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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

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Volume 19, Issue 4


Chronic low back pain is highly individualised: patterns of classification across three unidimensional subgrouping analyses

Martin RabeyORCID iD: https://orcid.org/0000-0003-3814-909X / Anne Smith / Peter Kent / Darren Beales / Helen Slater / Peter O’Sullivan
Published Online: 2019-06-29 | DOI: https://doi.org/10.1515/sjpain-2019-0073


Background and aims

Chronic low back pain (CLBP) is a complex disorder where central and peripheral nociceptive processes are influenced by factors from multiple dimensions associated with CLBP (e.g. movement, pain sensitivity, psychological). To date, outcomes for treatments matched to unidimensional subgroups (e.g. psychologically-based) have been poor. Therefore, unidimensional subgrouping may not reflect the complexity of CLBP presentations at an individual level. The aim of this study was therefore to explore patterns of classification at an individual level across the three previously-published, data-driven, within-dimension subgrouping studies.


Cross-sectional, multidimensional data was collected in 294 people with CLBP. Statistical derivation of subgroups within each of three clinically-important dimensions (pain sensitivity, psychological profile, pain responses following repeated spinal bending) was briefly reviewed. Patterns of classification membership were subsequently tabulated across the three dimensions.


Of 27 possible patterns across these dimensions, 26 were represented across the cohort.


This result highlights that while unidimensional subgrouping has been thought useful to guide treatment, it is unlikely to capture the full complexity of CLBP. The amount of complexity important for best patient outcomes is currently untested.


For clinicians this study highlights the high variability of presentations of people with CLBP at the level of the individual. For example, clinician’s should not assume that those with high levels of pain sensitivity will also have high psychological distress and have pain summation following repeated spinal bending. A more flexible, multidimensional, clinically-reasoned approach to profile patient complexity may be required to inform individualised, patient-centred care. Such individualised care might improve treatment efficacy. This study also has implications for researchers; highlighting the inadequacy of unidimensional subgrouping processes and methodological difficulties in deriving subgroups across multidimensional data.

Keywords: low back pain; subgrouping; biopsychosocial; pain sensitivity; movement


  • [1]

    Artus M, van der Windt D, Jordan K, Hay E. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology 2010;49:2346–56.PubMedCrossrefGoogle Scholar

  • [2]

    Saragiotto B, Maher C, Hancock M, Koes B. Subgrouping patients with nonspecific low back pain: hope or hype? J Orthop Sports Phys Ther 2017;47:44–8.CrossrefPubMedGoogle Scholar

  • [3]

    Costa L, Koes B, Pransky G, Borkan J, Maher C, Smeets R. Primary care research priorities in low back pain. An update. Spine 2013;38:148–56.CrossrefPubMedGoogle Scholar

  • [4]

    Rabey M, Slater H, O’Sullivan P, Beales D, Smith A. Somatosensory nociceptive characteristics differentiate subgroups in people with chronic low back pain: a cluster analysis. Pain 2015;156:1874–84.PubMedCrossrefGoogle Scholar

  • [5]

    Rabey M, Smith A, Beales D, Slater H, O’Sullivan P. Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles. Clin J Pain 2016;32:1015–27.CrossrefPubMedGoogle Scholar

  • [6]

    Rabey M, Smith A, Beales D, Slater H, O’Sullivan P. Pain provocation following sagittal plane repeated movements in people with chronic low back pain: associations with pain sensitivity and psychological profiles. Scand J Pain 2017;16:22–8.PubMedCrossrefGoogle Scholar

  • [7]

    Kent P, Keating J, Leboeuf-Yde C. Research methods for subgrouping low back pain. BMC Med Res Methodol 2010;10:62.PubMedCrossrefGoogle Scholar

  • [8]

    Hush J, Stanton T, Siddall P, Marcuzzi A, Attal N. Untangling nociceptive, neuropathic and neuroplastic mechanisms underlying the biological domain of back pain. Pain Manag 2013;3:223–36.PubMedCrossrefGoogle Scholar

  • [9]

    Simons L, Elman I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev 2014;39:61–78.CrossrefPubMedGoogle Scholar

  • [10]

    Apeldoorn A, Ostelo R, van Helvoirt H, Fritz J, Knol D, van Tulder M, De Vet H. A randomized controlled trial on the effectiveness of a classification-based system for sub-acute and chronic low back pain. Spine 2012;37:1347–56.CrossrefGoogle Scholar

  • [11]

    Bergbom S, Flink I, Boersma K, Linton S. Early psychologically informed interventions for workers at risk for pain-related disability: does matching treatment to profile improve outcome? J Occup Rehabil 2014;24:446–57.CrossrefPubMedGoogle Scholar

  • [12]

    Henry S, Van Dillen L, Ouellette-Morton R, Hitt J, Lomond K, DeSarno M, Bunn J. Outcomes are not different for patient-matched versus nonmatched treatment in subjects with chronic recurrent low back pain: a randomized clinical trial. Spine J 2014;14:2799–810.CrossrefPubMedGoogle Scholar

  • [13]

    Kamper S, Maher C, Hancock M, Koes B, Croft P, Hay E. Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Pract Res Clin Rheumatol 2010;24:181–91.CrossrefGoogle Scholar

  • [14]

    Backonja M, Attal N, Baron R, Bouhassira D, Drangholt M, Dyck P, Edwards R, Freeman R, Gracely R, Haanpaa M, Hansson P, Hatem S, Krumova E, Jensen T, Maier C, Mick G, Rice A, Rolke R, Treede R, Serra J, et al. Value of quantitative sensory testing in neurological and pain disorders: NeuPSIG consensus. Pain 2013;154:1807–19.PubMedCrossrefGoogle Scholar

  • [15]

    Baron R, Förster M, Binder A. Subgrouping of patients with neuropathic pain according to pain-related sensory abnormalities: a first step to a stratified treatment approach. Lancet Neurol 2010;11:999–1005.Google Scholar

  • [16]

    Rolke R, Baron R, Maier C, Tölle T, Treede R, Beyer A, Binder A, Birbaumer N, Birklein F, Bötefür I, Braune S, Flor H, Huge V, Klug R, Landwehrmeyer G, Magerl W, Maihöfner C, Rolko C, Schaub C, Scherens A, et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain 2006;123:231–43.PubMedCrossrefGoogle Scholar

  • [17]

    Scholz J, Mannion R, Hord D, Griffin R, Rawal B, Zheng H, Scoffings D, Phillips A, Guo J, Laing R, Abdi S, Decosterd I, Woolf C. A novel tool for the assessment of pain: validation in low back pain. PLoS Med 2009;6:e1000047.PubMedCrossrefGoogle Scholar

  • [18]

    Rabey M, Poon C, Wray J, Thamajaree C, East R, Slater H. Pro-nociceptive and anti-nociceptive effects of a conditioned pain modulation protocol in participants with chronic low back pain and healthy control subjects. Man Ther 2015;20:763–8.PubMedCrossrefGoogle Scholar

  • [19]

    Hayden J, Dunn K, Van Der Windt D, Shaw W. What is the prognosis of back pain? Best Pract Res Clin Rheumatol 2010;24:167–79.CrossrefPubMedGoogle Scholar

  • [20]

    Lovibond S, Lovibond P. Manual for the depression anxiety stress scales. Sydney: School of Psychology, University of New South Wales, 1995.Google Scholar

  • [21]

    Hasenbring M, Hallner D, Rusu A. Fear-avoidance- and endurance-related responses to pain: development and validation of the avoidance-endurance questionnaire (AEQ). Eur J Pain 2009;13:620–8.CrossrefPubMedGoogle Scholar

  • [22]

    Fish R, McGuire B, Hogan M, Morrison T, Stewart I. Validation of the chronic pain acceptance questionnaire (CPAQ) in an internet sample and development and preliminary validation of the CPAQ-8. Pain 2010;149:435–43.CrossrefGoogle Scholar

  • [23]

    Sullivan M, Bishop S, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:524–32.CrossrefGoogle Scholar

  • [24]

    Nicholas M. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2007;11:153–63.CrossrefPubMedGoogle Scholar

  • [25]

    Waddell G, Newton M, Henderson I, Somerville D, Main C. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157–68.CrossrefPubMedGoogle Scholar

  • [26]

    Sullivan M, Thibault P, Andrikonyte J, Butler H, Catchlove R, Larivière C. Psychological influences on repetition-induced summation of activity-related pain in patients with chronic low back pain. Pain 2009;141:70–8.PubMedCrossrefGoogle Scholar

  • [27]

    Salaffi F, Stancati A, Silvestri C, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 2004;8:283–91.CrossrefPubMedGoogle Scholar

  • [28]

    Nielsen A, Vach W, Kent P, Hestbaek L, Kongsted A. Using existing questionnaires in latent class analysis: should we use summary scores or single items as input? A methodological study using a cohort of patients with low back pain. Clin Epidemiol 2016;8:73–89.PubMedGoogle Scholar

  • [29]

    Nielsen A, Kent P, Hestbaek L, Vach W, Kongsted A. Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain. BMC Musculoskelet Disord 2017;18:57.CrossrefGoogle Scholar

  • [30]

    Nylund K, Asparouhov A, Muthén B. Deciding on the number of classes in latent class analysis and growth mixture modeling: a monte carlo simulation study. Struct Equ Model 2007;14:535–69.CrossrefGoogle Scholar

  • [31]

    Swanson S, Lindenberg K, Bauer S, Crosby R. A Monte Carlo investigation of factors influencing latent class analysis: an application to eating disorder research. Int J Eat Disord 2012;45:677–84.PubMedCrossrefGoogle Scholar

  • [32]

    Vlaeyen J, de Jong J, Geilen M, Heuts P, van Breukelen G. Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behav Res Ther 2001;39:151–66.CrossrefGoogle Scholar

  • [33]

    Wang W, Krishnan E. Big data and clinicians: a review on the state of the science. JMIR Med Inform 2014;2:e1.CrossrefPubMedGoogle Scholar

  • [34]

    O’Sullivan P, Caneiro J, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther 2018;98:408–23.CrossrefPubMedGoogle Scholar

  • [35]

    Vibe Fersum K, O’Sullivan P, Skouen J, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain 2013;17:916–28.CrossrefPubMedGoogle Scholar

  • [36]

    Moberg E. Two point discrimination test. A valuable part of hand surgical rehabilitation. Scand J Rehabil Med 1990;22:127–34.Google Scholar

  • [37]

    Dworkin R, Turk D, Farrar J, Haythornthwaite J, Jensen M, Katz N, Kerns R, Stucki G, Allen R, Bellamy N, Carr D, Chandler J, Cowan P, Dionne R, Galer B, Hertz S, Jadad A, Kramer L, Manning D, Martin S, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19.PubMedCrossrefGoogle Scholar

  • [38]

    Roland M, Morris R. Study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8:141–4.CrossrefPubMedGoogle Scholar

  • [39]

    Wai E, Howse K, Pollock W, Dornan H, Vexler L, Dagenais S. The reliability of determining “leg dominant pain”. Spine J 2009;9:447–53.PubMedCrossrefGoogle Scholar

  • [40]

    Dunn K, Croft P. Classification of low back pain in primary care: using “bothersomeness” to identify the most severe cases. Spine 2005;30:1887–92.PubMedCrossrefGoogle Scholar

  • [41]

    Linton S, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Örebro Musculoskeletal Pain Questionnaire. Clin J Pain 2003;19:80–6.PubMedCrossrefGoogle Scholar

  • [42]

    Brown K, Ryan R. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol 2003;84:822–48.PubMedCrossrefGoogle Scholar

  • [43]

    Wand B, Catley M, Rabey M, O’Sullivan P, O’Connell N, Smith A. Disrupted self-perception in people with chronic low back pain. Further evaluation of the Fremantle Back Awareness Questionnaire. J Pain 2016;17:1001–12.PubMedCrossrefGoogle Scholar

  • [44]

    McCracken L. Social context and acceptance of chronic pain: the role of solicitous and punishing responses. Pain 2005;113:155–9.PubMedCrossrefGoogle Scholar

  • [45]

    Littman A, White E, Satia J, Bowen D, Kristal A. Reliability and validity of 2 single-item measures of psychosocial stress. Epidemiology 2006;17:398–403.PubMedCrossrefGoogle Scholar

  • [46]

    Keefe F, Block A. Development of an observation method for assessing pain behavior in chronic low back pain patients. Behav Ther 1982;13:363–75.CrossrefGoogle Scholar

  • [47]

    Van Weel C, König-Zahn C, Touw-Otten F, Van Duijn N, Meyboom-De Jong B. Measuring functional status with the COOP/WONCA charts: a manual, 2nd ed. UMCG/University of Groningen, Research Institute SHARE, 2012.Google Scholar

  • [48]

    Rabey M, Smith A, Beales D, Slater H, O’Sullivan P. Multidimensional prognostic modelling in people with chronic axial low back pain. Clin J Pain 2017;33:877–91.CrossrefPubMedGoogle Scholar

  • [49]

    Öhlund C, Eek C, Palmblad S, Areskoug B, Nachemson A. Quantified pain drawing in subacute low back pain: validation in a nonselected outpatient industrial sample. Spine 1996;21:1021–30.CrossrefGoogle Scholar

  • [50]

    Macfarlane G, Croft P, Schollum J, Silman A. Widespread pain: is an improved classification possible? J Rheumatology 1996;23:1628–32.Google Scholar

  • [51]

    Buysse D, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213.CrossrefPubMedGoogle Scholar

  • [52]

    IPAQ Group. Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ) – Short and Long Forms [Online]. Available at: https://sites.google.com/site/theipaq/scoring-protocol. Accessed: 4 Apr 2013.

About the article

Corresponding author: Martin Rabey, PT, PhD, School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia, Phone: +447781168108

Received: 2019-05-08

Accepted: 2019-06-12

Published Online: 2019-06-29

Published in Print: 2019-10-25

Authors’ statements

Research funding: MR was supported by: Australian Postgraduate Award, Curtin University Postgraduate Scholarship, Musculoskeletal Association of Chartered Physiotherapists Doctoral Award, Chartered Society of Physiotherapy Charitable Trust. DB was supported by: National Health and Medical Research Council, Australia.

Conflict of interest: Authors state no conflict of interest.

Informed consent: Informed consent has been obtained from all individuals included in this study.

Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and was approved by the Curtin University Human Research Ethics Committee (EC00262), Approval Number: HR112/2012; Royal Perth Hospital Human Research Ethics Committee, Approval Number: EC 2012-148; Sir Charles Gairdner Hospital Human Research Ethics Committee, Approval Number: 2012-197; and Fremantle Hospital Human Research Ethics Committee, Approval Number: AR/13/1.

Declarations of interest: None.

Citation Information: Scandinavian Journal of Pain, Volume 19, Issue 4, Pages 743–753, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2019-0073.

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©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved..Get Permission

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