Prognosis of Low Back Pain: Difference between revisions
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== Prognostic Risk Factors == | == Prognostic Risk Factors == | ||
Prognostic risk factors are broadly categorised into biological and psychosocial. An important limitation of epidemiological studies assessing this area is that only factors asked about in a questionnaire can be considered. For example, if a study only uses assessment methods looking at psychosocial factors, they won't find any biological factors. Factors that appear significant when amongst a small list of possibilities may not be significant if it is diluted in a longer list of possibilities. The most reliable studies are those that consider an initial large number of possible factors and then undertake multiple regression analyses to eliminate spurious factors.<ref>Bogduk et al. Management of Acute and Chronic Low Back Pain. Chapter 5. Elsevier. 2002</ref> | Prognostic risk factors are broadly categorised into biological and psychosocial. An important limitation of epidemiological studies assessing this area is that only factors asked about in a questionnaire can be considered. For example, if a study only uses assessment methods looking at psychosocial factors, they won't find any biological factors. Factors that appear significant when amongst a small list of possibilities may not be significant if it is diluted in a longer list of possibilities. The most reliable studies are those that consider an initial large number of possible factors and then undertake multiple regression analyses to eliminate spurious factors.<ref name=":2">Bogduk et al. Management of Acute and Chronic Low Back Pain. Chapter 5. Elsevier. 2002</ref> | ||
Therefore, predictors of recurrence are often variable across studies | Following the above analysis, investigators should determine how much of the variation between patients is accounted for by the significant factor. Unfortunately this is not typically done in back pain research. Very often the researchers will take a factor found to be significant, ignoring that is may only account for a small proportion of the variance amongst patients, and incorrectly conclude that it is important. In other words, many of the reported risk factors only account for a small proportion of patients.<ref name=":2" /> | ||
Therefore, predictors of recurrence are often variable across studies. The psychosocial category are the strongest and potentially remediable factors. The risk factors generally include | |||
{| class="wikitable" | |||
|+Prognostic Risk Factors for Chronicity<ref name=":0" /><ref name=":2" /> | |||
! | |||
!Biological | |||
!Psychosocial | |||
|- | |||
|'''Immutable''' | |||
|<u>Duration of back pain</u> | |||
<u>Past history of back pain</u> | |||
Frequency of attacks | |||
Playing adult sport | |||
Female sex | |||
Previous episodes | |||
|Marital status | |||
Family status | |||
|- | |||
|'''Relatively immutable''' | |||
|<u>Leg pain</u> | |||
Severity | |||
Job demands | |||
Obesity | |||
|<u>Job dissatisfaction</u> | |||
<u>Education</u> | |||
<u>MMPI</u> | |||
Compensation | |||
Employment | |||
Wage | |||
Heavy lifting at work | |||
Awkward positions at work | |||
Somatisation | |||
Educational level | |||
|- | |||
|'''Potentially remediable''' | |||
|<u>Work Capacity</u> | |||
<u>Disability</u> | |||
Smoking | |||
BMI | |||
Inability to sit-up | |||
Physical activity | |||
|<u>Sickness Impact</u> | |||
<u>Depressing</u> | |||
<u>Poor coping skills</u> | |||
<u>Catastrophising</u> | |||
<u>Distress</u> | |||
<u>Rating of loads</u> | |||
<u>Fear-avoidance</u> | |||
Inappropriate signs | |||
Lack of understanding | |||
|- | |||
| colspan="3" |Strongest risk factors are underlined. Note clustering of important remediable risk factors in psychosocial category. | |||
|} | |||
The predictors may be similar across age groups. In older adults they include female gender, race, worse baseline clinical characteristics of back pain, leg pain, back-related disability and duration of symptoms, smoking, anxiety symptoms, depressive symptoms, a history of falls, greater number of comorbidities, knee osteoarthritis, wide-spread pain syndromes, and an index diagnosis of lumbar spinal stenosis.<ref>Rundell SD, et al. Predictors of Persistent Disability and Back Pain in Older Adults with a New Episode of Care for Back Pain. Pain Med. 2017 Jun 1;18(6):1049-1062. doi: 10.1093/pm/pnw236. PMID: 27688311.</ref> | The predictors may be similar across age groups. In older adults they include female gender, race, worse baseline clinical characteristics of back pain, leg pain, back-related disability and duration of symptoms, smoking, anxiety symptoms, depressive symptoms, a history of falls, greater number of comorbidities, knee osteoarthritis, wide-spread pain syndromes, and an index diagnosis of lumbar spinal stenosis.<ref>Rundell SD, et al. Predictors of Persistent Disability and Back Pain in Older Adults with a New Episode of Care for Back Pain. Pain Med. 2017 Jun 1;18(6):1049-1062. doi: 10.1093/pm/pnw236. PMID: 27688311.</ref> | ||
Revision as of 15:36, 29 August 2021
It is sometimes stated in guidelines that most patients with acute low back pain make an excellent recovery. The evidence is in fact quite conflicting, with markedly different findings across different studies. Overall the treating doctor can relay optimism, but be guarded about prognosis.
A systematic review of 11 studies performed in the US, Australia and Europe on patients with non-specific back pain found that recovery occurred in 33% of patients at 3 months, and by 1 year 65% still had pain. In studies that used total absence of pain as a criterion, 71% still had pain at 12 months. In studies that had a less stringent criteria, 57% still had pain at 12 months.[1]
Recurrences
Importantly, recurrences can occur after recovery. Again the literature has shown different rates for recurrence.
An old Dutch study of 443 people in General Practice found particularly poor rates with a relapse rate of 76% at 12 months, with a median number of two relapses (interquartile range 1-3), with a median time to relapse of 7 weeks (interquartile range: 5-12), and a median duration of 3 weeks for the first relapse, 2 weeks for the second and third, and 1 week for the fourth.[2]
A newer Australian study found lower rates of recurrence. They looked at 832 patients seen in General Practice with acute low back pain. Of these, 469 recovered (56%) within 6 weeks and were then followed to look for recurrences. The one year incidence of recurrence was 33%, and the one year incidence of recurrence with care seeking was 18%. Having two previous episodes tripled the odds of future recurrences.[3]
Another Australian study of 1334 patients found recurrences of 24% for "12-month recall" and 33% for "pain at follow-up" definitions of recurrence.[4]
Older Adults
A particular note should be made about older adults, where the prognosis tends to be worse. For example, in a US cohort study of 4,665 patients who had a new primary care visit for back pain, only 16% had complete resolution of their back pain and disability by two years. Average pain intensity reduced slightly from 5.0 to 3.7 at 3 months, and then stayed relatively static to 24 months, with around half having a clinically meaningful improvement in disability and pain. Baseline characteristics are more important predictors such as female gender, higher BMI, chronic back pain, higher disability, and negative expectations for recovery.[5]
Similar findings for older adults have been found in the Netherlands, [6] and the BACE study which took place in the Netherlands, Brazil, and Australia.[7][8]
Prognostic Risk Factors
Prognostic risk factors are broadly categorised into biological and psychosocial. An important limitation of epidemiological studies assessing this area is that only factors asked about in a questionnaire can be considered. For example, if a study only uses assessment methods looking at psychosocial factors, they won't find any biological factors. Factors that appear significant when amongst a small list of possibilities may not be significant if it is diluted in a longer list of possibilities. The most reliable studies are those that consider an initial large number of possible factors and then undertake multiple regression analyses to eliminate spurious factors.[9]
Following the above analysis, investigators should determine how much of the variation between patients is accounted for by the significant factor. Unfortunately this is not typically done in back pain research. Very often the researchers will take a factor found to be significant, ignoring that is may only account for a small proportion of the variance amongst patients, and incorrectly conclude that it is important. In other words, many of the reported risk factors only account for a small proportion of patients.[9]
Therefore, predictors of recurrence are often variable across studies. The psychosocial category are the strongest and potentially remediable factors. The risk factors generally include
| Biological | Psychosocial | |
|---|---|---|
| Immutable | Duration of back pain
Past history of back pain Frequency of attacks Playing adult sport Female sex Previous episodes |
Marital status
Family status |
| Relatively immutable | Leg pain
Severity Job demands Obesity |
Job dissatisfaction
Education MMPI Compensation Employment Wage Heavy lifting at work Awkward positions at work Somatisation Educational level |
| Potentially remediable | Work Capacity
Disability Smoking BMI Inability to sit-up Physical activity |
Sickness Impact
Depressing Poor coping skills Catastrophising Distress Rating of loads Fear-avoidance Inappropriate signs Lack of understanding |
| Strongest risk factors are underlined. Note clustering of important remediable risk factors in psychosocial category. | ||
The predictors may be similar across age groups. In older adults they include female gender, race, worse baseline clinical characteristics of back pain, leg pain, back-related disability and duration of symptoms, smoking, anxiety symptoms, depressive symptoms, a history of falls, greater number of comorbidities, knee osteoarthritis, wide-spread pain syndromes, and an index diagnosis of lumbar spinal stenosis.[10]
It is difficult to predict who will have a recurrence after recovery. Number of previous episodes may be the only predictor.[4]
References
- ↑ Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical Course of Non-Specific Low Back Pain: A Systematic Review of Prospective Cohort Studies Set in Primary Care. Eur J Pain. 2013;17(1):5-15. doi: 10.1002/j.1532-2149.2012.00170.x.
- ↑ van den Hoogen HJ, et al. On the course of low back pain in general practice: a one year follow up study. Ann Rheum Dis. 1998 Jan;57(1):13-9. doi: 10.1136/ard.57.1.13. PMID: 9536816; PMCID: PMC1752458.
- ↑ 3.0 3.1 Machado GC, et al. Can Recurrence After an Acute Episode of Low Back Pain Be Predicted? Phys Ther. 2017 Sep 1;97(9):889-895. doi: 10.1093/ptj/pzx067. PMID: 28969347
- ↑ 4.0 4.1 Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH. After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine (Phila Pa 1976). 2008 Dec 15;33(26):2923-8. doi: 10.1097/BRS.0b013e31818a3167. PMID: 19092626.
- ↑ Jarvik JG, et al. Long-term outcomes of a large, prospective observational cohort of older adults with back pain. Spine J. 2018 Sep;18(9):1540-1551. doi: 10.1016/j.spinee.2018.01.018. Epub 2018 Jan 31. PMID: 29391206.
- ↑ van der Gaag WH, Enthoven WTM, Luijsterburg PAJ, van Rijckevorsel-Scheele J, Bierma-Zeinstra SMA, Bohnen AM, van Tulder MW, Koes BW. Natural History of Back Pain in Older Adults over Five Years. J Am Board Fam Med. 2019 Nov-Dec;32(6):781-789. doi: 10.3122/jabfm.2019.06.190041. PMID: 31704746.
- ↑ Scheele J, et al. Back complaints in the elders (BACE); design of cohort studies in primary care: an international consortium. BMC Musculoskelet Disord. 2011 Aug 19;12:193. doi: 10.1186/1471-2474-12-193. PMID: 21854620; PMCID: PMC3182961.
- ↑ Enthoven WT, et al. Age Ageing. 2016 Nov;45(6):878-883. doi: 10.1093/ageing/afw127. Epub 2016 Aug 11. PMID: 27515678.
- ↑ 9.0 9.1 9.2 Bogduk et al. Management of Acute and Chronic Low Back Pain. Chapter 5. Elsevier. 2002
- ↑ Rundell SD, et al. Predictors of Persistent Disability and Back Pain in Older Adults with a New Episode of Care for Back Pain. Pain Med. 2017 Jun 1;18(6):1049-1062. doi: 10.1093/pm/pnw236. PMID: 27688311.
