Most cases of low-back pain resolve in four weeks, but up to 77% recur without treatment.
Three of four patients presenting to primary care with low-back pain are already in a recurring pain pattern.
If recovery is considered the cessation of serious back pain for a year, less than half of patients recover spontaneously.
In a review published recently by The Lancet, Dr. Chris Maher and colleagues state, “The simple portrayal of the course of low back pain needs reconsideration.”1 Dr. Maher refers to the view that most cases of acute, non-specific low back pain recover completely within four to six weeks. He qualifies this view as commonly held. Is this view oversimplified or a bad management guideline?
For older adults, data from a very large study suggests a new perspective.2 Researchers followed 5,239 adults, age 65+, after their first primary care visit for low back pain (LBP). At three months, only 42% (a minority) experienced a 30% or greater improvement in pain. At one year, 65% still experienced disability within 30% of baseline. Seventy-seven percent reported that their back pain had not resolved at 12 months.
For the general population, Dr. Maher and colleagues recommend a treatment protocol that differentiates acute LBP from persistent LBP (> two weeks). Among patients presenting to primary care with persistent low back pain, only 42% report recovery at 12 months.3 For patients with persistent low back pain, Dr. Maher and colleagues recommend immediate referral for treatments such as exercise therapy and manual therapy.
Research suggests a better prognosis for younger patients presenting with acute LBP, but only by using a narrow definition of recovery.4 When defining recovery as a singular report of no pain or disability, 72% of adults with acute LBP and presenting to primary care report recovery within 12 months. That still leaves an important percentage of patients without recovery. That definition of recovery excludes recurrence within 12 months. Among patients who report recovery from acute LBP after their primary care visit, one third experience recurrence.5 If one were to define recovery as a cessation of significant pain or disability and no recurrence within 12 months, only 48% of patients presenting with acute LBP would be considered recovered. Dr. Maher and colleagues state that these recovery patterns provide caution against overestimating the likelihood of spontaneous recovery.
Dr. Maher and colleagues suggest that some patients presenting with acute LBP should receive treatment beyond advice and analgesics on day one, and others should be given two weeks to allow for spontaneous recovery. They recommend using risk prediction methods such as the 10-item Orebro Musculoskeletal Pain Screening Questionnaire6 to determine which patients will have earlier access to treatment.
It is noteworthy that 76% of patients presenting to primary care with acute LBP report having a previous episode of LBP.7 Most LBP cases labeled as acute are from patients already in a recurring pain pattern. This would suggest that the majority of acute LBP patients would qualify for non-pharmacological treatments such as exercise therapy and manual therapies on day one. If we hypothesize that all patients age 65+ receive physical therapy referrals on day one and all patients with LBP lasting greater than two weeks get a physical therapy referral on day one, we define a situation where most patients presenting to primary care with non-specific LBP receive treatment. Using the most modern evidence in LBP prognosis, only the most healthy patients presenting with non-specific LBP (a minority of patients) would be eligible for wait-and-see.
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- Maher C, Underwood M, Buchbinder R. Non-specific low back pain. The Lancet. 2016; 389 (10070): 736-747.
- Rundell S, Sherman K, Heagerty P, et al. The clinical course of pain and function in older adults with a new primary care visit for back pain. J Am Geriatr Soc. 2015; 63 (3): 524-30.
- Costa Lda C, Maher C, McAuley J, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009; 339: b3829.
- Henschke N, Maher C, Refshauge K, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008; 337: a171.
- Stanton T, Henschke N, Maher C, et al. After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine. 2008: 33: 2923-28.
- Linton S, Nicholas M, MacDonald S. Development of a short form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine. 2011; 36: 1891-95.
- Henschke N, Maher C, Refshauge K, et al. Characteristics of patients with acute low back pain presenting to primary care in Australia. Clin J Pain. 2009; 25: 5-11.
- de Almeida AM, Demange MK, Sobrado MF, Rodrigues MB, Pedrinelli A, Hernandez AJ. Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial. The American Journal of Sports Medicine. 2012 Jun; 40 (6): 1282-8.