Back pain sufferers need patience more than anything else

A woman with back pain stands at her office desk.
© Lacheev/i-Stock

Temporary complaint or chronic affliction: a research team funded by the SNSF has identified typical trajectories for back pain. Psychosocial factors play a smaller role than expected.

Back pain is a widespread condition: at least once in their lives, almost 85% of people will experience pain in the area of the lumbar spine, in other words between the bottom rib and the tailbone. Treating this correctly is not easy, as in the vast majority of cases it is difficult to find the exact physical cause – the patient is experiencing “non-specific” back pain. For many, the symptoms will disappear by themselves after a while. However, sometimes they become entrenched and end up having a huge impact on sufferers’ everyday lives. “The outcome is probably determined by a large number of factors”, says Professor of Physiotherapy Sabina Hotz. But how exactly these interact is not yet known. In a study facilitated by the SNSF, Hotz has now characterised common pain trajectories with the aim of developing more individual treatment strategies.

To this end, the team at Zurich University of Applied Sciences (ZHAW) followed 176 people experiencing new or recurring symptoms of lower back pain for a year. The researchers asked the study participants how severe they felt their pain was at various points during the year. They did this using an online questionnaire which ranked the pain on a scale of one to ten, with 1 to 3 signifying mild pain, 4 to 7 moderate, and 7 to 10 severe. In this way, they were able to track fluctuations over the course of a year.

The team also used online questionnaires to record further aspects such as medical treatments, work situation, stress and depression. Clinical examinations were also carried out, the results of which were not directly incorporated into this publication. “With this study, we recorded both clinical data and psychosocial factors together in one long-term study for the first time. It was quite a big task”, says Hotz.

Rapid recovery is rare

The analysis showed four typical trajectories: in more than half of the subjects, the pain fluctuated between moderate and mild over the course of the year. In around 7%, the pain ranged between moderate and severe. One third of subjects experienced moderate pain throughout. And only in around 6% was the pain gone after a year – however, the recovery occurred only towards the end of the observation period. “This shows that, in the majority of cases, recovery from back pain or the development of chronic symptoms does not follow a linear path”, says Hotz. Patients’ expectations that an improvement will occur after a few weeks are seldom fulfilled.

Interestingly, it also made no difference to the intensity and duration of the symptoms whether the affected individuals were receiving physiotherapy or medical treatment for their back pain. Hotz infers from this that treatment does not contribute to a more rapid recovery in all cases. It is enough for sufferers to take it easy at first, and then return to normal activities. Mild painkillers can initially help to make the situation more tolerable. With a few exceptions – for example very intense pain persisting over several weeks – expensive procedures such as an MRI are not necessary or helpful either.

However, there were two factors which indicated a more severe trajectory even at an early stage: namely, when the pain was severe at the outset or if the subject had already had previous episodes of severe back pain. Treating physicians or physiotherapists should be giving these patients particular care right from the outset, the study found.

Role of the mind unclear

Surprisingly, the statistical analysis did not reveal any correlation between psychosocial factors and the severity of the trajectory. This contradicts the results of other studies, which for example indicate that people experiencing stress or depression more often have poorer trajectories. The present study was not able to corroborate this finding. It may be that different methods used to record the factors and for the statistical analysis are responsible for this.

Nevertheless, Hotz believes that psychosocial factors do also play a role in back problems: “Body and mind are always interacting and are not so easy to separate.” But perhaps this interaction does not take place in the way the previous research has suggested. For example, a psychological test used in cases of depression might not necessarily be appropriate for pain patients, who will often be in a special situation due to their condition and the strain it causes, and as a result will perhaps be more prone to negative thoughts. “Science needs to get a bit more creative here and consider better methods.” For example, as well as standardised questionnaires, in future Hotz suggests using qualitative methods which allow subjects to talk freely about how they experience their symptoms.

For the research team, which also includes specialist practising physiotherapists, the most important thing is for the knowledge obtained to flow directly into practice. “It is paramount, for example, to let people know that it is completely normal for the pain to last longer than a few weeks, or to subside for a while and then come back again.. And that there is no reason to worry that the load-bearing capacity of the back could get worse, says Hotz. She is therefore also recommending that we stop using the term non-specific, and instead talk about benign back pain.