Is the natural history of low back pain really that good?
The natural history of any disorder represents what happens when it is left untreated. For example, does it worsen and spread, or does it tend to be self-limiting and dissipate with time? Certain conditions have favorable natural histories, that when allowed to run their course resolve quickly and without incident. Other conditions have less favorable natural histories and require some form of intervention to prevent long-term problems.
When it comes to low back pain, however, the natural history is not as clear.
Most doctors have been taught to reassure their low back pain patients that they will get better with time. This sentiment is echoed by several international guidelines for low back pain, which state that the majority of cases will resolve in three months or less.
These healthcare providers and guidelines are essentially stating that the natural history of low back pain is favorable, and that patients should not worry because their pain will likely go away on its own. Said another way, they are implying that most low back pain is benign.
If this were the case, low back pain wouldn't be the world's leading cause of activity limitation, absenteeism from work, and years lived with disability.
But it is.
It also wouldn't result in a substantial medical burden and economic cost, one that has ballooned to roughly $100 billion annually in the United States.
But it has.
So to clear up this confusion, let's take a closer look at the natural history of low back pain (or at least most cases of low back pain), which can be characterized as episodic, recurrent, and progressive.
Episodic
This is where the favorable natural history information imparted by guidelines has the most merit, at least in the short term. Low back pain commonly occurs in episodes, meaning it arises and then recovers, with or without treatment.
We know that a sizable number of acute episodes of low back pain resolve quickly and spontaneously. For example, some research reports that 80-90% of attacks recover in about six weeks.
Now if low back pain mainly consisted of single, isolated, self-resolving episodes, then I would agree that you could describe it as relatively benign. Unfortunately, that's not the case, and the following two descriptors of its natural history demonstrate why.
Recurrent
For many individuals, recovery from an episode of low back pain is not the end of their back pain experience. More often than not, they will experience it again.
We know that the strongest risk factor for developing low back pain is a previous history. At least 75% of people who have had low back pain at some point will get it again, and perhaps two-thirds will have a recurrence within 12 months.
It's not uncommon for people to have dozens of episodes during their lifetime. As a result, the waiting rooms of clinics that treat low back pain are often full of patients seeking temporary relief for yet another attack.
And it's not as if these recurrent episodes are isolated events, uninfluenced by prior occurrences. Instead, they appear to be related to one another, and the third feature of the natural history of low back pain explains why.
Progressive
Perhaps the most troubling description of low back pain is that it is often progressive, meaning it worsens with time. This is demonstrated in workplace studies on low back pain, which show that recurrent episodes tend to lead to more time off than first time episodes.
It's not uncommon for people who undergo lumbar spine surgery for sciatica to report that their problem began many years prior with a single bout of low back pain. They state that over time their episodes of pain lasted longer, became more severe, and even began to radiate down their leg. At some point, they failed to recover on their own or with conservative treatment as they had in the past.
This progressive worsening likely indicates that the pain-generating tissue is being repeatedly insulted, even to the point that it is no longer capable of recovery through natural history or most forms of care. This is one reason why roughly one million lumbar spine surgeries are performed every year in the United States.
These features of low back pain don't sound like a benign natural history to me.
Even though they may seem depressing, if you look closely, there is a silver lining amid these characteristics. While the fact that low back pain is recurrent is often viewed in a negative light, it also implies that there are periods without pain. Said another way, these episodes have the ability to recover.
Perhaps the best way to describe this feature of low back pain is that it is reversible.
I would argue that when present, reversibility is the most important quality of low back pain, even more so than episodic, recurrent, or progressive. And because of this, patients should be given the opportunity to discover if their pain is reversible. This is best achieved through a careful assessment conducted by the right healthcare provider, which can often reveal movements and positions that worsen symptoms and others which improve symptoms. If a patient's pain fits into this pattern, then a single direction of movement, termed the directional preference, can substantially improve their condition. More importantly, it allows them to control their pain on their own, which can cut down on the number of recurrences and limit the overall progression.
And with a natural history described as episodic, recurrent, and progressive, ideal management for low back pain should aim at what someone can do for themselves in the long term, rather than simply providing short-term symptomatic relief until the next occurrence.
Dr. Jordan Duncan was born and raised in Kitsap County and graduated from the University of Western States in 2011 with a Doctor of Chiropractic Degree. He practices at Silverdale Sport and Spine. He is one of a small handful of chiropractors in Washington state to be credentialed in the McKenzie Method.
This article originally appeared on Kitsap Sun: Is low back pain a natural phenomenon that will go away on its own?
