Research Review By Dr. Joshua Plener©


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Date Posted:

April 2023

Study Title:

Prognosis of a new episode of low-back pain in a community inception cohort


Campos T, da Silva T, Maher C, Pocovi NC & Hancock MJ

Author's Affiliations:

Department of Health Sciences, Faculty of Medicine, Health and Huan Sciences, Macquarie University, Sydney, Australia; JW & M Cunningham Orthopaedic Clinical Research Fellow; St Vincent’s Private Allied Health Services, New South Wales, Australia

Publication Information:

European Journal of Pain 2023; published online ahead of print

Background Information:

Previous studies have shown that the natural course of low back pain is typically favorable, with most episodes substantially improving within 6 weeks (1, 2). Within these studies, the majority have assessed the prognosis of acute low back pain in participants presenting for care to a clinical setting, while very few studies have assessed the prognosis of acute low back pain within a community setting. As a result, the prognosis that has been determined for the care seeking population may not be representative of the prognosis of people in the community who do not seek care (3, 4).

Therefore, the aim of this study was to describe the prognosis, pain intensity and proportion of participants seeking care following an acute episode of low back pain in a community cohort.

Pertinent Results:

366 participants experienced a new episode of low back pain and were included in the current study. The average age of participants was 45.1 years and 51.6% were female. The median number of previous low back pain episodes was 8.

The median duration of a low back pain episode was 5 days. The proportion of participants who experienced a period of recovery before 1, 3, 6 and 12 weeks was 70%, 65.3%, 86.1% and 90.9% respectively. The average pain intensity was 3.7 and the worst pain intensity was 5.6. About 40% of participants in the study sought care.

Clinical Application & Conclusions:

This study found that most people in the community who have an episode of low back pain recover quickly, and substantially quicker than those typically reported for the care seeking population. The median duration of an episode of low back pain within the community was 5 days, with 70% recovered before 1 week and 91% before 6 weeks. This study demonstrates that as a result of the short duration of low back pain episodes, reassurance about its favorable prognosis should be communicated to individuals.

The findings of this study provide clarity on the importance of reassuring patients and can assist in describing to patients what they can expect with future episodes of pain upon discharging them from care. Patients should understand that although recurrences are common, the vast majority will recover rapidly. It will be important for future research to understand why a patient seeks care and if better community education on the favorable prognosis can have a positive effect.

Editor’s Note: This study reminds us that episodes of low back pain generally have a favorable prognosis and highlights an important consideration when interpreting prior literature in this area. Specifically, there appear to be differences between patients who do, and do not, seek care for their low back pain. It makes intuitive sense that those who do not recover as quickly from an episode may be more likely to seek care, but this study should serve as a reminder to continually educate our existing patients of the relatively quick recovery time for most episodes of low back pain. This is certainly a relevant conversation to have with a new patient who you’ve just helped through their first episode, as well as existing patients who are in the common pattern of occasional ‘flare-ups’ of their back pain.

Study Methods:

The data for this study was gathered from two previous studies (a cohort study and a randomized trial) that followed participants who did not have pain at the beginning of either study. Both studies followed participants for at least 12 months and collected data monthly to determine when a new episode of low back pain had occurred. Any participants reporting a new low back pain episode at monthly follow-ups were followed until they recovered from that new episode, or the study follow-up period ended.

Recovery was defined in the studies as a 0 or 1 on an 11 point numerical rating scale for 7 consecutive days.

The inclusion criteria in both studies were similar, as follows:
  • 18 years or older
  • Recovery within the last month from a previous episode of non-specific low back pain, with or without associated leg pain or radiculopathy
  • No previous spinal surgery
  • No spinal surgery scheduled in the next 12 months
  • Adequate English comprehension to complete the outcome measures
  • No comorbidity preventing participation in exercise, not pregnant and no previous exposure to McKenzie-based therapies (for the RCT only)
The primary outcome for the study was the duration of days of the episode of low back pain. The secondary outcomes were average pain intensity, worst pain intensity and whether they sought care for the episode of low back pain.

Monthly follow up assessments by text message/email were used to identify if the participants had experienced a new episode of low back pain. Participants who reported a low back pain episode during the follow-ups were contacted via a phone call as soon as possible, typically within 1 week to collect further information on the episode. If the participant was not recovered by the phone call, the individual was contacted by phone between 1 and 3 months later and asked the same questions and again at every subsequent 3 months if they still were not recovered. Participants were considered recovered when they reported an average pain of not greater than 1 on a numeric pain rating scale which was sustained for at least 7 days. The date of recovery was recorded as the first day of the 7 consecutive days with pain not greater than 1.

Study Strengths / Weaknesses:

  • This study was well conducted and provides important information on the prognosis of low back pain in a non-care seeking population.
  • This study used data from two previous studies and the participants may be different than a general community.
  • The methodology could have resulted in some recall bias, especially for individuals who took longer to recover.

Additional References:

  1. da C Menezes Costa L, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: A meta-analysis. CMAJ 2012; 184(11): E613–E624.
  2. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: A double-blind, randomized controlled trial. Lancet 2014; 384(9954): 1586–1596.
  3. Beyera, GK, O'Brien J, Campbell S. Health-care Utilization for low back pain: A systematic review and meta-analysis of population-based observational studies. Rheumatol Int 2019, 39(10): 1663–1679.
  4. Ferreira ML, Machado G, Latimer J, et al. Factors defining care-seeking in low back pain – A meta-analysis of population-based surveys. Eur J Pain 2009; 14(7): e741–e747.

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