Persistent Acute Lower Back Pain: The Importance of Psychosocial Evaluation
JB is a 56-year-old male who reports low back pain at his annual health examination. However, he is not seeking treatment for it. He indicates that he “doesn’t have time to worry about it,” with all the duties that maintaining his Midwestern farm requires, and he feels that “nothing can probably be done, anyhow.”
Low back pain is one of the most common pain conditions, affecting most people at some point in their lives.1-3 Data collected over three decades (1980-2009, inclusive) indicate that the 1-year incidence of any episode of low back pain (first ever or recurrent) ranges from 1.5% to 36%.1 Most episodes are short-lived; however, many patients experience multiple episodes of low back pain, and some patients develop chronic low back pain.2,4,5
Approximately half of these patients have recurrence of their low back pain within 1 year, and 70% have recurrence within 5 years.1 The annual prevalence of chronic low back pain has been estimated to be as high as 45%.2 Because chronic low back pain is a major cause of disability and associated healthcare costs,6,7 preventing the transition from acute to chronic pain is desirable.
Individuals with chronic low back pain have more comorbidities and use more pain-related medications and healthcare services than individuals without chronic low back pain.6 In a retrospective insurance claims analysis of data from 2008, mean (standard deviation [SD]) direct medical costs were $8385.97 ($17,507.11) and $3606.63 ($10,844.50) for patients with and without chronic low back pain, respectively.6 Practitioners must therefore remain aware of the many treatment options available for managing persistent acute pain (pain that lasts longer than required for usual healing but for less time than would be considered ‘chronic pain’) to be able to provide individualized therapy for patients, with the goal of preventing conversion to chronic low back pain.8-10
Although this idea is still somewhat controversial, the conversion of acute low back pain to chronic low back pain appears to be able to be prevented in some cases with appropriate intervention during the period in which acute pain persists.11 Identifying and managing patients at risk for conversion to chronic pain is, therefore, vital to preventing chronic low back pain and associated disability. The current case-directed review discusses how to identify and manage treatment of patients with persistent, acute low back pain; that is, acute, low back pain that has persisted beyond 4 to 6 weeks, as a possible means of preventing the transition to chronic pain.
Identifying Patients at Risk
ML is a 48-year-old man who reports that he has been experiencing low back pain for 6 weeks. Since he began experiencing low back pain, he has tried to reduce his physical activity “as much as possible,” because he is concerned that physical activity will make the pain worse. He reports that he lives alone, does not have many friends, and that the pain has caused him to miss work and stay at home more because he “has been feeling down and just doesn’t want to go out.”
This patient is not alone. Results of a 2010 systematic review of the literature suggest that multiple factors may predict the development of persistent, disabling low back pain, including high levels of maladaptive pain coping behaviors, the presence of nonorganic signs, high levels of functional impairment at baseline, low general health status, and the presence of psychiatric comorbidities.12
Psychosocial factors may be particularly useful for predicting chronicity in low back pain.13 These include “yellow flags,” which are characteristics indicative of psychosocial barriers to recovery (Table 1).14 Depression and “maladaptive cognitions” (eg, somatization, rumination, and negative attitudes toward work and activity) may also signal a risk for low back pain persistence.15
Pain catastrophizing, or the tendency to dwell on the most negative consequences conceivable, also has been associated with disability.16 Furthermore, patients who avoid activity and social interaction due to fear of pain, as well as those who experience low mood and/or seek passive rather than active treatments, also are at increased risk for poor outcomes.13 The fear-avoidance model of chronic pain (Figure 1) summarizes the relationship between anxiety; escape and activity avoidance; disuse, disability, and depression; and pain perpetuation.16,17
Employment and workplace factors with physical and psychological impact, such as heavy manual labor, prolonged walking or standing, monotonous work, and job dissatisfaction, also may contribute to low back pain development and persistence.1,2,18 Additional contributing factors include lifestyle and social-demographic risks such as obesity, smoking, low socioeconomic class, low education level, and increasing age.1,2 However, despite observed relationships between smoking and obesity and low back pain, smoking cessation and weight loss interventions have not been shown to reduce long-term disability.19
Clinicians have a variety of tools to help identify patients like the sample patient above, who are at risk for developing chronic low back pain. The presence of recovery-limiting yellow flags can be detected through casual questioning during the patient interview (Table 2).13
Structured questionnaires, such as the Pain Catastrophizing Scale,20 the Fear of Pain Questionnaire,21 the Fear-Avoidance Beliefs Questionnaire,22 and the Coping Strategies Questionnaire,23 also can be used to determine the risk for catastrophizing. Additionally, identification of the patient’s avoidance-
endurance model response subtype may prove useful, because 3 of the 4 response subtypes (fear-avoidance, distress endurance, and eustress [ie, “healthful stress”] endurance) have been associated with increased risk of future pain problems.24 Conversely, patients who demonstrate adaptive responses to their pain have a greater likelihood of recovery. Examples include pacing one’s activities with rest periods during the day and using cognitive strategies, including cognitive restructuring.
Developing Management Strategies
Staying active is recommended for almost all acute back pain patients. Patients who are very acute and can barely turn over in bed should ambulate as soon as possible without great increases in pain and receive counseling regarding the expected course of their condition and effective self-care options.25,26 Bed rest should be discouraged.26