What is the natural course of acute lower back pain (ALBP)?

From the Guidelines

The natural course of acute lower back pain (ALBP) is generally favorable, with most cases resolving spontaneously within 4-6 weeks regardless of treatment. About 90% of patients experience significant improvement within this timeframe [ 1 ]. Initially, pain may be severe and limiting, but typically begins to improve within the first two weeks. While most patients recover completely, approximately 20-30% will experience recurrent episodes within the first year, and 5-15% may develop chronic low back pain lasting beyond 3 months.

Key Points to Consider

• During recovery, patients should maintain gentle activity as tolerated rather than strict bed rest, which can actually delay healing [ 1 ].
• Over-the-counter pain medications like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs such as ibuprofen (400-600mg three times daily with food) can help manage symptoms during the acute phase.
• Heat or ice application for 15-20 minutes several times daily may also provide relief.
• The favorable natural history explains why many interventions appear effective in studies - patients would likely improve regardless of treatment [ 1 ].

Nonpharmacologic Therapies

• For acute low back pain, spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits [ 1 ].
• Supervised exercise therapy and home exercise regimens are not effective for acute low back pain [ 1 ].
• Other nonpharmacologic treatments have not been proven to be effective for acute low back pain, but may be considered for subacute or chronic low back pain, such as intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation [ 1 ].

Patient Education

• Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options [ 1 ].
• Patients should be informed of the generally favorable prognosis of acute low back pain, including a high likelihood for substantial improvement in the first month [ 1 ].

From the Research

Natural Course of Acute Lower Back Pain (ALBP)

The natural course of ALBP can be described as follows:

• Most people who seek care for acute low back pain improve markedly within the first six weeks, with low to moderate levels of pain and disability still present at one year, especially in people with persistent pain 2.
• The variance-weighted mean pain score (0-100) was 52 at baseline, 23 at 6 weeks, 12 at 26 weeks, and 6 at 52 weeks after the onset of pain for cohorts with acute pain 2.
• Treatment of an acute episode of back pain includes relative rest, activity modification, nonsteroidal anti-inflammatories, and physical therapy, with patient education being imperative to prevent further future episodes of back pain 3.
• The course of disability outcomes is similar to the time course of pain outcomes in acute pain cohorts, but for persistent pain cohorts, disability only improves slowly, despite substantial initial improvement in pain 2.

Factors Influencing the Natural Course of ALBP

Several factors can influence the natural course of ALBP, including:

• The duration of pain, with acute pain (less than 6 weeks) having a better prognosis than persistent pain (more than 6 weeks) 2, 4.
• The presence of underlying conditions, such as disc herniation, vertebral compression fractures, lumbar spondylosis, spondylolisthesis, and lumbosacral muscle strain, which can affect the natural course of ALBP 5.
• The use of pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids, which can provide relief but also have potential adverse effects and contraindications 6, 4, 5.

Outcomes of ALBP

The outcomes of ALBP can be summarized as follows:

• Most patients with acute low back pain experience significant improvement in pain and disability within the first six weeks, but some may continue to experience low to moderate levels of pain and disability at one year 2.
• Patients with persistent low back pain may experience slower improvement in disability, despite initial improvement in pain, and may require ongoing management and support 2, 4.
• The choice of pain medication and treatment approach should be based on individual patient preferences, contraindications, and potential adverse effects, with the goal of enabling patients to stay active and manage their pain effectively 4.