Factors in Recovery from Low Back Pain

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Factors in Recovery from Low Back pain

A recent study about low back pain noted the following as factors in how quickly a person recovered.  The authors found seven factors impacted on the speed of recovering:

  1. Older age 
  2. higher pain intensity
  3. longer duration of pain before consultation
  4. a compensation case, 
  5. more days of reduced activity before the consultation
  6. depression 
  7. perceived risk of persistence

If we look these factors, we can see the impact of many issues in the  modern , developed countries (in this case, Australia) on a problem (back pain) that has been a part of people’s lives for many years.

Let’s look at each factor by itself:

1) Older age: the population of the developed world is growing older as the “baby boomers” start to go into their “golden years” and morbidity (illness and disease, both communicable and chronic) and mortality (death) start to impact more on their lives.
2) Higher pain intensity: people feel pain greater as the factors of age and lifelong poor physical, nutritional, and emotional health are considered.
3) Many people wait for a long time before seeking care:  This could be an issue of inadequate or bad insurance, or even no insurance (an issue in the United States) or concern about taking time off from work to seek care (an issue also in the United States, but also being found in countries where there is national health care).

Also, people often have many episodes of low back pain that flare up and resolve themselves without intervention before they find themselves with symptoms that do not resolve and only then do they seek care.

4) a compensation case:  This one is often a crucial one.  Simply, is there a way for the patient to either get paid through a lawsuit or worker’s compensation, or to retire with benefits due to this episode of low back pain.  When it is considered that the population studied is older (factor 1) this issue may be one of the most significant.

5) More days of reduced activity before the consultation:  only when the patient is truly inconvenienced do they seek out a medical intervention.  We call the activities that people do “activities of daily living” and it is when a patient is unable to perform these that they seek care.  For some, it is caring for their family (cooking cleaning, and so on), for others this may be personal care (they are unable to wash themselves, climb into a shower, or lift their arm to brush their teeth) and for others this can be the inability to participate in their favorite sports (golf, soccer, weightlifting).

6) Depression:  as I have written about before, musculoskeletal pain can often be accompanied by depression.  The loss of capability of low back pain can have an immense impact on people’s sense of self and can lead to thought of sadness.

7) Perceived risk of persistence: simply, this means that a person suffering from low back pain becomes afraid the pain and loss of capability will go on for a long time and they will be incapacitated, perhaps permanently.

The last three factors should suggest that doctors treating low back pain must take into consideration psychosocial factors when treating these patients.  If the doctor perceives that the patient is not handling the issues around their low back pain with comfort and does not see it subsiding with care, they must either counsel them on these issues or direct them to other professionals who can assist the patient.  Failure to respond to psychosocial factors in recovery can lead to longer recovery times and accusation of malingering

–  Dr. Lane
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The Study:   Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study
 The Facts:
a. The authors looked at a patient group taken from the offices of general practitioners, physiotherapists and chiropractors.
b. Patients had suffered from non-specific low back pain for less than two weeks.
c. The mean age of the patients was approximately 43.
d. On average, recovery was not rapid. In fact, a third of these patients had not recovered within one year.
e. The observed rate of recovery was slower than had been reported by earlier studies.
f. They identified seven factors which were associated with a poor prognosis.
g. These could be referred to as “yellow flags”.
h. The factors which could be used to identify a poorer prognosis were: Older age, higher pain intensity, longer duration of pain before consultation, a compensation case, more days of reduced activity before the consultation, depression and a perceived risk of persistence.
i. The authors felt there was a need to further study these yellow flag items as predictors of poor outcome.
Take Home:
Providers should be alert in cases where the patient has one or more of these “yellow flags” for poor prognosis.
 Reviewer’s Comments:
It was interesting to see that a substantial number of the patients did not respond as rapidly as previous studies have led us to believe is typically the case with acute low back pain. It was also interesting to see that the authors identified factors that might be prognostic of a poor recovery. Both of these things may be quite helpful to field practitioners.
Reference: Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAulley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008 Jul 7;337:a171. doi: 10.1136/bmj.a171.

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