Low back pain is very common and experienced by people of all ages. The 1-year incidence of a first-ever episode of low back pain range from 6% to 15%, while estimates of 1-year incidence of any episode of low back pain can be as high as 36% according to statistics from 2010. Ranges of episode remission at one year are quite variable with estimates from 54% to as high as 96%.
Unfortunately, many people who experience activity-limiting low back pain go on to experience recurrent episodes and chronicity. The smaller percentage of patients with recurrent episodes of low back pain or chronic, ongoing back pain, account for a significant amount of direct and indirect costs associated with management of the problem.
Although many patients with low back pain improve, it is likely a myth that most low back pain is self-limiting and benign, as chronic or recurrent episodic low back pain is common, disabling and costly for individuals and the health care system. Generally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, primarily due to population increase and aging. The largest increase in low back pain over this time was in low and middle-income countries. Low back pain is now the leading cause of disability worldwide.
Dr. Mark Pfefer, director of research at Cleveland University-Kansas City, believes that care will eventually shift to a more proactive model.
“The future of back pain management will involve prevention of chronicity and less reliance on pharmacologic interventions, with more focus on active strategies to prevent and treat back pain,” Pfefer said. “In fact, research is emerging that demonstrates that use of anti-inflammatory medication for acute back pain may interfere with the healing process and actually lead to chronicity.”
The optimistic misperception of back pain resolving “on its own,” has likely led to false confidence in a passive management philosophy involving symptomatic approaches (rest and medication) or a non-management approach. The view that most acute episodes of back pain resolve quickly and completely is disputed by a number of studies based upon back pain patients seen in primary care practices. It is more cost-effective to intervene in ways to prevent chronicity in those at risk for it, rather than waiting to treat only those in whom it becomes fully apparent.
There is a wide variation in the literature, with up to 80% chance of recurrence and up to 30% chance of non-resolution of back pain within one year. For patients with multiple regions of back pain, the prognosis is more bleak. Natural history of back and neck pain may be more accurately described as “the future will likely reflect the past. If you have had episodes of back pain in the past, recurrence is common.”
Recent guidelines for low back pain from the American College of Physicians place an emphasis on non-pharmacologic treatment with the fewest harms and lowest costs. Recommendations include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, low-level laser therapy, cognitive behavioral therapy, and spinal manipulation.
Stephen Atlas points out in an editorial comment that this shift in low back pain management “represents a major change for primary care physicians” and “partly reflects the limited pharmacologic choices” for back pain. Atlas agrees with other back pain researchers that current guidelines “may represent a shift toward efforts to prevent progression to chronic low back pain by identifying patients at risk for persistent pain.”
Future trends in management of back pain will likely involve research to improve clinical prediction rules which will help in stratifying various types of back pain into groups that are either more or less likely to recover, and possibly match patients to different types of management strategies. Identifying the potential risk factors for acute back pain becoming recurrent or persistent will be an important issue going forward for back pain researchers.
