Anxiety is the Clinical Characteristic Associated with Chronic Low Back Pain Development
Among the options presented, anxiety is the clinical characteristic most strongly associated with increased likelihood of developing chronic low back pain in patients presenting with acute symptoms.
Evidence from Guidelines and Research
Psychosocial Factors as Primary Predictors
Psychosocial factors, particularly anxiety and depression, are stronger predictors of low back pain outcomes than physical examination findings or pain severity. 1 The American College of Physicians/American Pain Society guidelines explicitly identify these factors as critical in predicting which patients will develop chronic disability from acute low back pain. 1
Key psychosocial risk factors that predict poorer outcomes include:
- Presence of depression 1
- Passive coping strategies 1
- Job dissatisfaction 1
- Higher baseline disability levels 1
- Disputed compensation claims 1
- Somatization 1
Quantified Risk from Recent Research
A 2021 multicenter cohort study of 5,233 patients with acute low back pain found that diagnosed depression/anxiety was independently associated with a 66% increased odds of transitioning to chronic low back pain (adjusted OR 1.66,95% CI 1.28-2.15). 2 This study used the standardized National Institutes of Health definition of chronic low back pain and controlled for multiple confounding variables. 2
Additional factors from this high-quality study that predicted chronicity included:
- Obesity (adjusted OR 1.52) 2
- Smoking (adjusted OR 1.56) 2
- Severe baseline disability (adjusted OR 1.82-2.08) 2
Supporting Evidence on Anxiety-Pain Relationship
Anxiety and depression levels are significantly positively correlated with pain intensity (r = 0.471, p < 0.0005) and serve as significant predictors of pain intensity in acute low back pain patients. 3 The prevalence of anxiety symptoms among chronic low back pain patients ranges from 23.89% to higher, substantially elevated above general population rates. 4
Why Other Options Are Not Supported
BMI Less Than 18.5
The evidence actually shows obesity (not low BMI) is associated with chronic pain development, with an adjusted OR of 1.52. 2 Low BMI is not identified as a risk factor in any of the guideline or research evidence provided.
Age Less Than 50 Years
Guidelines do not identify younger age as a risk factor. In fact, age older than 65 years is mentioned in the context of spinal stenosis evaluation, but younger age is not associated with chronicity risk. 1
Male Sex
Gender is not identified as a predictor of chronic low back pain development in the guideline evidence. 1
Elevated Blood Pressure
Blood pressure is not mentioned as a predictor of chronic low back pain transition in any of the evidence reviewed. 1, 2
Clinical Implications
Assessment of psychosocial factors and emotional distress should be routine in all patients presenting with acute low back pain. 1 While evidence is insufficient to recommend specific optimal assessment methods, identifying patients with anxiety, depression, or other psychosocial risk factors allows for:
- Targeted interventions that may prevent chronicity 1
- Consideration of intensive multidisciplinary rehabilitation for high-risk patients 1
- Early psychological support alongside physical treatment 3, 5
Patients with persistent symptoms after 1 month should be reevaluated, with particular attention to psychosocial factors, as most acute low back pain improves substantially within the first month. 1