Q: What's the best way to predict prognosis after the first episode of low back pain?

A: Prognosis by definition is the forecast of what will probably happen and the outcome of an illness, injury, disease or other condition. Prognosis especially looks at the chances for recovery. Many times, recovery is based on pain relief, ability to perform daily activities, and return-to-work.

The natural history of back pain (what happens over time) varies from person to person. Scientists have not been able to accurately predict for everyone who will get well and who won't. Right now, researchers exploring back pain are dividing patients into groups and subgroups. Then they look for common traits that might predict who will get well and who won't. This type of classification scheme may also help us define what treatment type will work for each subgroup.

At the same time, efforts are being made to provide all health care professionals who treat back pain patients with a set of treatment guidelines called Clinical Practice Guidelines or CPGs. The CPGs are based on research evidence but also expert opinion and agreement. The idea is to create a response that is most likely to generate a positive outcome (prognosis) for as many people as possible.

There was a recent study where researchers from two large health care organizations tried to predict prognosis for patients with acute low back pain based on return to work. Over 600 people participated in the study. Each one had an episode of acute low back pain (with or without sciatica/leg pain) in the last 30 days. They were later contacted by phone (six months later and again two years later) to ask about their experience. As part of the survey, they reported their work status (full-time, part-time, unemployed and seeking work, not seeking work, retired).

Other data collected for review and study included how long the back pain lasted, level of pain intensity, and number of days in bed and/or off work. Each individual was also asked to rate their recovery as they viewed it on a scale from much worse to fully recovered.

Analysis of the data showed that prognosis when based on whether or not the person returned to work was much less favorable than when using other measures (e.g., pain, disability). Instead of the previously reported 10 per cent of patients who went from having acute low back pain to chronic pain, 13 per cent had chronic pain at six months and even more (19 per cent) had chronic low back pain at the end of two years.

Many of the remaining patients who did return to work did so with continued pain and physical limitations. Forty-one per cent (41%) reported having to change positions often just to get comfortable while 31 per cent tried to avoid bending or kneeling down. Other activities that posed problems for the group included turning over, walking quickly, getting up from a chair, or using stairs without a handrail.

In observing the results of the data, the authors make several other comments. First, there were quite a few people who were up and down with their back pain. Almost half of the group (47 per cent) had some additional recurrences of low back pain during the six months following their first episode. Second, patients with low back pain and sciatica (leg pain) were more likely to have a poor outcome. And third, results vary depending on the exact wording used to define acute and chronic low back pain.

The problems of going back to work while still in pain and continuing to work despite symptoms and disability need to be addressed. The fact that people often still have back pain six months after the first episode and that increases the risk of developing chronic back pain also needs attention. Efforts are needed to find ways to prevent back pain, recurrent back pain, and chronic back pain -- in other words, improve the prognosis!

Reference: Wolf E. Mehling, MD, et al. The Prognosis of Acute Low Back Pain in Primary Care in the United States. In Spine. April 15, 2012. Vol. 37. No. 8. Pp. 678-684.