The Trajectories of Low Back Pain

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

	Prospective Back Pain Trajectories or Retrospective Recall - Which Tells Us Most About the Patient? J Pain 2024 (May 6): 104555 ~ FULL TEXT In chronic musculoskeletal conditions, the prognosis tends to be more informative than the diagnosis for the future course of the disease. Many studies have identified clusters of patients who seemingly share similar pain trajectories. In a dataset of low back pain (LBP) patients, pain trajectories have been identified, and distinct trajectory types have been defined, making it possible to create pattern recognition software that can classify patients into respective pain trajectories reflecting their condition. It has been suggested that the classification of pain trajectories may create clinically meaningful subgroups of patients in an otherwise heterogeneous population of patients with LBP. A software tool was created that combined the ability to recognise the pain trajectory of patients with a system that could create subgroups of patients based on their characteristics. This tool is primarily meant for researchers to analyse trends in large heterogeneous datasets without large losses of data. Prospective analysis of pain trajectories is not directly helpful for clinicians. However, the tool might aid in the identification of patient characteristics which have predictive capabilities of the most likely trajectory a patient might experience in the future. This will help clinicians to tailor their advice and treatment for a specific patient.
	Development, Validation and Use of Custom Software for the Analysis of Pain Trajectories Sci Rep 2024 (Aug 12); 14 (1): 18719 ~ FULL TEXT In chronic musculoskeletal conditions, the prognosis tends to be more informative than the diagnosis for the future course of the disease. Many studies have identified clusters of patients who seemingly share similar pain trajectories. In a dataset of low back pain (LBP) patients, pain trajectories have been identified, and distinct trajectory types have been defined, making it possible to create pattern recognition software that can classify patients into respective pain trajectories reflecting their condition. It has been suggested that the classification of pain trajectories may create clinically meaningful subgroups of patients in an otherwise heterogeneous population of patients with LBP. A software tool was created that combined the ability to recognise the pain trajectory of patients with a system that could create subgroups of patients based on their characteristics. This tool is primarily meant for researchers to analyse trends in large heterogeneous datasets without large losses of data. Prospective analysis of pain trajectories is not directly helpful for clinicians. However, the tool might aid in the identification of patient characteristics which have predictive capabilities of the most likely trajectory a patient might experience in the future. This will help clinicians to tailor their advice and treatment for a specific patient.
	Do Visual Pain Trajectories Reflect the Actual Course of Low Back Pain? A Longitudinal Cohort Study J Pain 2023 (Apr 10); S1526-5900(23)00395-4 ~ FULL TEXT Self-reported back pain trajectories reflected pain intensities obtained through weekly SMS tracking over a year, but participants' recall did not reflect the pain patterns (episodes and fluctuations) discovered prospectively. Clinicians can use self-reported pain trajectories to facilitate a dialogue about pain experience, but not as a proxy for prospective measures.
	Association Between Physical Activity, Sedentary Behaviour and the Trajectory of Low Back Pain Spine J 2023 (Mar 20); S1529-9430(23)00110-9 ~ FULL TEXT Moderate-to-vigorous intensity physical activity was significantly associated with the probability of having a severe LBP trajectory (unadjusted β –0.0276; 95%CI –0.0456 to –0.0097, p=0.003). For every one-minute increase in moderate-to-vigorous intensity physical activity per week, there was a 2.8%–point reduction in a participant's probability of having a severe LBP trajectory. No significant associations were identified between sedentary behavior or light intensity physical activity, and the probability of having a severe LBP trajectory. Conclusion:   In people with a lifetime history of LBP, engagement in higher volumes of moderate to vigorous intensity physical activity at baseline was associated with a lower probability of developing a severe trajectory of LBP over one year.
	Validity of the Visual Trajectories Questionnaire for Pain Scand J Prim Health Care 2022 (Oct 31); 1–9 ~ FULL TEXT This study provides a new questionnaire (Visual Trajectories Questionnaire-Pain) that captures the longitudinal state of a patient's pain experience. The Visual Trajectories Questionnaire-Pain has shown aspects of face, criterion, and construct validity, and has the potential to be clinically useful.
	The Natural Course of Low Back Pain From Childhood to Young Adulthood - A Systematic Review Chiropractic & Manual Therapies 2019 (Mar 20); 27: 10 ~ FULL TEXT Although methodological heterogeneity, mainly due to different age ranges, an indication of a natural course of LBP was seen across studies. The majority of children and adolescents repeatedly reporting no or low probability of LBP. With recall periods between one week to three months and sampling rates ranging from one to four years, a very low rate repeatedly reported LBP, and approximately one-fifth to one-third of children and adolescents had fluctuating reports of LBP. A need of future research of LBP trajectories with short reporting period lengths and narrower sampling windows in a long-term perspective is emphasized in order to study childhood influences on the development of LBP throughout life. There are more articles like this at our Pediatrics Section
	Contrasting Real Time Quantitative Measures (Weekly SMS) to Patients’ Retrospective Appraisal of Their One-year’s Course of Low Back Pain; A Probing Mixed-methods Study Chiropractic & Manual Therapies 2019 (Feb 26); 27: 12 ~ FULL TEXT This study shows that a real time quantitative measure (weekly SMS) and the patient's retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient's ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.
	An Observational Study on Trajectories and Outcomes of Chronic Low Back Pain Patients Referred From a Spine Surgery Division for Chiropractic Treatment Chiropractic & Manual Therapies 2019 (Feb 5); 27: 6 ~ FULL TEXT Chiropractic treatment is a valuable conservative treatment modality associated with clinically relevant improvement in approximately half of patients with chronic LBP. These findings provide an example of the importance of interdisciplinary collaboration in the treatment of chronic back pain patients.
	Trajectories and Predictors of the Long-term Course of Low Back Pain: Cohort Study with 5-year Follow-up Pain 2018 (Feb); 159 (2): 252–260 ~ FULL TEXT Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in 1 primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was conducted on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-year follow-up plus at least 3 (of 6) subsequent monthly questionnaires.
	Long-term Trajectories of Patients with Neck Pain and Low Back Pain Presenting to Chiropractic Care: A Latent Class Growth Analysis European J Pain 2018 (Jan); 22 (1): 103–113 ~ FULL TEXT Most patients with NP or LBP presenting in chiropractic care show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain. The two most common classes ‘recovering from mild baseline pain’ and ‘recovering from high baseline pain’ were consistent for both NP and LBP and accounted for 90% of the patients. The other two classes were less frequent and differed between NP and LBP patients. The four different classes showed distinct baseline patient characteristics and outcome in pain and functional status at 6 and 12 months
	How Can Latent Trajectories of Back Pain be Translated into Defined Subgroups? BMC Musculoskelet Disord. 2017 (Jul 3); 18 (1): 285 ~ FULL TEXT This study was the first to demonstrate that suggested definitions of LBP trajectory subgroups can be readily applied to individuals’ observed data resulting in subgroups that match well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with infrequent and mild LBP. Further, we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.
	Leg Pain Location and Neurological Signs Relate to Outcomes in Primary Care Patients with Low Back Pain BMC Musculoskelet Disord. 2017 (Mar 31); 18 (1): 133 ~ FULL TEXT The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.
	What Have We Learned From Ten Years of Trajectory Research in Low Back Pain? BMC Musculoskelet Disord. 2016 (May 21); 17 (1): 220 ~ FULL TEXT Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.
	Trajectories of Acute Low Back Pain: A Latent Class Growth Analysis Pain. 2016 (Jan); 157 (1): 225–234 ~ FULL TEXT Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised: 567 (35.8%) patients who recovered by week 2 (cluster 1, rapid pain recovery) 543 (34.3%) patients who recovered by week 12 (cluster 2, pain recovery by week 12) 222 (14.0%) patients whose pain reduced but did not recover (cluster 3, incomplete pain recovery) 167 (10.5%) patients whose pain initially decreased but then increased by week 12 (cluster 4, fluctuating pain); and 86 (5.4%) patients who experienced high-level pain for the whole 12 weeks (cluster 5, persistent high pain).
	Exploring the Definition of Acute Low Back Pain: A Prospective Observational Cohort Study Comparing Outcomes of Chiropractic Patients With 0–2, 2–4, and 4–12 Weeks of Symptoms and Multiple Comorbidities J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 141–149 ~ FULL TEXT Patients with 0–2 weeks of symptoms were significantly more likely to "improve" at 1 week, 1 month, and 6 months compared with those with 2–4 weeks of symptoms (P < .015). Patients with 0–2 weeks of symptoms reported significantly higher NRS and Oswestry change scores at all data collection time points. Outcomes for patients with 2–4 weeks of symptoms were similar to patients having 4–12 weeks of symptoms. The time period 0–4 weeks as the definition of "acute" should be challenged. Patients with 2–4 weeks of symptoms had outcomes similar to patients with subacute (4–12 weeks) symptoms and not with patients reporting 0–2 weeks of symptoms.
	Patients With Low Back Pain Had Distinct Clinical Course Patterns That Were Typically Neither Complete Recovery Nor Constant Pain. A Latent Class Analysis of Longitudinal Data Spine J 2015 (May 1); 15 (5): 885–894 ~ FULL TEXT The clinical course of LBP is complex. Most primary care patients do not become pain-free within a year, but only a small proportion reports constant severe pain. Some distinct patterns exist which were identified independently of the way the outcome was modeled. These patterns would not be revealed by using the simple summary measures traditionally applied in LBP research or when describing a patient's pain history only in terms of duration. The appropriate number of subgroups will depend on the intended purpose of subgrouping.
	Is Puberty a Risk Factor For Back Pain in the Young? A Systematic Critical Literature Review Chiropractic & Manual Therapies 2014 (Oct 15);   22 (1):   27 ~ FULL TEXT It has previously been established that back pain starts during childhood. [1–4] According to two recent systematic literature reviews [1, 2], the lifetime prevalence increases between the ages of 7 and 12 (on average from 1% to 17%) to reach the adult level around the age of 20. [5] In relation to low back pain, it appears that puberty is the time for a rapid increase. Girls start puberty earlier than boys, which may explain why they report back pain earlier than boys. [5] There are more articles like this at our Pediatrics Section
	Long-term Trajectories of Back Pain: Cohort Study With 7-year Follow-up BMJ Open. 2013 (Dec 11); 3 (12): e003838 ~ FULL TEXT Four clusters with different back pain trajectories at follow-up were identified: (1) no or occasional pain (2) persistent mild pain (3) fluctuating pain and (4) persistent severe pain. Trajectory clusters differed significantly from each other in terms of disability, psychological status and other symptoms. Most participants remained in a similar trajectory as 7 years previously (weighted κ 0.54; 95% CI 0.42 to 0.65).
	Trajectories of Low Back Pain Best Pract Res Clin Rheumatol. 2013 (Oct); 27 (5): 601–612 ~ FULL TEXT 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.
	Trajectories of Pain in Adolescents: A Prospective Cohort Study Pain. 2011 (Jan); 152 (1): 66–73 ~ FULL TEXT Identification of different patterns of change in pain over time – trajectories – has the potential to provide new information on the course of pain. Describing trajectories among adolescents would improve understanding of how pain conditions can develop. This prospective cohort study identified distinct trajectories of pain among adolescents (11–14 years) in the general population (n=1,336). Latent class growth analysis was carried out on the self-reported frequency of back pain, headache, stomach pain and facial pain, which was collected every 3 months for 3 years. Forty four percent of adolescents had a 'painful' trajectory for at least one pain site, and 12% reported persistent pain at one or more pain site. Headache was the most common; 25% of subjects were in a 'painful' trajectory and 5% reported persistent pain. Back pain and stomach pain were also common, with 22% and 21% of subjects in painful trajectories, respectively. Facial pain was the least common, with only 10% in a painful trajectory, and 1% reporting persistent pain. Trajectory characteristics were similar at baseline across pain sites, with the more painful trajectories having significantly higher levels of depression and somatization, lower life satisfaction and more females. There are more articles like this at our Pediatrics Section
	Identifying Episodes of Back Pain Using Medical Expenditures Panel Survey Data: Patient Experience, Use of Services, and Chronicity J Manipulative Physiol Ther. 2010 (Oct); 33 (8): 562–575 ~ FULL TEXT These findings suggest that other longitudinal studies based only on data that reflect service use, for example, claims data, may incorrectly infer the nature of back pain and back pain episodes. Many individuals report ongoing back pain that continues beyond their Episodes-of-Care, and many individuals with persistent back pain may use prescription drugs, medical services, and other health services only intermittently.
	Characterizing the Course of Low Back Pain: A Latent Class Analysis American Journal of Epidemiology 2006 (Apr 15); 163 (8): 754–761 ~ FULL TEXT Understanding the course of low back pain is important for clinicians and researchers because it provides information on the need for, and potential benefits of, treatment. [1, 2] It also helps patients learn what to expect in terms of symptoms, the impact of the problem on their life, and the interventions they may receive. Information on symptom course may enable patients with nonspecific low back pain to be classified into clinically meaningful subgroups. There are currently no accepted methods for classifying these patients, who constitute 85–95 percent of those seeking care for low back pain. [3] Thus, it is difficult to select clearly defined subgroups of patients for clinical trials, and the potential effectiveness of treatments may be masked by the heterogeneity of the patients studied.

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