to evaluate the severity of a patient's condition at a single time point, for example to determine if a patient visiting a hospital had a light or serious case of back pain. Here, we measured the scores of each domain of the JOABPEQ in patients with LBP in 1657 hospitals and general practices nationwide that represented Japanese primary care and orthopaedic settings. In addition to the reference values of the JOABPEQ in healthy volunteers in previous report, the reference scores of the JOABPEQ in patients with LBP can be useful for physicians to evaluate the status of individual patients at baseline, monitor patients and evaluate therapeutic efficacy at any time point.
4. Discussion Here, for the first time, we describe reference scores and interquartile ranges of the JOABPEQ in a Japanese population with low back pain, based on the data obtained from a multicenter,
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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Fig. 5. a, b: Distribution of scores for “Social life disturbance” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
Fig. 6. a, b: Distribution of scores for “Psychological disorder” stratified by age and sex. The median scores and interquartile ranges are marked by parallel lines inside the box. The highest and lowest point within 1.5 interquartile range from the box are indicated as whiskers.
JOABPEQ consists of five domains: Pain-related disorder, Lumbar spine dysfunction, Gait disturbance, Social life disturbance, and Psychological disorder. Age- and sex-related difference in the scores have been noted [5,8]. In this study, we investigated the age and sex difference in each JOABPEQ domain and revealed that there are variations in reference scores and interquartile ranges for the five domains stratified by age and sex. Interestingly, the median score and interquartile range are the same in the domain of Pain-related disorder in all ages and sexes. The reference scores for Gait disturbance, Social life disturbance and Psychological disorder declined with increasing age in both age- and sex-stratified groups, while there was some different trend in Lumbar spine dysfunction between men and women; The score had a tendency to increase with age in men and decrease with age in women. On the other hand, previous study reported that the scores for Lumbar spine dysfunction, Gait disturbance, and Social life disturbance decreased significantly with increasing age, while the influence of age was small for Pain-related disorder and Psychological disorder in the five domains of the JOABPEQ [5]. These discrepancies are considered to be due to the differences in target populations and participating institutions. The present study targeted patients with LBP regardless of the underlying causes and the data were obtained from Japanese primary care and orthopaedic settings, whereas the previous study included healthy volunteers out of clinical settings.
Another study which included patients with lumbar spinal diseases reported that Pain-related disorder and Gait disturbance scores were significantly different according to age, and that Lumbar spine dysfunction, Social life disturbance, and Psychological disorder scores were independent of age [8]. Some differences between the two studies might be due to differences in the categorization of age and sex or the severity of the underlying condition of the patients; the present study included patients with LBP in primary care settings, whereas the previous study included patients with lumbar spinal disease who visit specialist: spine surgeons. This study has a number of strengths: it is the first multi-center, nationwide study to investigate the reference scores and interquartile ranges for JOABPEQ in patients with LBP, and enrolled more than ten thousand participants. Participants with LBP were enrolled regardless of cause. We believe that establishment of the reference values of JOABPEQ in patients with LBP caused by various etiologies in primary care and orthopaedic settings is essential for evaluating dysfunctions, disabilities, and psychosocial problems at presentation as a first step. This study also has several limitations. First, the data were not acquired by random sampling from a population-based record, and therefore the reference data acquired in this study did not completely represent population-based values. Although LBP is one
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010
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of the most common complaints that lead to a medical examination, it is almost impossible to adopt random sampling in a nationwide setting. Consecutive sampling is the best available method to survey the reference values for this scale. Second, we did not evaluate JOABPEQ scores according to underlying disease, such as intervertebral disc herniation, lumbar spinal stenosis, spondylosis, and non-specific low back pain. It has been reported that each domain has significant differences in scores by causation [8]. Patients in this survey were included with or without leg symptoms that might affect the scores of Gait disturbance or Social life disturbance, results of this study, therefore, have to be taken with caution when using this reference scores. It will be necessary to investigate the reference values and ranges for each disease that causes LBP in future studies. Third, it should be considered that a selection bias occurred when the patients were included regardless of the duration of LBP. As the proportion of patients with chronic/acute LBP might affect values of JOABPEQ, these results should be interpreted with caution. 5. Conclusion Reference scores and interquartile ranges for JOABPEQ were established for patients with LBP in this study. Not unexpectedly, JOABPEQ scores may change by domain, sex, and age. The reference scores and interquartile ranges of symptomatic population shown in this study provide a reference standard for evaluating patients presenting with LBP at baseline or another single time point. Conflicts of interest The authors declare that they have no conflict. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jos.2018.03.010. Appendix The Lumbar Spinal Stenosis Diagnosis Support Tool (DISTO) project group consists of the following members: Chairman: Shin-ichi Kikuchi (Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine). Research members: Shin-ichi Kikuchi, Shin-ichi Konno, Miho Sekiguchi (Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine), Kazuhisa Takahashi, Seiji Ohtori (Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University), Tatsuyuki Kakuma, Koji Yonemoto (Bio-statistics Center, Kurume University), Kazuo Yonenobu (Department of Orthopaedic Surgery, Osaka Minami Medical Center), Keisuke Takahashi, Hideki Iizuka (Department of Orthopaedic Surgery, Saitama Medical University, Faculty of Medicine), Toshihiko Taguchi, Tsukasa Kanchiku (Department of Orthopaedic Surgery Yamaguchi University Faculty of Medicine and Health Sciences), Katsushi Takeshita, Nobuhiro Hara (Department of Orthopaedic Surgery, The University of Tokyo Faculty of Medicine), Toshikazu Tani, Ryuichi
Takemasa (Department of Orthopaedic Surgery, Kochi Medical School), Kazuhiro Chiba (Department of Orthopaedic Surgery, Kitasato University Kitasato Institute Hospital), Naofumi Hozogane (Department of Orthopaedic Surgery, Keio University School of Medicine), Kensei Nagata, Kimiaki Sato (Department of Orthopaedic Surgery, 308 Kurume University School of Medicine), Yutaka Nohara, 309 Hiroshi Taneichi (Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine), Yuichi Hoshino, Atsushi Seichi (Department of Orthopaedic Surgery, Jichi Medical University), Toshihiko Yamashita, Tsuneo Takebayashi (Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine), Munehito Yoshida, Hiroshi Yamada (Department of Orthopaedic Surgery, Wakayama Medical University). References [1] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Wada E, Yonenobu K, Tanaka T, Hirota Y. JOA back pain evaluation questionnaire: initial report. J Orthop Sci 2007 Sep;12(5):443e50. [2] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Wada E, Yonenobu K, Tanaka T, Hirota Y. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 3. Validity study and establishment of the measurement scale : Subcommittee on low back pain and Cervical Myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association. Jpn J Orthop Sci 2008 May;13(3):173e9. [3] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Yonenobu K, Wada E, Tanaka T, Hirota Y. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability : the Subcommittee on low back pain and Cervical Myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association. J Orthop Sci 2007 Nov;12(6):526e32. [4] Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K, Takeshita K, Tani T, Toyama Y, Yonenobu K, Wada E, Tanaka T, Hirota Y. JOA back pain evaluation questionnaire (JOABPEQ)/JOA Cervical Myelopathy evaluation questionnaire (JOACMEQ). The report on the development of revised versions. April 16, 2007. The Subcommittee of the clinical outcome committee of the Japanese orthopaedic association on low back pain and Cervical Myelopathy evaluation. J Orthop Sci 2009 May;14(3):348e65. [5] Hashizume H, Konno S, Takeshita K, Fukui M, Takahashi K, Chiba K, Miyamoto M, Matsumoto M, Kasai Y, Kanamori M, Matsunaga S, Hosono N, Kanchiku T, Taneichi H, Tanaka N, Kanayama M, Shimizu T, Kawakami M. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) as an outcome measure for patients with low back pain: reference values in healthy volunteers. J Orthop Sci 2015 Mar;20(2):264e80. [6] Ohtori S, Sekiguchi M, Yonemoto K, Kakuma T, Takahashi K, Konno S. Awareness and use of diagnostic support tools for lumbar spinal stenosis in Japan. J Orthop Sci 2014 May;19(3):412e7. [7] Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ. Chapter 2. European guidelines for prevention in low back pain. Eur Spine J 2006 Mar;15(Suppl. 2):S136e68. [8] Ohtori S, Ito T, Yamashita M, Murata Y, Morinaga T, Hirayama J, Kinoshita T, Ataka H, Koshi T, Sekikawa T, Miyagi M, Tanno T, Suzuki M, Aoki Y, Aihara T, Nakamura S, Yamaguchi K, Tauchi T, Hatakeyama K, Takata K, Sameda H, Ozawa T, Hanaoka E, Suzuki H, Akazawa T, Suseki K, Arai H, Kurokawa M, Eguchi Y, Suzuki M, Okamoto Y, Miyagi J, Yamagata M, Toyone T, Takahashi K. Chiba Low Back Pain Research G. Evaluation of low back pain using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire for lumbar spinal disease in a multicenter study: differences in scores based on age, sex, and type of disease. J Orthop Sci 2010 Jan;15(1):86e91. [9] Kasai Y, Fukui M, Takahashi K, Ohtori S, Takeuchi D, Hashizume H, Kanamori M, Hosono N, Kanchiku T, Wada E, Sekiguchi M, Konno S, Kawakami M. Verification of the sensitivity of functional scores for treatment results e Substantial clinical benefit thresholds for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). J Orthop Sci 2017 Jul;22(4):665e9.
Please cite this article in press as: Tominaga R, et al., Establishment of reference scores and interquartile ranges for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with low back pain, Journal of Orthopaedic Science (2018), https:// doi.org/10.1016/j.jos.2018.03.010