McGorry RW, MSBE, PT et al. Spine 2000;25(7): 834-841. Two thirds of the people who have had back pain in the past can be expected to have some symptoms every year.

Borkan, PhD, Van Tulder, PhD, et al. Advances in the field of low back pain in primary care. A report from the Fourth International Forum. Spine;2002 27(5):E128-132. LBP is not easily classified as either an acute, self-limited condition or a chronic, unremitting ailment. It is more typically a recurrent or

intermittent syndrome tt erupts periodically over t course of a lifetime. The concept of LBP has undergone a dramatic shift in t dominant paradigm. Until 10 yrs ago, LBP was considered purely biomechanical & involved looking for anatomic damage & finding ways of fixing it. This approach hasn’t worked. The inadequacy of this model led to a radical shift – from thinking about LBP as a biomedical “injury” to viewing it as a multifactorial biopyschosocial pain syndrome.

McKenzie, R. The Myth of Short term Acute Low Back Pain. NZFP 2005; 32(2): 125-6. The chance of having a recurrence of BP after a first episode is >50%. Many recurrences are common & >1/3 of t BP population have a long-term problem. The message is that, in any one year, recurrences, exacerbations & persistence dominate t experience of LBP in t community. An individual’s experience of BP may well encompass their life history. T high rate of recurrences, episodes & persistence of symptoms seriously questions t myth of an acute/chronic dichotomy. BP should be seen from t perspective of t sufferer’s lifetime – & given such a perspective t logic of self-management is over-whelming. Yet, the Accident Compensation Corporation has repeatedly advised t public & health care providers tt acute BP is short term. All that is required is to remain active, remain at work & maintain a positive outlook for early recovery. This advice denies t opportunity for Pts to learn, in t early stages of their problem, self management protocols known to assist in early resolution.

Suni J, PT, PhD, Rinne M, PT, MSci, Natri A, MD, DSci, et al. Control of the lumbar neutral zone decreases low back pain and improves self-evaluated work ability: a 12-month randomized controlled study. Spine 2006;31:E611-20. A single episode of ALBP has a favorable natural Hx but t course of LBP for most Pts is recurrent rather than acute or chronic. Recurrence rates are high ranging from 60-86% in t first yr.  Recurrent findings underscore t signif of early intervention aimed to prevent chronic problems. There’s growing evidence tt changes in motor control & function of trunk muscles may result in disorders as a result of abnormal tissue loading & pain. Stress, fear, anxiety, & depression are known to disrupt motor behavior. Controlling t neutral zone (NZ) in lumbar motion & avoiding full lumbar flexion appear to provide protection from ligament injury & posterior disc herniation. Co-contraction of torso muscles is necessary for maintaining stability around t NZ.

Hayden JA, DC, PhD, Dunn KM, PhD, van der Windt DA, PhD, Shaw WS, PhD. What is the prognosis of back pain? Best Practice & Research Clinical Rheumatology 2010;24:167–179. Most LBP episodes are mild & rarely disabling, w only a small proportion of Ss seeking care. Most new episodes recover within a few weeks. Among Pts presenting for care, ~62% will continue to have pain at 1 yr & ~16% who were initially off work will still be off at 6 mo. Among those w a new episode of ALBP, rapid improv’ts are common during t 1st mo after consultation. In studies looking at the most ‘acute’ Pts: 75–90% recover from pain & disability w/i wks of seeking care, & many off work will rapidly RTW. However, from a longer-term perspective, many Pts have recurrences after an initial LBP episode: 1/4 to 1/3 of ALBP Pts still report Sx 6–12 mo after a consultation. Chronic LBP Ss have a more persistent course w 2/3 not fully recovered 1–2 yrs after onset & ~80% still having pain a 1 yr F-U. Studies of mixed primary-care LBP Pts persistence rates are similar to chronic populations, reflecting t high proportion of primary care Ss w long-term problems. Between the initial visit & 1 yr F-U the course commonly consists of relapses: ~60% have relapses of pain & 33% repeated episodes of work absence. LBP has for 4 recovery courses: (1) recovering, (2) persistent mild symptoms, (3) constantly fluctuating problems & (4) severe chronic levels of pain. Important prognostic factors explaining the variability of outcomes include: individual & psychological characteristics, work & social environment.

Dagenais S, DC, PhD et al. Review Article: NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain. The Spine Journal 2010; 10: 918–940. The 1- year incidence of LBP is ~20% & most initial episodes are mild. The point prevalence of LBP ranges from 6% to 33%. 1-yr prevalence from 22% to 65%. In most cases of acute LBP (ALBP), an objective cause can’t found & are described as ‘‘nonspecific.’’ LBP is commonly classified as acute (<3 mo) or chronic (>3 mo).  ALBP tends to improve with time & generally has a good prognosis, but improvement in pain & disability doesn’t correlate well w RTW. Recent studies show tt a significant proportion of ALBP sufferers will develop recurrent or chronic LBP. A survey of 35 to 45 yr olds found that LBP resolved quickly in only 27% of Ss, whereas 40% developed persistent LBP. Even among those whose LBP had initially resolved, 29% had recurrent LBP w/i 6 mo. Other studies find similar recurrence trends.  Although it’s difficult to predict wh first episodes of LBP Ss will develop recurrent or chronic Sx, factors related to determinants of disability & to prediction of chronic disability appear by 14 days after onset of pain, supporting tt as a cutoff point in the transition from acute to subacute pain.  Psychological factors play an important role in tt transition & related disability.

Itz CJ,et al. Clinical course of non-specific low back pain: A systematic review of prospective cohort studies set in primary care. Eur J Pain 2013; 17: 5–15. In current guidelines, the prognosis of acute non-specific LBP is assumed to be favorable. This systematic review investigates the clinical course of pain in non-specific acute LBP Pts (<3 mo) who seek primary medical care Tx based on studies (from 1990 thru 2010) w F-U of at least 12 mo. Results: 11 studies were reviewed. In the first 3 mos, recovery is observed in 33% of Pts, but 1 yr after onset, 65% still report pain. The studies showed that after 3 mo there was little additional recovery. Between 3 & 12 mo the % of Pts still reporting pain decreased by only 1–7%. The conclusion of this review is in line with a previous systematic review that questioned the prognosis of acute LBP & also found high rates of LBP after 1 year varying between 42% and 75%. Conclusions: The findings show that spontaneous recovery from nonspecific LBP occurs in the first 3 months after onset of LBP in ~1/3 of Pts, but 65% of Pts still experience pain 1 yr after onset of LBP. The assumption underlying current guidelines that spontaneous recovery occurs in a large majority of Pts is not justified. There should be more focus on intensive F-U & monitoring of Pts who have not recovered w/I the first 3 mo. Future research should be directed at improvement of classification of non-specific LBP in more specific groups.

Carroll L, PhD, et al. Course & Prognostic Factors for NP in t General Population: Results of t Bone & Jt Decade 2000-2010 task Force on NP & Its Assoc Disorders. Spine 2008;33:S75-82. Of 226 articles on the course & prognosis in NP & its assoc disorders, 70 (31%) were accepted on scientific merit. NP is common w typical 12 mo prevalence estimates of 30-50% in adults.   Among children & adolescents: 21-42%. NP w activity limitations is less common w 12 mo prevalence estimates of 2-11%. Like NP in workers & in WAD, NP in t general population is frequently persistent &/or recurrent. Studies suggest tt between 50% & 85% of Ss in t general population or primary care setting who experience NP will report NP 1 to 5 yrs later.  About 10% of Ss w initially mild or intense but nondisabling NP report NP tt became disabling over t F-U period; whereas 20% experienced recovery followed by worsening. Almost 40% experienced persistent levels of NP. It is unclear what proportion of Ss experienced continuous NP. The evidence is clear tt most people w NP do not experience a complete resolution of this problem.

Hush JM, PhD, et al. Prognosis of Acute Idiopathic Neck Pain is Poor: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2011;92:824-9. A systematic review on the prognosis of acute nonspecific or idiopathic neck pain (NP) & disability. Most episodes of NP are of unknown origin, referred to as nonspecific or idiopathic & are frequently recurrent. There is a lack of high-quality evidence on the prognosis of acute idiopathic NP. Systematic reviews have been done on t prognosis of WAD & ALBP, we are unaware of any reviews of the course of acute nonspecific/idiopathic NP. Methods: Identify RCT & cohort studies thru database searches thru July 2009: EMBASE, CINAHL, Medline, AMED, PEDro, & CENTRAL. Studies included if they were prospective & followed the course of nonspecific NP measuring pain &/or disability w Pts enrolled as an inception cohort (=/<6wk after onset of pain). Results: 6 studies.  3 used an inception cohort design, following the course of acute NP in Ss recruited from chiropractic, PT, & general practice clinics. 3 other studies were RCTs & data were extracted data from the minimal Tx grps: sham ultrasound, placebo, tetrazepam, neck collar, rest, & pain meds. Pain Scores: 86% of Pts (244/283) had an onset of NP in t past 2 wks. At the onset of acute NP, the mean pain score was 64 on a 0 to 100 scale. At 6.5 wks, mean pain score was 35. After this initial reduction of neck pain by 45% from onset to 6.5 wks, pain severity does not appear to resolve further from this stage to 52 wks. At 1 year, pain score was 42. Disability scores: The course of disability was similar to pain severity. Disability reduced from a mean score of 30 on a 0 to 100 scale at onset, to 23 at 1 wk. By 6.5 wks, neck disability had reduced by 42% to 17, but no further improvements were evident at 12, 26, or 52 wks. Discussion: This first systematic review about the course of acute idiopathic NP from inception reports tt outcomes for acute NP are surprisingly poor & resolution is incomplete. There is a rapid decrease in pain by 45% & disability by 43% during the first 6.5 wks. This degree of Sx reduction may be helpful, but t severity & duration of Sx persistence (37–42 on a 0–100 scale) up to 1 yr are likely to interfere w ADLs & quality of life. T intensity of persisting NP is twice as high as tt for LBP (wh remains at ~15 on a 0 to 100 scale from 3 to 12 mo). The course of disability for NP reduces from 30 to remain at 17 from 6.5 wk to 1yr & comparable w LBP prognosis. The course of acute idiopathic NP beyond 1 year is unknown. Conclusion:  Idiopathic NP doesn’t resolve further after 6.5 wks & pain severity at 12 mo is higher (42), although disability is similar (17) at 12 mo. Results show tt t prognosis of acute idiopathic NP is markedly worse than previously recognized & resolution is incomplete.