Chou R, Shekelle P Will this patient develop persistent disabling low back pain? JAMA 2010;303(13):1295-1302
- systemic review drawn from 20 studies
- conclusion:The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.
- Patient scenario
- A 48-year-old woman is evaluated in clinic with a 3-day history of low back pain without leg pain. She has no previous history of cancer and no weight loss, anorexia, or night sweats. Her physical examination reveals mild paralumbar tenderness with normal strength, sensation, and lower extremity reflexes. She has not worked for 3 days due to the back pain. She does not recall any specific word-related injury. She rates the pain as 8 out of 10 and reports little improvement with over-the-counter acetaminophen.
- As her physician, you suspect acute nonspecific low back pain. You encourage her to remain active and prescribe nonsteroidal anti-inflammatory drugs. The patient states she is worried about her ability to return work. She is avoiding many of her usual activities and has stopped doing her daily 2-mile walk due to the pain and fear of making her back worse. She also has a history of chronic depression. Will this patient develop chronic disabling low back pain?
- Bottom line
- A systemic approach for primary care patients with low back pain that includes an assessment for high levels of maladaptive pain coping behaviors, presence of nonorganic signs, high levels of baseline functional impairment, low general health status, and psychiatric comorbidities can increase the likelihood of correctly predicting the development of persistent disabling low back pain through 1 year. Low levels of fear avoidance and low baseline functional impairment are the most useful items for predicting likelihood of recovery. Variables related to the work environment, baseline pain, and presence of radiculopathy are less useful for predicting worse outcomes, and a history of prior low back pain episodes and demographic variables (age, sex, smoking status, weight, and educational level) are not useful. Although Waddell’s signs are often used to assess for psychological components to back pain, they were designed to assess current pain rather thatn to predict future disability and have not been studied for that purpose.
- A systemic approach for primary care patients with low back pain that includes an assessment for high levels of maladaptive pain coping behaviors, presence of nonorganic sighs, high levels of baseline functional impairment, low general health status, and psychiatric comorbidities can increase the likelihood of correctly predicting the development of persistent disabling low back pain through 1 year.
- Low levels of fear avoidance and low baseline functional impairment are the most useful items for predicting likelihood of recovery. Variables related to the work environment, baseline pain, and presence of radiculopathy are less useful for predicting worse outcomes, and a history of prior low bac pain episodes and demographic variables (age, sex, smoking status, weight, and educational level) are not useful.
