Professional Documents
Culture Documents
Correspondence
Jose W. Geurts
E-mail: jose.geurts@mumc.nl
Funding sources
None declared.
Conicts of interest
None declared.
Accepted for publication
30 April 2012
doi:10.1002/j.1532-2149.2012.00170.x
Abstract
Background and objective: Non-specific low back pain is a relatively
common and recurrent condition for which at present there is no effective
cure. In current guidelines, the prognosis of acute non-specific back pain is
assumed to be favourable, but this assumption is mainly based on return to
function. This systematic review investigates the clinical course of pain in
patients with non-specific acute low back pain who seek treatment in
primary care.
Databases and data treatment: Included were prospective studies,
with follow-up of at least 12 months, that studied the prognosis of patients
with low back pain for less than 3 months of duration in primary care
settings. Proportions of patients still reporting pain during follow-up were
pooled using a random-effects model. Subgroup analyses were used to
identify sources of variation between the results of individual studies.
Results: A total of 11 studies were eligible for evaluation. In the first 3
months, recovery is observed in 33% of patients, but 1 year after onset,
65% still report pain. Subgroup analysis reveals that the pooled proportion
of patients still reporting pain after 1 year was 71% at 12 months for
studies that considered total absence of pain as a criterion for recovery
versus 57% for studies that used a less stringent definition. The pooled
proportion for Australian studies was 41% versus 69% for European or US
studies.
Conclusions: The findings of this review indicate that the assumption
that spontaneous recovery occurs in a large majority of patients is not
justified. There should be more focus on intensive follow-up of patients
who have not recovered within the first 3 months.
1. Introduction
Non-specific low back pain (LBP) is a relatively
common and recurrent condition with major medical
and economical implications for which today there is
no effective cure (van Tulder et al., 1995; Roelofs
et al., 2008; Becker et al., 2010; van Middelkoop
et al., 2011). Most treatment strategies and guidelines are based on the assumption that the prognosis
of acute LBP is favourable and that the pain resolves
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
Database
This systematic review investigates the clinical
course of low back pain in primary care settings.
Nonspecific low back pain is a relatively common
and recurrent condition for which at present
there is no effective cure. In current guidelines
the prognosis of acute nonspecific back pain is
assumed to be favourable but this assumption is
mainly based on return to function. Included
were 11 prospective studies, with follow-up of at
least 12 months, which studied the prognosis of
patients with back pain for less than 3 months of
duration set in primary care.
What does this review add?
This review shows that after 3 months recovery
is observed in 33% and after one year 65% of
patients with low back pain still report pain.
2. Methods
2.1 Study selection
A literature search was performed for suitable articles
published between 1990 and 2010 in English, German
and Dutch, referenced on MEDLINE and PUBMED,
and EMBASE (Table 1). The search was started at 1990
because in 1987 Spitzer wrote his monograph: Scientific
approach to the assessment and management of activityrelated spinal disorders. A monograph for clinicians. Report
of the Quebec Task Force on Spinal Disorders (Spitzer et al.,
1987). This study had a major impact on the treatment
of LBP, and still has impact today. Therefore, we were
basically interested in evidence provided by studies
that were published in the years following this
publication.
6
(350)
(87)
(10008)
(4823)
(24)
(29)
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
Table 2 Three methodological tests containing 12 individual criteria for prevalence studies to determine the quality of the studies.
1.
A.
B.
C.
2.
D.
E.
F.
G.
H.
I.
3.
J.
K.
L.
Modied Leboeuf criteria adding E: appropriate use of statistics (Leboeuf-Yde and Lauritsen, 1995). LBP, low back pain.
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
Table 3 Assessment of quality according to the modied Leboeuf criteria (Leboeuf-Yde and Lauritsen, 1995).
Representativeness
Study
Total %
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
NA
+
+
+
+
NA
NA
+
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
+
+
+
+
-
+
+
+
+
-
+
+
+
+
+
+
+
+
70
60
50
50
80
90
40
80
60
80
80
3. Results
Provisional inclusion n = 16
Exclusion
n=3
Inclusion n = 11
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
4. Discussion
The findings of this review indicate that the majority
of patients (65%) still experience pain 1 year after
onset of LBP. In the first 3 months, recovery is
observed in a substantial part of the patients, but
thereafter only few patients recover.
The conclusion of this review is in line with a previous systematic review that questioned the prognosis
of acute LBP and also found high rates of LBP after 1
year varying between 42% and 75% (Hestbaek et al.,
2003). This review differed from the present review by
also including studies that were performed in second-
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
10
Age in years
223
524
83
55
55
Pain intensity
Maximal pain
intensity
Pain/disability
Sick leave
Pain intensity
52
56
62
48
Fear-avoidance 50
behaviour
100
81
Pain
intensity
Functional
status
Disabling LBP
38 (10)
51% >45
38 (2946)
53 (4267)
43 (14)
32 (7)
28
43 (11)
47 (3852)
610
01 [ 3]
012 21(1463)
06
03
02 [4]
012 [14]
01
Pain localized T6 or
below
54.7
25
30
25
52.7
20.8
Denition of pain
free at FU time point
(pain scale)
110/126
(87%)
573/955
(60%)
3 weeks of LBP
complaints free and
current pain (VAS)
1 week of VAS
score of 0 (VAS 0100)
6 months (84%); 12
months (80%)
131/175
(75%)
37/72
(51%)
457/956
(48%)
149/188
(79%)
93/117
(79%)
133/191
(70%)
99/165
(60%)
291/484
(61%)
22/60
(37%)
107/177
(61%)
123/169
(72%)
235/491
(48%)
20/46
(44%)
97/123
(79%)
388/944
(41%)
63/78
(81%)
72/115
(63%)
128/170
(75%)
98/126
(78%)
62/89
(70%)
Free of constant or
intermittent pain (pain
drawing)
3 months (87%); 6 months Score of 010 mm on
(72%); 12 months (55%)
pain intensity (VAS
0100 mm)
1 month (96%); 6 months Combination of sick
385/503
(92%); 12 months (94%)
leave and question about (77%)
feeling of well-being
concerning LBP (question
with answer yes)
3 months (81%); 6 months No back pain problem
(76%); 12 months (77%)
Score of 0 (GCPS 04)
12 months (41%)
12 months (56%)
12 months (72%)
Onset LBP in
FU time points
weeks [mean
1LE- (response rate
days] median(IR) LBP % on pain scale)
012
Fear-avoidance 45
beliefs
Physical
activity
Main study
parameter
LBP, low back pain; , not specied; PCP, primary care practice; GP, general practitioner; FU, follow-up; 1LE-LBP, rst lifetime; IR, Interquartile Range; DDS, Descriptor Differential Scale (Gracely and Kwilosz, 1988); GCPS, Graded Chronic Pain Scale (Von Korff
et al., 1992); VAS, Visual Analogue Scale (Price et al., 1983); NRS, Numeric Rating Score (Childs et al., 2005); SF36, Quality of Life Short Form; SD, standard deviation.
a (Bousema et al., 2007); b (Burton et al., 1999); c (Croft et al., 1998); d (Dettori et al., 1995); e (Epping-Jordan et al., 1998); h (Henschke et al., 2008); k (Klenerman et al., 1995); m (McGuirk et al., 2001); s (Schiottz-Christensen et al., 1999); t (Sieben et al., 2005);
w (Werneke and Hart, 2001).
States of America
80%
Schiottz-Christensen
et al. (1999)s
Denmark 60%
Australia 80%
222
Sieben et al. (2005)t
The Netherlands 80%
149
140
Epping-Jordan et al.
(1998)e United States
of America 80%
Henschke et al. (2008)h 973
Australia 90%
162
North East United
Kingdom 60%
218
Croft et al. (1998)c
Manchester area
United Kingdom 50%
124
Baseline Description
N
of sample
Pain proportion
Current history/baseline FU
Denition of LBP
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
Figure 2 Course of low back pain. Dots show pooled proportions. Error
bars show 95% condence intervals. The gures at the bottom of the gure
depict the number of studies that provided information for the specic
time points.
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
11
Study
ID
ES (95% CI)
Weight
Bousema (2007)
8.88
Burton (1999)
9.18
Croft (1998)
9.26
Dettori (1995)
8.98
Epping (1998)
8.99
Henschke (2008)
9.53
Klenerman (1995)
9.18
McGuirk (2001)
8.11
Schiottz (1999)
9.45
Sieben (2005)
9.24
Werneke (2001)
9.21
100.00
Figure 3 Forest plot of a random-effects meta-analysis on the proportion of patients with low back pain 1 year after onset. The size of the square box is
proportional to the weight that each study contributes in the meta-analysis. The pooled estimate and 95% condence interval (CI) are marked by a
diamond.
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
Figure 4 Difference in pooled proportions with pain at 12 months between subgroups. Studies are categorized into subgroups according to presence
versus absence of a specic study characteristic. Presented are differences in pooled proportion with [95% condence intervals (CIs)] between subgroups
of studies. Positive difference indicates higher pooled proportion in studies in the rst subgroup compared with the pooled proportion of the second
subgroup. Negative difference indicates lower pooled proportion in the rst subgroup compared with the pooled proportion of the second subgroup.
LBP, low back pain.
5. Conclusions
This systematic review shows that spontaneous recovery from non-specific LBP occurs in the first 3 months
after onset of LBP in about one-third of patients, but
the majority of patients (65%) still experience pain 1
year after onset of LBP. These findings indicate that the
assumption underlying current guidelines that spontaneous recovery occurs in a large majority of patients
is not justified. There should be more focus on intensive follow-up and monitoring of patients who have
not recovered within the first 3 months. Futureresearch should be directed at improvement of classification of non-specific LBP in more specific groups.
Eur J Pain 17 (2013) 515 2012 European Federation of International Association for the Study of Pain Chapters
13
Author contributions
Both C.I. and J.G. independently screened the titles,
abstracts and keywords of all references identified by the
literature search, extracted data from selected studies on
population and study characteristics, and assessed the quality
of the articles. J.G. corresponded with authors from studies
considered for evaluation. Analyses were performed by J.G.
and P.N. P.N. and M.v.K. oversaw and contributed to the
overall execution of the project. All authors discussed the
results and commented on the manuscript. All authors
helped to write the manuscript.
Acknowledgement
The authors like to thank Sander van Kuijk from the Department of Epidemiology of the Maastricht University for
his help.
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