Chronic Non-Specific Low Back Pain


The headlines in the lay press are troubling and disturbing. A front section full-page in the newspaper Wall Street Journal showing a person clenching their back while proclaiming (1):


“More Then 100 Million American Adults Live with Chronic Pain”


Another cover study in the Wall Street Journal quantifying the anatomical regions for American’s chronic pain (2):


Hip Pain 07.1%


Finger Pain 07.6%


Shoulder Pain 09.0%


Neck Pain 15.1%


Severe Headache 16.1%


Knee Pain 19.5%


Lower-Back Pain 28.1%


An editorial discussion in the newspaper USA Today, referencing the Institutes of Medicine of the United States noting (3):


“One hundred sixteen million Americans suffer from chronic pain, costing the US up to $635 billion in treatment and lost productivity. Chronic pain even increases the risk of depression and suicide.”


These appalling numbers indicate that more than a third of all Americans, and more than half of American adults, suffer from chronic daily pain. More than a quarter of this chronic pain is located in the low back.


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For decades, conventional wisdom pertaining to Low Back Pain (LBP) has been that the great majority (90%) of this pain will resolve quickly (within two months) with no treatment or with any form of treatment. This “wisdom” became entrenched in the minds of health care providers, insurance companies, government bodies and practice guidelines after it was succinctly stated by the exceptional spine care pioneer Alf Nachemson, MD, PhD, in the debut issue of the journal SPINE in 1976. Dr. Nachemson stated (4):


“Irrespective of treatment given, 70% of [back pain] patients get well within 3 weeks, 90% within 2 months.”


A few years later (1979 first edition, 1990 second edition), the authoritative reference text Clinical Biomechanics of the Spine, is published (5). Written by Harvard’s Augustus White, MD, and Yale’s Manohar Panjabi, PhD, the text reiterates Dr. Nachemson’s message, stating:


“There are few diseases [low back pain] in which one is assured improvement of 70% of the patients in 3 weeks and 90% of the patients in two months, regardless of the type of treatment employed.”


Therefore, “it is possible to build an argument for withholding treatment.”


This “quick recovery regardless of treatment conventional wisdom” pertaining to low back pain was fervently challenged in 1998 by Peter R. Croft, PhD, and colleagues. Dr. Croft is a Professor of Primary Care Epidemiology at KeeleUniversity in Staffordshire, UK. Dr. Croft and colleagues published their work in 1998 in the British Medical Journal in an article titled (6):


Outcome of Low back Pain in General Practice:


A Prospective Study


These authors evaluated the statistics on the natural history of low back pain, noting that it is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month. They consequently investigated this claim by prospectively following 463 cases of acute low back pain for a year.


These researchers discovered that 92% of these low back pain subjects ceased to consult their primary physician about their low back symptoms within three months of onset; they were no longer going to their doctor for low back pain treatment. Yet, most of them still had substantial low back pain and related disability. Only 25% of the subjects who consulted about low back pain had fully recovered 12 months later; 75% had progressed to chronic low back pain sufferers, but they were no longer going to their doctor!


This study is adamant that NOT seeing a doctor for a back problem does NOT mean that the back problem has resolved. This study showed that 75% of the patients with a new episode of low back pain have continued pain and disability a year later, even though most are not continuing to go to the doctor. They conclude that the belief that 90% of episodes of low back pain seen in general practice resolve within one month is false.


The belief that most low back pain episodes will be “short lived and that ‘80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment’” is untrue, false. Many patients seeing their general practitioner for the first time in an episode of back pain will still have pain or disability 12 months later but will not be consulting their doctor about it. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.


Important quotes from this article include:


“It is generally believed that most of these episodes [of low back pain] will be short lived and that ‘80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.’”


“By three months after the [initial] consultation with their general practitioner, only a minority of patients with low back pain had recovered.”


“There was little increase in the proportion who reported recovery by 12 months, emphasizing the recurrent and persistent nature of this [low back pain] problem.”


“The findings of our interview study are in sharp contrast to the frequently repeated assumption that 90% of episodes of low back pain seen in primary care will have resolved within a month.”


“However, the results of our consultation figures are consistent with the interpretation that 90% of patients presenting in primary care with an episode of low back pain will have stopped consulting about this problem within three months of their initial visit.”


“The inference that the patients have completely recovered [because they have stopped going to the doctor] is clearly not supported by our data.”


“We should stop characterizing low back pain in terms of a multiplicity of acute problems, most of which get better, and a small number of chronic long term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences. This takes account of two consistent observations about low back pain: firstly, a previous episode of low back pain is the strongest risk factor for a new episode, and, secondly, by the age of 30 years almost half the population will have experienced a substantive episode of low back pain. These figures simply do not fit with claims that 90% of episodes of low back pain end in complete recovery.”


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In 2003, Lise Hestbaek, DC, PhD, and colleagues from the University of Southern Denmark published a study in the European Spine Journal, titled (7):


Low back pain: what is the long-term course? A review of studies of general patient populations


These authors performed a comprehensive review of the literature on this topic, noting “it is often claimed that up to 90% of low back pain (LBP) episodes resolve spontaneously within 1 month.” They used 36 articles that met their criteria. The tabulated results showed that on average 62% (range 42-75%) still experienced pain after 12 months. The authors concluded:


“The overall picture is that LBP does not resolve itself when ignored.”


“The overall picture is clearly that LBP is not a self-limiting condition. There is no evidence supporting the claim that 80– 90% of LBP patients become pain free within 1 month.”


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Ronald Donelson, MD, is a Board Certified Orthopedic Surgeon and the current Vice President of the American Back Society. Dr. Donelson is associated with the State University of New Youk, in Syracuse. In 2102, Dr. Donelson and colleagues published a study in the journal Physical Medicine and Rehabilitation, titled (8):


Is It Time to Rethink the Typical Course of Low Back Pain?


The purpose of this study was to determine the frequency and the characteristics of low back pain (LBP) recurrences by asking these questions:


1) Are low back pain (LBP) recurrences common?


2) Do episodes worsen with multiple recurrences?


Questionnaires were given to 589 LBP patients from 30 clinical practices (primary care [7%], physical therapy [67%], chiropractic [19%], and surgical spine [7%]) in North America and Europe. The results were:


1) Are low back pain (LBP) recurrences common?: [rounded]


73% had suffered a previous episode of LBP


54% had experienced ≥10 episodes of prior LBP in their lifetime


20% had experienced >50 episodes of prior LBP in their lifetime


27% with a previous episode of LBP had 5 or more episodes of LBP per year


2) Do LBP episodes worsen with multiple recurrences?: [rounded]


61% reported in the affirmative


Dr. Donelson and colleagues are critical of clinical practice guidelines that characterize the typical course of LBP as benign and favorable, stating:


“It is often stated that LBP is normal; has an excellent prognosis, with 90% of individuals recovering within 3 months of onset in most cases; and is not debilitating over the long term. One guideline states that recovery usually takes place within as little as 6 weeks.”


“Acute LBP is perceived as largely self-limiting and requiring little if any formal treatment. This benign view justifies what has become the standard clinical guideline recommendation that clinicians often need do nothing more than simply reassure patients that they will likely recover.”


“In any one year, recurrences, exacerbations, and persistence dominate the experience of low back pain in the community. This clinical picture is very different from what is typically portrayed as the natural history of LBP in most clinical guidelines.”


They note that few clinicians realize that this positive recovery prognosis was derived from flawed protocols:


1) When patients with LBP did not return for follow-up assessment, the researchers assumed that the patients had recovered. It is now known that the failure of a patient with acute LBP to return to the same doctor “does not necessarily indicate recovery.” “A patient’s disappearance from the practice is a poor proxy for recovery.” When persistent LBP does not respond to a doctor’s care, the patient tends to drop out of care.


2) A number of studies used the “ability to return to work” as a proxy for recovery, even if the patient has substantial low back pain.


Dr. Donelson and colleagues note:


“Recurrences of back pain are widely recognized as common, reported as occurring in 60%-73% of individuals within 1 year after recovery from an acute episode.”


“Consistent with many other published studies, the recurrence rate among our respondents with LBP was 73%.”


“Most persistent disabling back pain is preceded by episodes that, although they may resolve completely, may also increase in severity and duration over time.”


“Many patients with chronic LBP had prior recurrent episodes that had become longer and more severe until the most recent episode did not resolve and thus became chronic.”


“The conventional view of the natural history of acute LBP is that it is self-limiting and that 90% of patients experiencing LBP recover within 90 days or less, but there is no evidence to suggest that either of these statements is accurate. In reality, the recovery rates reported in population studies and in our survey data are far less optimistic.”


“Collectively, our findings, and those of other studies, indicate that it may be inaccurate to characterize LBP as having an excellent prognosis. Recurrences are frequent and are often progressively worse over time. Recovery from acute LBP is not as favorable as is routinely portrayed.”


“Eventually, there may be no recovery, and the underlying condition may become chronically painful. In light of these characteristics, it seems inappropriate to characterize the natural history of LBP as benign and favorable.”


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In 2013, Coen J. Itz, PhD, and colleagues from the Department of Health Service Research, MaastrichtUniversity, The Netherlands, published a study in the European Journal of Pain, titled (9):


Clinical Course of Non-Specific Low Back Pain: A Systematic Review of Prospective Cohort Studies set in Primary Care


Dr. Itz and colleagues performed a systematic literature review investigating the clinical course of pain in patients with non-specific acute low back pain that obtained treatment in primary care. All included studies were prospective studies, with follow-up of at least 12 months. Proportions of patients still reporting pain during follow-up were pooled. A total of 11 studies were eligible for evaluation. In the first 3 months, recovery was observed in 33% of patients, but the pooled proportion of patients still reporting pain after 1 year was 71%. These authors state: