There are two major schools of thought when it comes to the nature of LBP. The prevailing viewpoint is that this condition consists of discrete episodes which are interspersed by periods without LBP. And while some people may be fortunate enough to have only a single episode, it is common for people to have more than that over the course of their lives.1 Currently there is insufficient evidence to provide a reliable estimate of the of the risk of LBP recurring . However, one recent review (seven studies; 1780 participants) suggests around a third of people will have another episode within a year of recovering from their last one.2 Much of the research to date has been based on this ‘episodic’ model, which I think is best described by the common cold metaphor. Like a cold, a LBP episode can start for little or no apparent reason, and usually resolves by itself over a period of days or weeks (occasionally requiring intervention). You also aren’t typically ‘injured’ by a cold, since the unpleasant symptoms we experience are actually our immune system’s response to the virus. This is similar to many cases of LBP in which there is no obvious injury, and most of the unpleasant signs and symptoms could best be described as our body ‘overreacting to the initial stimulus’.
The other increasingly popular belief is that LBP is a life-long (or at least long-lasting) condition with a variable course.3 This is supported by a growing body of evidence which shows that a substantial amount of people do not recover from their initial episode.1,4 Instead, these people will have ongoing pain which fluctuates in intensity (usually low to moderate), while an even less fortunate few will have persistent high levels of pain.5 This viewpoint does seem to have some merit as it certainly helps explain these varieties of LBP better than the former one. It also gives more relevance to the term ‘flare-up’, which can be considered an exacerbation of a pre-existing condition (rather than an unrelated (‘new’) episode). Still, the fact that not even the best minds in the industry can reach a consensus does gives you some idea of the complexity of this condition. In any case, I guess we’ll just have to wait and see what future evidence reveals.
Give me some good news for good-news’ sake! 😊
When I think back to my first episode, the thing that bothered me most was the feeling that I had somehow become ‘damaged goods’ and that I would ‘never be the same again’. This caused me to rue all the things that I had [possibly] done to cause the “injury” (which itself is a ridiculous notion). All it did was leave me feeling miserable – mainly angry and sorry for myself. However, at some point I started to feel a bit better and not surprisingly my thoughts started to change too. No doubt this was helped by the fact that I often saw people get through worse cases than mine. Still, my point is that it’s very common to find yourself in a dark place during your initial episode (especially if it’s severe). I’m not going to tell you that an episode of LBP isn’t that bad. Mine was a cake-walk compared to many I’ve seen and yet it was still awful – I guess it’s all relative anyway. Just know that even though it’s awful now, things almost certainly improve, often to the same level they were before the episode began. 😊
What can I do to reduce the risk of a future LBP episode?
We know that there are associated risk factors for LBP although as yet none of them are particularly robust. The good news is that this means that none of them are likely to be THAT significant and therefore I’m not going to tell you to avoid them (except smoking – that’s always bad!). Instead, I’m going to give you one thing to do: exercise. Just do it! And no, I’m not endorsing Nike apparel although I wouldn’t mind if you purchased some if it meant you were going to exercise. Exercise is the closest thing we have to a silver bullet in LBP. A systematic review (23 studies, 30850 participants) found that exercise alone reduced the risk of a LBP episode and sick leave by 35% and 75% respectively.6 When combined with education it decreased the risk of LBP by a further 10% (45% reduction). Be warned though, this study reported that the effect sized diminished (exercise and education) or disappeared (exercise alone) after one year. This emphasises the importance of performing exercise on a regular (ongoing) basis and not just for a few months until you get too busy again! As we’ve seen already there is insufficient evidence to suggest any one type of exercise is better (or worse) than the rest (the same can be said for both the frequency and intensity).7 Put another way, the best type of exercise is the one that you will do! So pick one you enjoy!
What if I get another episode?
Since my first episode I’ve had one major ‘flare-up’. And while the level of pain and disability was probably worse (it’s hard to compare), the experience wasn’t anywhere near as bad. This is because nothing prepares you better for an episode of LBP (than a previous one)! Not only are you psychologically fortified against the fear and uncertainty (having been there already and gotten through it before), but you’ll also have gained a bunch of tools that will assist you through it. And while a severe episode will always challenge you (remember every episode is different), your experience will translate into far greater confidence in your ability to get through it.
More about that darn cold metaphor…
In case you hadn’t noticed already I like this metaphor! Specifically, I like it for the following reasons: 1) It places less emphasis on the mechanism of onset and the injury itself, and more on the symptoms; and 2) It suggests that I still have SOME control in reducing the chance of an episode. Do you blame yourself for catching a cold? Probably not! The way I see it is that if I look after myself well (eat healthy, exercise, don’t let myself get run down etc.) then there is a reduced risk of me getting another cold (but I still might). Furthermore, you make full recoveries from ‘the cold’ so why should LBP be any different!? Not only does this metaphor make it easier to stop blaming yourself for ‘causing’ your LBP episode, it also should motivate you to prevent future episodes by exercising and looking after yourslef in general (mind-body).
A final word of encouragement
The vast majority of episodes aren’t that serious however over the last few years of clinical practice I have heard of several serious (specific) LBP episodes (including fractured spines) where people have made FULL recoveries. Better yet some of them did it in a matter of weeks or months. From my perspective most of these people had one thing in common – belief. They believed they would get better regardless of the diagnosis. A guy I went to university with ‘busted’ his back (including herniating several discs) while playing rugby. He was told by a specialist he’d never be able to run again. You can guess the rest of the story. He was one of the fittest persons I knew and wasn’t the least bit limited in what exercises he could do. Seemingly nothing is set in stone. Therefore don’t spend your time worrying about when or if you’ll have another episode. By all means take the necessary actions (exercising, eating well etc.) but also remember that if your back feels good, it is!
• LBP can be viewed as consisting of discrete episodes (episodic) or as a long-lasting condition with a variable course.
• Like the common cold, LBP can occur for little or no apparent reason; usually resolves to a large extent by itself in a matter of weeks; and its symptoms are usually worse than the ‘injury’ itself.
• Regular exercise on a continual basis is the best way to prevent future episodes of LBP.
• If you do have another episode, your previous experience will help you enormously by preparing you psychologically and giving you the ‘tools’ to manage it better.
• Many people make remarkable recoveries from even the most serious cases of LBP. You can too!
1. 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.
2. da Silva T, Mills K, Brown BT, Herbert RD, Maher CG, Hancock MJ. Risk of Recurrence of Low Back Pain: A Systematic Review. J Orthop Sports Phys Ther. 2017;47(5):305-313. doi:10.2519/jospt.2017.7415.
3. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013;27(5):591-600. doi:10.1016/j.berh.2013.09.007.
4. 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.
5. Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord. 2016;17(1):220. doi:10.1186/s12891-016-1071-2.
6. Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back Pain. JAMA Intern Med. 2016;176(2):199. doi:10.1001/jamainternmed.2015.7431.
7. Toward Optimized Practice (TOP) Low Back Pain Working Group. Evidence-informed primary care management of low back pain: clinical practice guideline. 2017. http://www.topalbertadoctors.org/cpgs/885801.