Abstract
Background
Most studies investigating the prognosis of low back pain (LBP) enrol people presenting for care, rather than all people who have an episode of LBP. We aimed to describe the prognosis of an acute episode of LBP in a community inception cohort.
Methods
We used data from two previous studies investigating recurrence of LBP. Participants without current LBP were contacted monthly to assess if they had experienced a new episode of LBP. 366 participants reporting a new episode of LBP were included in the current study. The primary outcome was duration of the new episode of LBP. Secondary outcomes were average and worst pain during the episode and the proportion of participants seeking care.
Results
The median duration of the episode was 5 days (95% CI 3.99 to 6.02). The cumulative probability of recovery was 70.0% (95% CI 65.3 to 74.7) before 1 week, 86.1% (95% CI 82.6 to 89.6) before 3 weeks, 90.9% (95% CI 88.0 to 93.8) before 6 weeks, and 93.5% (95% CI 90.8 to 96.0) before 12 weeks. The mean average pain intensity was 3.7 (SD ± 1.5), and the mean worst pain intensity was 5.6 (SD ± 1.9). The proportion of patients who sought care was 39.5% (95% CI 33.9 to 46.4).
Conclusions
This study found most episodes of LBP recover rapidly and more quickly than typically reported for clinical populations. The worst pain during the episode was typically moderate despite the rapid recovery for most people. Approximately 40% of the participants who experienced an episode of LBP sought care.
Significance
This study describes the prognosis of an acute episode of LBP in a community inception cohort. This study found the majority of episodes of LBP, in community‐dwelling adults, recover rapidly (median of 5 days) and more quickly than typically reported for clinical populations. The community should be reassured about the favourable prognosis of acute LBP.
1. INTRODUCTION
Low back pain (LBP) is an extremely common health condition; (Hoy et al., 2012) it is the number one cause of disability in most countries according to the Global Burden of Disease studies (Vos et al., 2016, 2017). In the adult population, it is expected that about 39% will experience LBP in any given year (Hoy et al., 2012). Despite the high prevalence of LBP, existing literature suggests that the natural course of an episode of LBP is typically favourable (Costa et al., 2012; Williams et al., 2014).
A systematic review on the prognosis of acute LBP (15 cohort studies and 3316 participants) provides strong evidence that most episodes of acute LBP improve substantially within 6 weeks, and by 12 weeks, the majority of participants are recovered (Costa et al., 2012). The median duration of an episode of LBP varies across studies but is commonly reported to be between 2 weeks and 8 weeks (Costa et al., 2012; Gurcay et al., 2009; Heneweer et al., 2007; Henschke et al., 2008). The different definitions of recovery from an episode and the different populations included likely contribute to this variability. However, the vast majority of studies investigating prognosis of an episode of acute LBP, including those studies in the systematic review of prognosis, enrol people presenting for care (Costa et al., 2012). The prognosis of care‐seeking populations may not represent the prognosis of people in the community who have an episode of LBP, many of whom do not seek care (Beyera et al., 2019; Ferreira et al., 2009). The prognosis of an episode of LBP for people in the community may be more favourable than in the subset who seek care; however, little data are available from community populations. High‐quality information on the prognosis of people in the community, will further understanding of LBP and can be used to inform recommendations and public health campaigns for people in the community experiencing LBP. Several current LBP guidelines recommend self‐management as the initial step in managing LBP (Lin et al., 2020; National Guideline Centre (UK), 2016; Oliveira et al., 2018).
There is a paucity of high‐quality inception cohort studies that investigate the course of an episode of LBP in community‐dwelling adults (i.e., not drawn from a care‐seeking population). Therefore, the aim of this study was to describe the prognosis, pain intensity and the proportion of participants seeking care following an acute episode of LBP in a community inception cohort.
2. METHODS
2.1. Source of data
The data for the current study were gathered from two previous longitudinal studies that followed participants without pain at study entry (Figure 1). The first study was a cohort study investigating how commonly recurrences occurred in people recently recovered from an episode of non‐specific LBP (Da Silva et al., 2019). The second study was a randomized controlled trial (RCT) investigating the effectiveness of the McKenzie method‐based self‐management and educational approach to prevent recurrence of LBP in people recently recovered from an episode of non‐specific LBP (De Campos et al., 2020). These studies were carried out in Sydney—Australia. Both studies followed participants for at least 12 months and collected data monthly on whether a new episode of LBP had occurred. Further details and results for these studies have been published elsewhere (Da Silva et al., 2019; De Campos et al., 2020). Any participant in either study who reported a new episode of LBP at the monthly follow‐ups was followed until they recovered from that new episode, or the study follow‐up period ended. Data describing that new episode including the duration of the episode, pain intensity and care‐seeking are the focus of the current study.
FIGURE 1.
Flow diagram of participants through the study.
2.2. Participants: Cohort study
In brief, the cohort study assessed 409 people for eligibility and 159 were excluded. The study comprised 250 participants, recruited from August 2015 to August 2017, who had recently recovered from a previous episode of non‐specific LBP (Da Silva et al., 2019). Recovery was defined as a score of 0 or 1 on an 11‐point numerical rating scale for 7 consecutive days. Participants for the study were recruited from primary care settings (physiotherapy and chiropractic) after being discharged from care. Further details of the inclusion criteria are provided in Table 1. Ethics for the cohort study was granted by the Human Research Ethics Committee, Macquarie University (reference number 5201500494).
TABLE 1.
Eligibility criteria for the Cohort study and the RCT study.
| Inclusion criteria for the cohort study | Inclusion criteria for the RCT study |
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Abbreviations: LBP, low back pain; RCT, randomized controlled trial.
2.3. Participants: RCT
This RCT assessed 670 people for eligibility and 408 were excluded. The study recruited 262 participants from July 2016 to June 2018, who had recently recovered from an episode of non‐specific LBP. Recovery was defined as a score of 0 or 1 on an 11‐point numerical rating scale for 7 consecutive days. Participants were randomly assigned to either a self‐management approach group (involving 2 physiotherapy visits to teach a McKenzie‐based prevention exercise programme and to provide education), or a minimal intervention control group (advice over the phone to increase physical activity). Participants were recruited into the study via community advertisements (e.g. public noticeboards, websites and social media) (De Campos et al., 2020). Further details of the inclusion criteria are provided in Table 1. Participants from the treatment arm of the RCT were excluded from the analyses of care‐seeking (secondary outcome for the current study) as the main trial suggested the intervention reduced care‐seeking for future episodes. Ethics for the RCT study was granted by the Human Research Ethics Committee, Macquarie University (reference number 5201600187). Trial registration: ACTRN12616000926437.
2.4. Participants: Current study
To be eligible for the current study, participants from either of the two previous studies must have reported a new episode of LBP (with or without leg pain) during the follow‐up period. Monthly follow‐up assessments by text message/email were used to identify if the participants had experienced a new episode of LBP. Specifically, participants were asked whether they had experienced a new episode of LBP with intensity >2 on a numeric pain rating scale (ratings = 0–10) lasting at least 24 h within the past 4 weeks or since the last contact from the research team. This method of recruiting from prospectively monitored participants, who were not seeking care, meant that we were able to enrol a true inception cohort of people in the community who experienced a new episode of LBP. Ethics for the current study was granted by the Human Research Ethics Committee, Macquarie University.
2.5. Outcome measures
The primary outcome of the current study was the duration (days) of the episode of LBP. The secondary outcomes were average pain intensity, worst pain intensity and whether they sought care for the episode of LBP.
Participants who reported an episode of LBP during monthly follow‐ups were contacted via phone call as soon as possible and typically within 1 week, to collect further information about this episode. This included the start date for the episode, whether the episode was ongoing or had already resolved, the duration (days) of the episode if already recovered, the worst and average pain intensity during this episode, and whether they had sought care as a result of the episode. Participants who had not recovered from that episode when contacted, were contacted by phone between 1 and 3 months later and asked the same questions about whether the episode had recovered, average and worst pain intensity and care‐seeking. If the participant remained not recovered, they were contacted again each 3 months until they did recover, or the study ended. Participants were considered recovered when they reported average pain no >1 on a numeric pain rating scale (ratings = 0–10), and this was sustained for at least 7 days. The date of recovery was recorded as the first day of the 7 consecutive days with pain no greater than 1. For the outcomes of average and worst pain intensity, we used the last reported value and the highest value, respectively, in those participants who were contacted more than once (i.e., not already recovered when first contacted).
2.6. Data analysis
For the primary outcome of duration (days) of the new episode of LBP we used survival analysis. Any participant who had not recovered from their new episode (event) by the final follow‐up, or 365 days after the onset of the new episode, was censored and the duration of the episode was recorded. If a participant was lost to follow‐up before they recovered from the LBP episode (event) they were censored at the time of the last successful follow‐up. The duration of recurrences was presented as 1‐ survival curves and median days to recovery with 95% Confidence Interval (CI). We also calculated the cumulative proportion recovered with 95% CIs by 1, 3, 6 and 12 weeks. We conducted a post‐hoc sensitivity analysis to see if the results were similar across the 2 included populations.
For the secondary outcomes of average pain intensity and worst pain intensity, we used descriptive analyses and reported mean, SD and range. For the proportion of episodes resulting in care‐seeking, we reported the proportion and 95% CI. Participants from the treatment arm of the RCT were excluded from the analyses of care‐seeking as the main trial suggested the intervention reduced care‐seeking for future episodes. This decision was made prior to conducting any analyses for the current study. In addition, participants who had not reported seeking care, but had an ongoing episode (not recovered) and were followed for less than 1 month (end of study or lost to follow‐up), were excluded from the analyses of care‐seeking. We conducted a sensitivity analysis, excluding all participants who had an ongoing episode when the study finished or who were lost to follow‐up, but had not yet reported care‐seeking.
3. RESULTS
There were a total of 512 participants enrolled in the cohort study and the RCT. Of these, 349 (95.4%) were successfully followed until they recovered or for a minimum of 12 months. Of these, 366 (71.5%) experienced a new episode of LBP and were included in the current study. The flow diagram of participants throughout the study is presented in Figure 1.
The mean age of participants was 45.1 years (SD ± 14.0) and 51.6% were female. The median number of previous episodes was 8 (IQR 3 to 20). The characteristics of the participants included in this study are presented in Table 2.
TABLE 2.
Demographic characteristics of eligible participants included in the analysis.
| Variable | Cohort study (n = 170) | RCT study (n = 196) | Current study (n = 366) |
|---|---|---|---|
| Age (years), mean (SD) | 47.7 (15) | 42.9 (12.7) | 45.1 (14) |
| Gender, n female (%) | 88 (51.8) | 101 (51.5) | 189 (51.6) |
| Body mass index (kg/m2), mean (SD) | 26.6 (5.3) | 25.4 (5.3) | 25.9 (5.3) |
| Previous episodes (n), median (IQR) | 6 (3 to 20) | 8 (4 to 19) | 8 (3 to 20) |
| Education level, n (%) | |||
| Primary school | 1 (0.6) | 0 (0) | 1 (0.3) |
| Some secondary school | 0 (0) | 2 (1) | 2 (0.5) |
| Completed high school | 40 (23.5) | 13 (6.6) | 53 (14.5) |
| Some additional training | 34 (20) | 31 (15.8) | 65 (17.8) |
| Undergraduate university | 58 (34.1) | 78 (39.8) | 136 (37.2) |
| Postgraduate university | 37 (21.8) | 72 (36.7) | 109 (29.8) |
| Work status, n (%) | |||
| Full time | 95 (55.9) | 118 (60.2) | 213 (58.2) |
| Part‐time | 34 (20) | 40 (20.4) | 74 (20.2) |
| Unemployed | 4 (2.4) | 5 (2.6) | 9 (2.5) |
| Students or homeworkers | 5 (2.9) | 14 (7.1) | 19 (5.2) |
| Other | 32 (18.8) | 19 (9.7) | 51 (14) |
| General health, n (%) | |||
| Excellent | 19 (11.2) | 42 (21.4) | 61 (16.7) |
| Very good | 64 (37.6) | 73 (37.2) | 137 (37.4) |
| Good | 73 (42.9) | 73 (37.2) | 146 (39.9) |
| Fair | 13 (7.6) | 8 (4.1) | 21 (5.7) |
| Poor | 1 (0.6) | 0 (0) | 1 (0.3) |
| Smoking, n (%) | |||
| Never | 118 (69.4) | 146 (74.5) | 264 (72.1) |
| Ex‐smoker | 43 (25.3) | 42 (21.4) | 85 (23.2) |
| Current smoker | 9 (5.3) | 8 (4.1) | 17 (4.6) |
| DASS‐21, mean (SD) a | |||
| Depression | 5.6 (6.7) | 4.5 (5.7) | 5 (6.2) |
| Anxiety | 4.6 (5.7) | 4.2 (4.8) | 4.4 (5.3) |
| Stress | 11.4 (7.6) | 10.8 (8.3) | 11 (8) |
Abbreviation: DASS‐21, 21‐item Depression Anxiety Stress Scale.
The 21‐item Depression Anxiety Stress Scale (DASS‐21) has each domain score ranging from 0 to 21.
3.1. Description of episode
The duration of the episode of LBP is presented in Figure 2. The median duration of the new episode of LBP was 5 days (95% CI 3.99 to 6.02). The cumulative proportion of participants who experienced a period of recovery before 1, 3, 6 and 12 weeks was 70.0% (95% CI 65.3 to 74.7), 86.1% (95% CI 82.6 to 89.6), 90.9% (95% CI 88.0 to 93.8), and 93.5% (95% CI 91.0 to 96.0), respectively. Sensitivity analyses exploring the survival curves for both data sets found remarkably similar results (Appendix S1). The median days to recovery was 5 (95% CI 4.23 to 5.77) in the cohort study (Appendix S1, Figure S1a), and 5 (95% CI 3.96 to 6.04) in the RCT (Appendix S1, Figure S1b).
FIGURE 2.
Kaplan–Meier survival curves for the duration of the new episode of LBP.
The average pain intensity was 3.7 (SD ± 1.5) and the worst pain intensity was 5.6 (SD ± 1.9). There was relatively large degree of variability in average pain intensity (10th percentile = 2/10; 90th percentile = 6/10) and worst pain intensity (10th percentile = 3/10; 90th percentile = 8/10). The proportion of patients who sought care for the episode was 39.5% (95% CI 33.9 to 46.4; 107/271). The proportion was very similar 39.8% (95% CI 34.1 to 45.7; 107/269) in the sensitivity analysis excluding all participants who had an ongoing episode when the study finished, or they were lost to follow‐up but had not yet reported care‐seeking.
4. DISCUSSION
4.1. Key findings
This study found that the majority of people from community who have episodes of LBP recover quickly and substantially more quickly than typically reported for care‐seeking episodes (Costa et al., 2012; Gurcay et al., 2009; Heneweer et al., 2007; Henschke et al., 2008). The median duration of a community episode of LBP was only 5 days, with 70% of episodes recovered before 1 week and 91% before 6 weeks. Despite the typically rapid recovery, the worst pain intensity during the episode was still moderate on average (5.6) and about 40% of episodes resulted in care‐seeking.
4.2. Comparison to other literature
We are unaware of previous studies that have followed an inception cohort of people from the community who experienced an episode of LBP and described the episodes in terms of duration, pain intensity and care‐seeking. On the other hand, many studies have described the prognosis of people with LBP who present for care. Henschke et al. (2008) conducted a cohort study of 973 people presenting to care with LBP and found the median time to recovery was 58 days (95% CI 53 to 63), which is much greater than the 5 days in our study. They used a stricter definition of recovery (pain‐free for 30 days) that will contribute to some of the differences. Similarly, to us they considered the first of the 30 days as the date of recovery. Hancock et al. (2007) used an identical definition of recovery to ours in an RCT (investigating manual therapy and non‐steroidal anti‐inflammatory medications) including people with acute LBP presenting to care. They found the median time to recovery was 15 days, and it did not vary significantly by treatment allocation. The patients had a median of 9 days of pain prior to entering the study, so the duration for the full episode was approximately 24 days, again substantially longer than in our study. Together, these findings demonstrate that the duration of a typical episode of LBP in people from the community appears substantially shorter than a typical episode in people presenting to care.
In terms of pain intensity, it is difficult to directly compare our findings to other studies of care‐seeking cohorts, which typically report pain intensity at baseline and defined follow‐up time points, unlike our study that assessed worst and average pain across the episode. An RCT aiming to prevent LBP in military personnel (George et al., 2011) collected pain intensity scores for the last 24 h at the first reported episode (George et al., 2012). The mean pain intensity reported was 2.0 (SD ± 1.9) and worst pain intensity was 3.2 (SD ± 2.5). These values are lower than we found. Possible reasons for the different findings include a military population, lower threshold for reporting an episode (we only recorded episodes where the average intensity was greater than 2 on a numeric pain rating scale) or the high rates of loss to follow‐up for this outcome in the military RCT. The baseline pain intensity of care‐seeking patients in the systematic review by Costa et al. (2012) (15 cohort studies and 3316 patients) was 5.2 on a 0‐10 scale. This is somewhat higher than our findings for average pain intensity of 3.7 and similar to our findings for worst pain intensity of 5.6. These findings suggest that the average pain of an episode of LBP in people from community is probably less intense than the average pain of an episode of LBP in people presenting for care.
We are unaware of any community inception cohort study assessing what proportion of patients experiencing an episode of LBP seek care for that episode. A cross‐sectional population‐based survey in Denmark found that 38% of people who had experienced LBP in the previous year had sought care (Leboeuf‐Yde et al., 2011). Previous reviews (Beyera et al., 2019; Ferreira et al., 2009) have reported that a little more than half of people with LBP seek care 0.58 (0.3 to 0.85), based on recall for periods ranging from 2 weeks to 12 months (Ferreira et al., 2009). Our data demonstrate that less than half of those with an acute episode of LBP seek care for that episode.
4.3. Meaning and implications of findings
The main implication of our study is that given the short duration of most episodes of LBP, the community should be reassured about the favourable prognosis of LBP and encouraged to try to self‐manage most episodes, seeking care only if the episode does not resolve quickly or if the episode is severe. Currently, many unhelpful beliefs about LBP exist in the general community that are inconsistent with current evidence on LBP (Gross et al., 2006; Jenkins et al., 2016), including our findings. Previous mass media campaigns have aimed to change community attitudes towards LBP to become more in line with current evidence, with mixed results (Gross et al., 2012). Our finding that most episodes recover rapidly provides further compelling and simple evidence that could enhance campaigns to change community attitudes towards LBP.
Despite the overall good prognosis and rapid recovery for many people experiencing an episode of LBP, we found that about 40% of participants still sought care for the episode. This paradox suggests that recommendations to self‐manage most episodes of LBP before seeking care may not be well understood in the community or may not be acceptable to some individuals with LBP. Further research is required to explore why patients seek care and if better community understanding of the positive prognosis of LBP, identified in this study, can assist to reassure patients to self‐manage and therefore reduce care‐seeking.
Our findings also have implications for clinicians managing LBP. Our findings further support international guideline recommendations to reassure patients about the favourable prognosis for an episode of LBP. However, as our findings directly relate to people from the community, they are particularly relevant to the advice clinicians should provide about future episodes when discharging patients from care. Patients should be advised that despite recurrences being common (Da Silva et al., 2019), the vast majority will recover rapidly. Ideally, clinicians would provide patients with the skills and confidence to self‐manage most future episodes of LBP. Our previous trial investigating a brief prevention intervention (two sessions of McKenzie exercise and education) found that while the intervention did not prevent recurrences it did appear to substantially reduce care‐seeking when an episode occurred (De Campos et al., 2020).
4.4. Limitations
Our study used data from two previous studies including an RCT (Da Silva et al., 2019; De Campos et al., 2020). These patients may be somewhat different from the general community. Both studies used relatively few exclusion criteria and the baseline characteristics appear relatively typical of those experiencing LBP; however, we cannot rule out other important unmeasured differences. The participants in the intervention groups of the RCT (De Campos et al., 2020) received two sessions of exercise and education, which aimed to prevent an episode and provide skills to manage a future episode. This intervention did not reduce the risk of a recurrence but did appear to reduce the risk of care‐seeking, so we excluded the patients in the intervention group from our analysis of the proportion of people seeking care. The different definitions of recovery from an episode make comparison between studies difficult and our definition of at least 7 consecutive days with no greater than 1 on a numeric pain rating scale (ratings = 0–10), must be considered when interpreting our results. Our methods of follow‐up may have produced some recall bias, especially for those who took longer to recover. Many participants with short episodes had recovered when we first made contact by phone, so the recall period was short. However, for some participants with longer episodes, the recall period could be up to a maximum of 3 months.
5. CONCLUSIONS
We found the majority of people from the community who have episodes of LBP recover quickly, with an estimated median duration of 5 days. The worst pain intensity was typically moderate and approximately 40% of episodes resulted in care‐seeking.
AUTHOR CONTRIBUTIONS
Prof Mark Hancock, Dr Tarcisio F. de Campos, and Dr Tatiane M. da Silva had full access to all of the data in the studies and take responsibility for the integrity of the data and the accuracy of the data analysis. Prof Mark Hancock, Prof Chris Maher, Dr Tarcisio F. de Campos, Dr Tatiane M. da Silva, and Miss Natasha C. Pocovi contributed to concept and design. Prof Mark Hancock, Dr Tarcisio F. de Campos, Dr Tatiane M. da Silva, and Miss Natasha C. Pocovi contributed to acquisition, analysis or interpretation of data. Prof Mark Hancock, Dr Tarcisio F. de Campos contributed to drafting of the manuscript. All authors contributed to critical revision of the manuscript for important intellectual content. Prof Mark Hancock, Dr Tarcisio F. de Campos contributed to statistical analysis. Prof Mark Hancock and Prof Chris Maher obtained funding.
FUNDING INFORMATION
The RCT study was supported by a grant from the International Mechanical Diagnosis and Therapy Research Foundation—USA. The funders of the RCT had no role in the study design, data collection, data analysis, data interpretation or the decision to publish and writing of the RCT manuscript.
CONFLICT OF INTEREST STATEMENT
Dr Tarcisio F. de Campos received an International Mechanical Diagnosis and Therapy Research Foundation (IMDTRF) continuation grant during the conduct of the RCT study.
Supporting information
Appendix S1
ACKNOWLEDGEMENTS
Dr Tarcisio F. de Campos received a PhD scholarship from Macquarie University (Macquarie University Research Excellence Scholarship (MQRES)). Prof Chris G. Maher is supported by a National Health and Medical Research Council Principal Research Fellowship. Dr Tatiane M. da Silva received a fellowship from (FAPESP São Paulo Research Foundation) with grant number: 2018/20035‐7. Miss Natasha C. Pocovi receives a PhD scholarship from Macquarie University (Macquarie University Research Excellence Scholarship (MQRES)). The authors thank all the participants recruited into the studies, and all physiotherapist practitioners involved in the RCT study. Furthermore, we thank the International Mechanical Diagnosis and Therapy Research Foundation (IMDTRF) for funding the RCT study. Open access publishing facilitated by Macquarie University, as part of the Wiley ‐ Macquarie University agreement via the Council of Australian University Librarians.
de Campos, T. F. , da Silva, T. M. , Maher, C. G. , Pocovi, N. C. , & Hancock, M. J. (2023). Prognosis of a new episode of low‐back pain in a community inception cohort. European Journal of Pain, 27, 602–610. 10.1002/ejp.2083
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Supplementary Materials
Appendix S1