A severe episode of acute LBP can be scary, especially if you haven’t experienced it before. Imagine suddenly being unable to perform basic functions like walking, bending over, or even moving, without experiencing excruciating pain. Naturally then one of the first things you’re going to want to know is ‘When will it stop?’.
Like a common cold!?
Acute LBP usually has marked improvement within the first 4-6 weeks, with or without treatment.12,10,17,13,2 This makes LBP largely self-limiting (a fancy way of saying it gets better by itself), similar to the common cold. However, some researchers dispute this, arguing that since full resolution doesn’t occur in a significant amount of cases, it cannot be truly considered self-limiting.6 After the initial 4-6 weeks, the improvement is reported as slowing, resulting in only minor decreases in pain and disability until 12 weeks. (There’s that 3 month mark again! 😉) Between 12 and 52 weeks there is no significant difference at the 1 year mark.13,2 In essence, research suggests that people with LBP have rapid improvement initially, followed by a ‘plateauing’ effect which peaks around 3 months. My own clinical experience corroborates these findings, which at times makes me question the effectiveness of my treatment, especially in the acute stage. Unless a person experiences a significant response to the treatment, I’m more likely to attribute their improvement to the natural course of the LBP (rather than the treatment). We will come back to this issue at a later point in time.
And the likely outcome is…
You’re probably wondering by now, ‘So how many people recover from acute LBP?’. Before I answer this (as best I can), it’s important you realise that LBP isn’t only challenging for patients and clinicians – it’s difficult for researchers too! As such the prognosis (likely outcome) of LBP has been widely debated by academics. Whereas some estimates indicate the prognosis is still favourable, there is a growing body of evidence which suggests this may not be as true. For example, even though clinical practice guidelines state that 80-90% of acute LBP cases resolve within 6 weeks1, more recent studies have painted a gloomier picture with estimates of short-term recovery ranging from 39% to 76%.2–4
Recurrent? Nobody mentioned that part before…
One of the most challenging aspects of LBP for patients, is that it is recurrent in nature, with many people experiencing multiple episodes.2,4–10 In fact, the greatest predictor of a LBP episode is having a previous episode!11 Fortunately, the severity of these recurrent episodes aren’t usually as severe.12 They can be spaced anywhere from days to decades apart, and while the pain may completely disappear between episodes, it may not always be so clear. To make matters worse these recurrent episodes often seem to happen for no reason at all (not unlike a ‘cold’ again eh!?). Both of these factors make it difficult to determine whether these ‘flare-ups’ are due to the persistence of ‘old’ back pain (original episodes), or to new (recurrent) episodes.13 This question poses significant challenges for researchers, who must carefully design their studies to account for these recurrent episodes. Importantly, by considering the influence of recurrence, this will alter the prognosis14 and may explain (at least partially) the more pessimistic outlook for LBP. Furthermore, other differences in study methodology and interpretations (definitions) may also lead to drastically different outcomes. For example, when designing a study, what do you define as a resolution for LBP? Is it minimal or no pain/disability? How long must this last? What then do you define as a ‘new’ episode of LBP? Tricky stuff!
To recur, or not to recur (that is the question)!
As for how often these recurrent episodes occur, given the challenges for researchers outlined above, it’s perhaps not surprising that these results vary greatly. Reported cumulative risks for experiencing a recurrent episode range from 24% to 84% in the first 12 months7,13, while a longer term forecast (three years) was found to be 84%15. The mean (average) length of time before a recurrent episode occurred was reported as 2 months.16
A final word
While I can understand if you were hoping for more concrete details in this section, there simply aren’t black and whites when it comes to LBP. Those clever researchers are constantly refining their processes and techniques which will hopefully lead to some more consensus on the prognosis of LBP (and more importantly how to treat it). In the meantime, it’s important you remember that every person is different and also every LBP episode is different too. No matter how similar your previous episodes have been, your next one could be very different. It’s kind of like those ads for investments with the voice over at the end which says, ‘Past performance is not indicative of future results’. 😉 Some people go their whole lives without experiencing LBP. Some people have one episode, others a handful, while others yet experience dozens. Some people experience it for days, others months or years (etc.). There is always hope though! In the next section we will look at some of the things that might increase your chance of getting LBP (risk factors).
• LBP normally gets better by itself, with or without treatment (like a common cold).
• Improvement occurs rapidly in the first 4-6 weeks (after the onset), after which it slows and then plateaus by around 3 months.
• LBP not only poses problems for patients, but also researchers.
• Estimates for recovery from acute LBP vary widely: from 39% to 90% chance of recovery.
• The likely outcome of an acute LBP episode is still quite favourable: be optimistic!
• LBP tends to recur with most people who have had it experiencing more than one (recurrent) episode in their lives.
• Recurrent episodes tend to be less severe, may occur for no apparent reason and can happen days, months or years after the original episode.
• You will get through this! 😊
1. van Tulder M, Becker A, Bekkering T, et al. European guidelines for the management of acute nonspecific low back pain in primary care (Chapter 3). Eur Spine J. 2006;15(S2):s169-s191. doi:10.1007/s00586-006-1071-2.
2. da C Menezes Costa L, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LOP. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184(11):E613-24. doi:10.1503/cmaj.111271.
3. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337(jul07 1):a171-a171. doi:10.1136/bmj.a171.
4. Grotle M, Brox JI, Veierød MB, Glomsrød B, Lønn JH, Vøllestad NK. Clinical Course and Prognostic Factors in Acute Low Back Pain. Spine (Phila Pa 1976). 2005;30(8):976-982. doi:10.1097/01.brs.0000158972.34102.6f.
5. Tamcan O, Mannion AF, Eisenring C, Horisberger B, Elfering A, Müller U. The course of chronic and recurrent low back pain in the general population. Pain. 2010;150(3):451-457. doi:10.1016/j.pain.2010.05.019.
6. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 12(2):149-165. doi:10.1007/s00586-002-0508-5.
7. 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;33(26):2923-2928. doi:10.1097/BRS.0b013e31818a3167.
8. Mehling WE, Gopisetty V, Bartmess E, et al. The Prognosis of Acute Low Back Pain in Primary Care in the United States. Spine (Phila Pa 1976). 2012;37(8):678-684. doi:10.1097/BRS.0b013e318230ab20.
9. Cassidy JD, Côté P, Carroll LJ, Kristman V. Incidence and Course of Low Back Pain Episodes in the General Population. Spine (Phila Pa 1976). 2005;30(24):2817-2823. doi:10.1097/01.brs.0000190448.69091.53.
10. Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirsch JA. Epidemiology of low back pain in adults. Neuromodulation. 2014;17 Suppl 2:3-10. doi:10.1111/ner.12018.
11. Taylor JB, Goode AP, George SZ, Cook CE. Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. Spine J. 2014;14(10):2299-2319. doi:10.1016/j.spinee.2014.01.026.
12. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430-1434. doi:10.1136/bmj.332.7555.1430.
13. Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323. doi:10.1136/bmj.327.7410.323.
14. Delitto A, George SZ, Professor A, et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association Associate Professor in Physical Therapy and Orthopaedic Surgery, Program in Physical Therapy HHS Public Access. Man Ther. doi:10.2519/jospt.2012.42.4.A1.
15. Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med (Chic Ill). 2001;51(2):124-135.
16. Bergquist-Ullman M, Larsson U. Acute low back pain in industry. A controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand. 1977;(170):1-117. http://www.ncbi.nlm.nih.gov/pubmed/146394. Accessed February 23, 2018.
17. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Acute low back pain management in general practice: uncertainty and conflicting certainties. Fam Pract. 2014;31(6):723-732. doi:10.1093/fampra/cmu051.
18. Cassidy J, Carroll L, Spine PC-, 1998 undefined. The Saskatchewan health and back pain survey: the prevalence of low back pain and related disability in Saskatchewan adults. journals.lww.com. https://journals.lww.com/spinejournal/Abstract/1998/09010/The_Saskatchewan_Health_and_Back_Pain_Survey__The.12.aspx. Accessed February 18, 2018.
19. Van Tulder M, Becker A, Bekkering T, et al. Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care On behalf of the COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Eur Spine J. 2006;15:169-191. doi:10.1007/s00586-006-1071-2.