What is the Natural History
for Lower Back Pain?

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

Craig Liebenson, D.C.

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We have all heard the statistics that say 85% of patients are better in 6 weeks. Is this universally advertised short term outcome true? What do we mean by better? If our goal is to improve the quality of care for back pain patients then we first need to establish benchmark outcomes of recovery.

If improvement is the goal then 90% of patients are improving after only 3 weeks. But, if asymptomatic is the goal then only 46% reached this goal after 7 weeks. If not having any activity limitations due to pain is the goal, as AHCPR suggests, then only 38% have achieved this goal by 7 weeks.

A new outcome question to ask patients has been proposed by Cherkin and Deyo. They suggest asking "If you spent the rest of your life with the symptoms of the last 24 hours how satisfied would you be?" It turns out that 1/3 of patients are satisfied after 1 week. But, that 1/3 are dissatisfied after 7 weeks. Offering overly optimistic forecasts for recovery risks disappointed 1/3 of our patients.

Two recent papers, one by Cherkin, et al and one by Van Korff and Saunders both suggest that the natural history is not so rosey for low back disorders as was believed. In fact, we should evaluate outcomes relative to recovery from the acute episode as well as recurrences one year later. Key outcomes include pain intensity (VAS), activity limitations (Oswestry, Roland-Morris, Neck Disability Index), use of pain medication, time off work, and utilization or cost of health care services. Measuring these outcomes on a regular basis will allow us to defend appropriate care and establish a universal database for chiropractic care. James Weinstein, DO the chief editor of Spine said at our chiropractic centeniel in Washington, D.C. that research in the future will be done not by randomized, controlled clinical trials, but by hundreds of clinics capturing outcomes on patients classified into meaningful groups.

A key classifications is sciatica patients. Sciatica patients have a worse prognosis than mechanical back pain patients. Which other patients are at greater risk of prolonged recovery or recurrences? Patients with job dissatisfaction, depression, and poor self-rated health.

How can you learn more about gathering outcomes and documenting patient prognosis and recovery?  Steven Yeomans, D.C. teaches this material as part of L.A.C.C.'s rehabilitation Diplomate program-  call LACC  (562) 902-3379.

Synergy Solutions has developed a software package that captures this data and autowrites initial and progress reports - Call the Gym Ball Store @  (800) 393-7255   for more information.

References:

1. Cherkin DC, Deyo RA, Street JH, Barlow W.
Predicting poor outcomes for back pain seen in primary care using patients' own criteria
Spine 1996; 21: 2900-2907

2. Von Korff M, Saunders K.
The course of back pain in primary care
Spine 1996; 21: 2833-2839

3. Bigos S, Bowyer O, Braen G, et al.
Acute low back problems in adults. Clinical Practice Guideline
Rockville, MD: U.S. Department of Health and Human Services,
Public Health Service, Agency for Health Care Policy and Research, 1994

4. CareTrack Outcome System.
Synergy Solutions. Grand Rapids, MN (800) 950-8133

5. Yeomans SG, Liebenson C.
Applying outcomes to clinical practice
JNMS 1997; 5(1); 14

6. Liebenson C, Yeomans SG.
Outcomes assessment in musculoskeletal medicine
Manual Therapy 1997; 2(2): 67-74

7. Bolton JE.
Evaluation of treatment of back pain patients: clinical outcome measures
European J of Chiro 1994; 42: 29-40

8. Bolton JE.
Methods of assessing low back pain and related psychological factors
European J of Chiro 1993; 41: 31-38

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Since 8-01-1997