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Gustavo C. Machado, Chris G. Maher, Paulo H. Ferreira, Jane Latimer, Bart W. Koes, Daniel Steffens, Manuela L. Although recurrence is common after an acute episode of low back pain, estimates of recurrence rates vary widely and predictors of recurrence remain largely unknown. The purposes of the study were to determine the 1-year incidence of recurrence in participants who recovered from an acute episode of low back pain and to identify predictors of recurrence.
For 12 months, of the participants who initially presented to primary care within the first 7 days of an episode of low back pain were followed. Of these participants, recovered 1 month pain free from the index episode within 6 weeks and were included in this study. Recurrence was defined as a new episode lasting more than 1 day, or as an episode of care seeking. Putative predictors were assessed at baseline and chosen a priori. No other factors were associated with recurrences.
After an acute episode of low back pain, one-third of patients will experience a recurrent episode, and approximately half of those will seek care. Experiencing more than 2 episodes of low back pain triples the odds of a recurrence within 1 year. L ow back pain is the leading cause of disability according to the Burden of Disease Study, 1 and affects 9. Most studies that investigated recurrence of low back pain have focused on participants with persistent pain, therefore unlikely to recover or have a recurrence.
Other factors not showing an association included smoking, perceived global health, perceived risk of recurrence, red flags, physical activity, 5 and imaging findings.
Moreover, other Future lower back problems tumblr such as leg pain, pain and disability levels in the first 24 hours of the episode, use of medications, and anxiety have not yet been investigated. There is, therefore, a paucity of research in this area, leading to limited understanding of the risk factors for recurrence and the development of effective preventive management strategies for low back pain. In the current inception cohort study we aimed to investigate the 1-year incidence of recurrence of low back pain in a large representative sample of patients who had recently recovered from an acute episode of low back pain presenting to primary care.
We also investigated the risk factors associated with recurrences within 1 year, including novel factors not considered in studies. This is an inception cohort study with a 1-year follow-up nested in the case-crossover study Triggers for Low Back Pain. To be included, patients needed to have presented for care within 7 days from pain onset and report moderate pain intensity item 7 of the Item Short Form Survey [SF] in the first 24 hours.
Low back pain was defined as a primary complaint of pain between the 12th rib and the buttock crease, with or without leg pain, causing the patient to seek health care or take medication. In this inception cohort study, we only included patients who had recovered after an acute episode of low back pain ie, within 6 weeks. A baseline assessment was conducted through telephone interviews. These variables, chosen a priori, have been associated with poorer prognosis, 16 - 18 and were included in this study as putative predictors of recurrence of low back pain.
This approach has been used in studies investigating history of low back pain as a predictor of outcomes. Work status was simply measured by asking participants if they were in paid employment. Table 1 shows ly investigated factors associated with recurrence in other studies, 56 and those included in our analysis. The primary outcome for the study was recurrence of low back pain. Our primary definition of recurrence was an episode of low back pain that was still present 24 hours after the onset of symptoms, of at least mild pain intensity, 23 and followed a period of at least 30 days pain free pain intensity 0 or 1.
These data were obtained at 1-year follow-up interviews conducted via telephone, and participants responded whether they had recovered from the original episode of low back pain. If participants had recovered, we then asked how long they took to recover, and from this we calculated the duration of the episode for each participant. Thereafter, participants were asked whether they had experienced a recurrent episode, based on the above definitions.
Our secondary definition of recurrence required participants to also seek care for their new episode of low back pain. We also asked about the intensity of pain and interference with function associated with the recurrent episode, based on modified questions from the SF questionnaire. We calculated the 1-year incidence of recurrence of low back pain as the proportion of participants who reported recurrence divided by the total of people who had recovered within 6 weeks.
Descriptive statistics were used to report the characteristics of participants, including means and standard deviations SD for continuous variables, and frequencies and proportions for categorical variables. Multivariable logistic regression analysis was conducted for our main definition of recurrence and used to identify associations between baseline characteristics of participants and recurrence of low back pain within 1-year follow up. In a sensitivity analysis, we used our second definition of recurrence episode of care as the outcome.
Of the participants presenting to primary care clinics for an acute episode of low back pain, were successfully contacted at 1-year follow up. Reasons for loss to follow-up include participants refusing to participate or unavailable to answer the telephone. Within 1 year, participants had Future lower back problems tumblr from the original episode within 6 weeks and comprised our sample Fig.
The mean age of those who recovered was See Table 2 for other baseline characteristics of participants.
Using this definition of recurrence, participants who reported 3 or more episodes of low back pain had 3. Table 3 shows odds ratios and P values for the variables that entered into our multivariable regression analysis. No other factors were associated with recurrences Future lower back problems tumblr required care seeking in our sensitivity analysis Tab. A post hoc analysis comparing any prior history of low back pain with no prior history revealed similar. Although we investigated other factors not included in studies, we confirm that only 1 factor—having multiple episodes of low back pain—was associated with future recurrences.
This factor remained associated with recurrence of low back pain when we used a second, and stricter, definition of recurrence, where participants needed to also seek care for the new episode. Moreover, a range of factors not ly investigated were chosen a priori as putative risk factors for recurrence of low back pain, including factors related to sociodemographics, current history, general health, work status, and presence of yellow flags. We have also used ly recommended definitions of episodes of pain, for both recovery and recurrence of low back pain.
Recovery was defined as experience of a period of at least 1 month without low back pain pain intensity 0 or 1, on an point scale15 while a recurrent episode consisted of a new episode of at least mild intensity that lasted more than 24 hours.
A limitation of this study is the reliance on recall, as participants were asked to report recovery and recurrence information 1 year after the original episode of low back pain.
Memory of painful events, such as an episode of low back pain, may be distorted by time. Some studies have reported that low back pain episodes tend to be underreported as the recall period increases, 2526 while others have found that pain episodes are often overestimated.
However, it seems that patients experiencing recurrent low back pain tend to have greater recall accuracy compared with patients with chronic pain.
Despite our attempt to include different putative predictors of recurrence, other relevant factors not included in our study might have contributed to the onset of the recurrent episode. We acknowledge, however, that self-reported measures of physical activity participation tend to yield overestimatedand suggest, therefore, that future studies measure physical activity using accelerometers.
To ensure the baseline interview was feasible and the duration of the interview acceptable to participants, we only included single questions depression and anxiety from the Orebro Musculoskeletal Pain Questionnaire rather than administering the entire questionnaire. Therefore, in our regression model we used the responses to a subset of questions rather than the entire questionnaire as 1 possible predictor of recurrence. Another limitation of our study is the lack of data on the type of interventions participants received during the course of the low back pain episode, and whether this may have influenced our.
Further, our sample may not represent the general population, given we only included people who sought care for the original episode of low back pain. Although recruiting clinicians indicated whether patients presented radiating pain below the knee, we did not assess for s of nerve root compression, such as by testing lower limb reflexes, muscle function, or using the straight leg raise test. Therefore, these data were not available to be included in our analysis as potential predictors of recurrence.
Most studies investigating the incidence of recurrence of low back pain have not used standardized definitions of episodes as suggested by de Vet et al. Hancock et al also used a similar definition of recurrence related to an episode of care, though no estimates were reported due to limited of events. This is an important factor, given the strong association with cases of health care utilization, which are usually the ones likely to be more disabling and for the major burden of the condition.
In conclusion, our revealed that about one-third of patients who recover from an acute episode of low back pain will have a recurrence within 1 year, with half of those requiring further care. Having 3 or more episodes of low back pain triples the odds of having a recurrence within 1 year. Further research is required in this field, with a particular focus on including potential predictors of recurrence not investigated in our study, such as objective measures of physical activity participation.
Maher, P. Ferreira, J. Latimer, B. Koes, M. Writing: G. Machado, C. Maher, J. Latimer, D. Steffens, B. Koes, P.Future lower back problems tumblr
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