Trajectories of Low Back Pain
SOURCE: Best Pract Res Clin Rheumatol. 2013 (Oct); 27 (5): 601–612
Iben Axén, Charlotte Leboeuf-Yde
Unit of Intervention & Implementation Research,
Institute of Environmental Medicine,
Nobels väg 13, S-171 77 Stockholm, Sweden
Low back pain is not a self-limiting problem, but rather a recurrent and sometimes persistent disorder. To understand the course over time, detailed investigation, preferably using repeated measurements over extended periods of time, is needed. New knowledge concerning short-term trajectories indicates that the low back pain ‘episode’ is short lived, at least in the primary care setting, with most patients improving. Nevertheless, in the long term, low back pain often runs a persistent course with around two-thirds of patients estimated to be in pain after 12 months. Some individuals never have low back pain, but most have it on and off or persistently. Thus, the low back pain ‘condition’ is usually a lifelong experience. However, subgroups of patients with different back pain trajectories have been identified and linked to clinical parameters. Further investigation is warranted to understand causality, treatment effect and prognostic factors and to study the possible association of trajectories with pathologies.
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Until recently, low back pain (LBP) was believed to be a self-limiting condition, much like the common cold. The European guidelines for the management of acute LBP state that 90% of patients will recover within 6 weeks. 
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However, research in the past two decades has shown that the majority of back pain sufferers experience episodes of the problem; LBP is actually a recurrent condition.  Thus, LBP resembles a long-term condition such as asthma rather than a self-limiting condition such as the common cold. This means that we need to look at LBP (and perhaps all types of spinal pain) as a lifelong process, perhaps with different causes and modifying factors as life goes on, but always present as an underlying ‘trait’.
This shift of paradigm directs the focus of attention away from LBP seen as a single entity to the LBP condition regarded as a chain of LBP episodes , that is, with the focus on the course of LBP.  This new paradigm comes with a hope of being able to classify nonspecific LBP into clinically meaningful subgroups.  Such subgroups may offer new insights into causal mechanisms, prognostic factors and effective treatment strategies. In the past, most studies related to LBP as though it has an ‘end point’, measuring for example, pain intensity, return to work, or recovery at a rather arbitrarily chosen point in time with questionnaire surveys. Because patients with LBP experience ups and downs of varying intensity and duration, such end points are likely to capture LBP at different phases of the condition, making comparison between people and studies potentially meaningless. These outcomes should instead be viewed in the light of the long-term development of LBP (see also chapter 2 of this edition). However, little is known about the detailed course, and trajectory, of LBP.