Is It Time to Rethink the Typical Course of Low Back Pain?

Physical Medicine and Rehabilitation (PM&R) Volume 4, Issue 6, June 2012, Pages 394 – 401 Ronald Donelson MD, Greg McIntosh MS; Hamilton Hall MD The purpose of this study was to determine the frequency and the characteristics of low back pain (LBP) recurrences by asking these questions: 1) Are low back pain (LBP) recurrences common? 2) Do episodes worsen with multiple recurrences? 3) Does pain change location in any recognizable pattern during an episode? The questionnaire was given to 589 LBP patients from 30 clinical practices(primary care [7%], physical therapy [67%], chiropractic [19%], and surgical spine[7%]) in North America and Europe. There were no exclusions based on type of LBP,history of onset, or comorbidities. Results: 1) Are low back pain (LBP) recurrences common?: [rounded] 73% had suffered a previous episode of LBP 54% had experienced ≥10 episodes of prior LBP in their lifetime 20% had experienced >50 episodes of prior LBP in their lifetime 27% with a previous episode of LBP had 5 or more episodes of LBP per year 2) Do LBP episodes worsen with multiple recurrences? [rounded] 61% reported that at least one of the survey domains was worse 37% reported that recent LBP episode was not worse 21% were worse in all domains 9% were better or the same in all domains 3) Does LBP pain change location in any recognizable pattern during anepisode? [rounded] 76% yes 63% reported that their pain first spread distally then retreated proximallyduring recovery; there was a strong trend toward those reportingworsening episodes also reporting proximal-to-distal-to-proximalchanges in pain location during their episodes. KEY POINTS FROM THIS ARTICLE: 1) Recurrent LBP episodes were common and numerous. Recurrences oftenworsened over time. It seems inappropriate to characterize the typical course of LBPas benign and favorable. [KEY POINT] 2) Sadly, LBP clinical guidelines are unequivocal in their position that the naturalhistory is highly favorable. 3) It is often stated that LBP is normal; has an excellent prognosis, with 90% ofindividuals recovering within 3 months of onset in most cases; and is not debilitatingover the long term. One guideline states that recovery usually takes place within aslittle as 6 weeks. 4) Acute LBP is perceived as largely self-limiting and requiring little if any formaltreatment. This benign view justifies what has become the standard clinical guidelinerecommendation that clinicians often need do nothing more than simply reassurepatients that they will likely recover. 5) Few clinicians [or insurance companies and their representatives]realize that this positive recovery prognosis was derived from a 1966 UK study thatnever collected data on the natural history of LBP; and that when patients with LBPdid not return for follow-up, the researchers assumed that the patients hadrecovered. 6) It is known that the failure of a patient with acute LBP to return to the samedoctor does not necessarily indicate recovery. A patient’s disappearance from thepractice is a poor proxy for recovery. When persistent LBP does not respond to adoctor’s care, the patient tends to drop out of care. 7) These authors cite a handful of studies that showed these numbers: * 69% of patients with recent LBP were still experiencing LBP pain 1 year later. * 82% of patients with non-recent onset of back pain were still experiencingLBP pain 1 year later. * 20-25% of recent LBP patients were still reporting substantial activity limitations1 year later. * Only 21% of LBP patients reported complete recovery at 3 months.[Key Point: note 33%, not 90% as often stated] * 90% of LBP patients had stopped consulting with their doctor within 3 months,further discrediting the termination of care seeking from a single source as asurrogate for recovery; yet 75% had not returned to their pre-episodelevel of function or achieved symptom-free status a year later. * LBP and disability often persist beyond the often-quoted 6-week mark. 8) A review of 36 articles about the long-term course of LBP concluded that theoverall picture is clearly that LBP is not a self-limiting condition. 9) There is no evidence supporting the claim that 80%-90% of patients with LBPbecome pain free within 1 month. 10) Recurrences of back pain are widely recognized as common, reported asoccurring in 60%-73% of individuals within 1 year after recovery from an acuteepisode. 11) In any one year, recurrences, exacerbations, and persistence dominate theexperience of low back pain in the community. This clinical picture is very differentfrom what is typically portrayed as the natural history of LBP in most clinicalguidelines. 12) Considerable clinical experience, contemporary research, and published dataindicate that recurrences of LBP often worsen over time. 13) Most persistent disabling back pain is preceded by episodes that, although theymay resolve completely, may also increase in severity and duration over time. 14) 84% of total medical costs for patients with LBP are related to a recurrence. 15) Many persons with back pain that extends into the buttock or leg report thattheir episode begins with only axial LBP that subsequently spreads distally. 16) Many patients report that, before complete pain abolition, their buttock or legpain retreats or returns to their low back and centralizes, which may represent animportant element of the natural history of LBP in a substantial subset of individuals. 17) In this study, 83% had back and/or buttock pain, 17% had leg pain only. 18) The conventional view of the natural history of acute LBP is that it is self-limitingand that 90% of patients experiencing LBP recover within 90 days or less, butthere is no evidence to suggest that either of these statements is accurate. In reality,the recovery rates reported in population studies and in our survey data are far lessoptimistic. 19) Consistent with many other published studies, the recurrence rate among ourrespondents with LBP was 73%. 20) Many respondents had numerous recurrences, with 27% reporting 5 or moreepisodes per year and [20%] having had more than 50 episodes in their lifetime." 21) Patients whose recurrences are worsening, their underlying condition may bedeteriorating over multiple recurrences. [Important] 22) Recurrent episodes of LBP should not be routinely viewed as independentevents. It appears, as a rule, that LBP recurrences grow progressively worse. 23) Many patients with chronic LBP had prior recurrent episodes that had becomelonger and more severe until the most recent episode did not resolve and thusbecame chronic. [Important] 24) Most disabling back pain episodes increase in severity and duration over time. 25) Could the underlying pain generator(s) responsible for episodic acute LBPprogressively deteriorate over multiple recurrences, finally reaching the point wherereversal is impossible and the pain becomes chronic? If so, then any pain-free periodbetween acute episodes would indicate that the underlying problem is still capable ofrecovery and would accentuate the need for effective preventive measures.Alternatively, worsening recurrent pain would suggest that the repeated insults on theunderlying pain generator carry an increasing risk of non-recovery. 26) When considering the multitude of studies, including our own, that indicate thatmany patients experience LBP episodes that worsen over time, guideline panelsshould begin to incorporate these data and acknowledge the impact of recurrence onthe true natural history of LBP. 27) These authors cite evidence that implicates the intervertebral disk as theprimary low back pain generator. [Important] 28) We hypothesize that the specific pattern of change in pain location within eachepisode reflects pain arising from a particular physical structure that is usually able torecover but that also progressively deteriorates over many episodes to the point thatit can no longer recover. [like the disc] 29) Collectively, our findings, and those of other studies, indicate that it may beinaccurate to characterize LBP as having an excellent prognosis. Recurrences arefrequent and are often progressively worse over time. Recovery from acute LBP is notas favorable as is routinely portrayed. 30) Eventually, there may be no recovery, and the underlying condition maybecome chronically painful. In light of these characteristics, it seems inappropriate tocharacterize the natural history of LBP as benign and favorable.These authors specifically bad-mouth two practice guidelines as beingincorrect and overly optimistic in their view of the natural history of LBP: *Practice guidelines low back disorders K. Hegmann, J. Talmage (Eds.), OccupationalMedicine Practice Guidelines (Revised ed.), American College of Occupational andEnvironmental Medicine, Elk Grove Village, IL (2007), p. 368. *M. van Tulder, A. Becker, T. Bekkering et al.; European guidelines for themanagement of acute non-specific low back pain in primary care; 2004. COMMENTS FROM DAN MURPHY: These authors suggest that the generators of LBP (primarily the intervertebral disc)deteriorate with successive recurrences of LBP until the patient suffers from constantchronic LBP. Consequently, they stress the importance to accentuate the need foreffective preventive measures. Remember the Cifuentes study (Journal of Occupational and Environmental Medicine, 2011) clearly showed that LBPpatients who remained under chiropractic maintenance care after an episode of acuteLBP incurred significantly fewer (and significantly delayed) episodes of LBPrecurrences (Article Review #16-12). Also recall that David Taylor presented anexcellent academic and case review article suggesting that the frequency of suchchiropractic maintenance care should be once every 2 to 4 weeks (Article Review#23-23). Practice guidelines, insurance companies and their representatives that indicate thenatural history of acute LBP is 6-12 weeks with good clinical outcomes are bogus andshould be challenged as being bogus. This study is excellent for that purpose. A number of years ago I investigated the 90% recovery rate for acute LBP andauthored an article on the topic; it is also an excellent review. I have been asked forthousands of reprints of that article. If anyone wants a copy, email my professional assistant, Michelle Schaer, DC, at [email protected] and ask for the 90% article.