Dutch Treat: Back Pain

ABSTRACT & COMMENTARY

Synopsis: A prospective study of 443 Dutch patients with low back pain followed for a year after presentation found that the initial episode of back pain improved with time, but only 50% of patients had resolution of back pain within two months, 80% by six months, and 90% by one year.

Source: van den Hoogen HJM, et al. Ann Rheum Dis 1998; 57:13-19.

Back pain is one of the more common musculoskeletal problems for which people seek medical attention, affecting an estimated 80% of Americans at least once in their lifetime.1 We expect most patients whose back pain is not associated with malignancy or significant trauma to improve. This study from the Netherlands helps to establish realistic expectations for patients with low back pain and the physicians who care for them. The authors enrolled 443 adults at the time of presentation to general practices with back pain. The back pain could have been present for any length of time prior to initial presentation and was classified as "acute" if present for less than seven weeks and as "chronic" if present for seven weeks or more.

After enrollment, patients received "usual care" from the physicians, and the study involved follow-up by questionnaire at monthly intervals for one year. Presence of and severity of pain were assessed for each week of each month, and patients were classified as having had resolution of their back pain if four consecutive weeks passed without reporting pain. A relapse was recorded if pain recurred after at least four weeks free of pain. Disability was also assessed. There was an approximately logarithmic increase in the percentage of patients whose pain resolved so than only 10% had pain continuously for the entire year. The duration of back pain prior to presentation had a statistically significant effect upon the time to resolution of back pain. The median time to resolution was 10 weeks for those with chronic pain and six weeks for those with acute low back pain. A small number, (n = 35; 6%) of the patients were felt to have a specific cause of low back pain by the generalists. And, of those, only 10 (2%) had confirmation of a diagnosis, including nine with disc herniation and one with ankylosing spondylitis.

Even if pain did not resolve, it tended to decrease in severity, as did disability. Relapses were very common, with 76% of patients having at least one episode of recurrent low back pain. Relapses were shorter than the initial episode, with a median duration of three weeks. Patients who had several relapses were noted to have, on average, shorter periods of time before resolution. Fourth or fifth relapses lasted a median of one week.

COMMENT BY JERRY M. GREENE, MD

Back pain is a challenging disorder. An optimist would look at the data in this study and be encouraged by the fact that 90% of patients got over their episode of back pain. The pessimist would reply that one in 10 was still in pain a year later. Unfortunately, the study offers no insights regarding work, compensation, or litigation-factors that, in my experience, must be considered in patients with back pain. While resolution of back pain is a worthy goal, the reality is that many patients will either have chronic low back pain or frequent relapses of back pain, and the therapeutic goal may need to be redefined as maximizing function of, and minimizing the negative economic effect upon the patient with low back pain.

This study does not shed any light on what form of management is most useful for low back pain sufferers. However, a recently published study of acute low back pain indicated that, on average, patients were treated with about three medications-generally, an NSAID, an analgesic, and a muscle relaxant. They were advised to rest in bed at home, and about 80% of those who had been working were out of work for a mean of roughly eight days for an episode. About one-third had imaging studies, 30% were referred for physical therapy, and 5% were referred to specialists.2 This last group, who are referred for refractory or severe low back pain, represent the hard and sometimes frosty tip of the iceberg. Which is, perhaps, why I sometimes get a chill up my spine when I see the letters "LBP." (Dr. Greene is Instructor in Medicine, Harvard Medical School; Chief, Rheumatology Section, Brockton/W. Roxbury VA Hospital.)