Course Of Low Back Pain Research Articles

Low back pain.

Low back pain is a major burden to society. Many people will experience an episode of low back pain during their life. Some people develop chronic low back pain, which can be very disabling. Low back pain is associated with high direct and indirect costs. Recent epidemiological data suggest that there is a need to revise our views regarding the course of low back pain. Low back pain is not simply either acute or chronic but fluctuates over time with frequent recurrences or exacerbations. Also, low back pain may frequently be part of a widespread pain problem instead of being isolated, regional pain. Although epidemiological studies have identified many individual, psychosocial and occupational risk factors for the onset of low back pain, their independent prognostic value is usually low. Similarly, a number of factors have now been identified that may increase the risk of chronic disability but no single factor seems to have a strong impact. Consequently, it is still unclear what the most efficient strategy is for primary and secondary prevention. In general, multi-modal preventative approaches seem better able to reflect the clinical reality than single-modal interventions.

The impact of treatment confidence on pain and related disability among patients with low-back pain: results from the University of California, Los Angeles, low-back pain study

Background context: Although many researchers and practitioners believe that patients' positive expectations of their treatment favorably influence clinical outcomes, there is little scientific evidence to support this belief. Purpose: To describe the level of patients' initial confidence in the success of their assigned treatment, by treatment group and other factors; and to estimate the effects of treatment confidence on subsequent changes in low-back pain and related disability. Study design and patient sample: Randomized clinical trial involving 681 patients treated for low-back pain in a managed-care facility in Southern California. Outcome measures: Treatment confidence; and changes in three clinical measures of low-back pain: average pain, most severe pain and back-pain–related disability. Methods: Patients were randomly assigned to one of four treatment groups: medical care with and without physical therapy, and chiropractic care with and without physical modalities. Information was collected by questionnaires at baseline, 2 weeks, 6 weeks and 6 months. Treatment confidence was measured just after randomization on a scale of 0 to10. Results: Treatment confidence was lowest, on average, for patients assigned to medical care only and highest for patients assigned to medical care plus physical therapy. Other predictors of high treatment confidence were having acute pain and being older, female and nonwhite. Although treatment confidence was only weakly associated with subsequent changes in low-back pain or disability in the total sample, high treatment confidence was associated with greater improvement among patients assigned to medical care plus physical therapy. Conclusions: Initial confidence in treatment for low-back pain varies by type of care and other factors. Higher confidence may have some beneficial effect on the course of low-back pain in certain patients, but this effect may depend on the type of interaction between client and provider.

Clinical Science (40)

Longitudinal quantitative measures of the natural course of low back pain. (Ohio State University, Columbus, OH) Spine 2000;25:1950–1956.This prospective study compared traditional self‐report measures of low back pain recovery with quantitative measure of recovery. Sixteen occupational and 16 non‐occupational patients with low back pain were recruited. Recovery was monitored prospectively every 2 weeks for 3 to 6 months, using subjective work status, pain symptoms, activities of daily living, and objective functional performance probability (trunk kinematics). Return to work underestimated the percentage of subjects impaired, as compared with all other outcome measures. Symptoms, activities of daily living, and functional performance probability all showed similar patterns of recovery for 0 to 12 weeks. At 14 weeks, there was a lag in functional performance recovery. Both symptoms and activities of daily living indicated that 80% of the population was recovered, whereas functional performance indicated the figure to be 68%. Conclude that the objective kinematic functional performance measure of recovery quantifies a different aspect of impairment not evaluated by traditional subjective measures. Use of several outcome measures may lead to a better understanding of low back pain recovery or residual impairment, which may minimize the risk of recurrent injury. Comment by Hemmo A. Bosscher, MD.This study evaluates several traditional and not so traditional quantitative measures in the recovery of low back pain. The authors hypothesize that a better understanding of the natural course of low back pain (LBP) recovery may provide the knowledge necessary to prevent high cost recurrent low back injuries. But the relationship between acute low back pain, its recovery, and the subsequent recurrence of LBP is not studied here at all. However the study offers some other interesting information. The traditional outcome measure “back to work” is a very insensitive one. It depends on the job rather than the severity of the LBP. A relatively new functional outcome measure was introduced: the lumbar motion monitor, a device that evaluates trunk kinematics. This measure seems more important in later stages of recovery.

Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: A practice-based feasibility study

Background: Chronic low-back pain is a significant public health problem for which few therapies are supported by predictable outcomes. In this report, practice activities and 1-month outcomes data are presented for 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain.Design: A prospective, observational, community-based feasibility study involving chiropractors and family medicine physicians.Setting: Forty private chiropractic clinics, the outpatient clinic of the Department of Family Medicine of Oregon Health Sciences University, and 5 other Portland area family medicine clinics.Outcomes Measures: The main outcome measures were pain severity, functional disability, sensory and affective pain quality at 1 month, and patient satisfaction assessed at 7 to 10 days and at 1 month.Results: Although differences were noted in age, sex, education, and employment, the patients were closely matched at baseline with respect to frequency, severity, and type of low-back pain and the psychosocial dimensions of general health. The treatment of choice for chiropractors was spinal manipulation and physical therapy modalities; for medical physicians antiinflammatory agents were most frequently used. Chiropractic patients averaged 14 visits, and medical patients averaged 1 visit. On average, chiropractic patients showed improvement across all outcomes: 31% change in pain severity, 29% in functional disability, 36% in sensory pain quality, and 57% in affective pain quality. Medical patients showed minimal improvement in pain severity (6%) and functional disability (1%) and showed deterioration in the sensory (29%) and affective (26%) dimensions of pain quality. Satisfaction scores were higher for chiropractic patients. Outcomes for medical patients were heavily dependent on psychosocial status at baseline.Conclusion: Patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians. Nonclinical factors may play an important role in patient progress. Findings from the Health Resources and Services Administration-funded project will include a report on the influence of practice activities, including more frequent visits by chiropractic patients, on the clinical course of low-back pain and patient outcomes.

Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: A practice-based feasibility study

Chronic low-back pain is a significant public health problem for which few therapies are supported by predictable outcomes. In this report, practice activities and 1-month outcomes data are presented for 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain. A prospective, observational, community-based feasibility study involving chiropractors and family medicine physicians. Forty private chiropractic clinics, the outpatient clinic of the Department of Family Medicine at Oregon Health Sciences University, and 5 other Portland area family medicine clinics. The main outcome measures were pain severity, functional disability, sensory and affective pain quality at 1 month, and patient satisfaction assessed at 7 to 10 days and at 1 month. Although differences were noted in age, sex, education, and employment, the patients were closely matched at baseline with respect to frequency, severity, and type of low-back pain and the psychosocial dimensions of general health. The treatment of choice for chiropractors was spinal manipulation and physical therapy modalities; for medical physicians antiinflammatory agents were most frequently used. Chiropractic patients averaged 4 visits, and medical patients averaged 1 visit. On average, chiropractic patients showed improvement across all outcomes: 31% change in pain severity, 29% in functional disability, 36% in sensory pain quality, and 57% in affective pain quality. Medical patients showed minimal improvement in pain severity (6%) and functional disability (1%) and showed deterioration in the sensory (29%) and affective (26%) dimensions of pain quality. Satisfaction scores were higher for chiropractic patients. Outcomes for medical patients were heavily dependent on psychosocial status at baseline. Patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians. Nonclinical factors may play an important role in patient progress. Findings from the Health Resources and Services Administration-funded project will include a report on the influence of practice activities, including more frequent visits by chiropractic patients, on the clinical course of low-back pain and patient outcomes. (J Manipulative Physiol Ther 2000;23:239-45).

The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting.

Three hundred patients, attending their general practitioners with attacks of acute low back pain, formed the subject population for a study of fear avoidance and other variables in the prediction of chronicity. Follow-up was at 2 and 12 months. The hypothesis to be tested was that evidence of psychological morbidity, particularly fear-avoidance behavior, would be manifest from the outset of the presenting attack in susceptible subjects. While back pain is an almost universal human experience, only about 5% of sufferers seek medical advice. Most of these respond to conservative treatment. However, approximately 10% of those who experience an acute attack of low back pain go on to become chronic sufferers. Psychosocial and physiological data (including fear-avoidance measures) were collected from a sample of 300 acute low back pain patients within 1 week of presentation and at 2 months, to try to predict 12 month outcome. Data analysis showed that subjects who had not recovered by 2 months were those who went on to become chronic low back pain patients (7.3%). Using multiple regression analyses, fear-avoidance variables were the most successful in predicting outcome. Using multiple discriminant function analyses, the results suggest that the outcome in terms of the future course of low back pain can be correctly classified in 66% from fear-avoidance variables alone and in 88% of patients from all variables. The results suggest that, at the earliest stage of low back pain, fear of pain should be identified by clinicians and, where this is severe, pain confrontation should arguably form part of the approach to treatment.

Low-Back Pain-Reply

In Reply.— Dr Coodley appropriately points out the contribution of psychosocial factors to the etiology and course of low-back pain. The usual distinction between psychogenic and organic pain is certainly artificial, and most patients have elements of both. 1 Psychosocial factors may certainly affect the physician's choice of therapy and the patient's response to treatment, but such information is rarely collected in clinical trials. This is another argument for the need to provide better description of the patients who are entered into therapeutic studies. We also apparently agree that psychosocial function may be as important as physiological function in assessing therapeutic results. Although such outcomes are notoriously difficult to measure, clinical expertise and social science methodology are being fused to create new questionnaire instruments for assessing both physical and psychosocial function. We have tested one of these instruments among patients with low-back pain 2 and find it promising for both