by clicking the arrows at the side of the page, or by using the toolbar.
by clicking anywhere on the page.
by dragging the page around when zoomed in.
by clicking anywhere on the page when zoomed in.
web sites or send emails by clicking on hyperlinks.
Email this page to a friend
Search this issue
Index - jump to page or section
Archive - view past issues
Chiropractic Journal of Australia : CJA September 2013
94 Chiropractic Journal of Australia Volume 43 Number 3 September 2013 the assessment and treatment of people with chronic LBP, develop beliefs and perceptions of current literature about the transition from acute to chronic LBP. Further to this, we explore what information practitioners use to develop these beliefs and perceptions, in order to make a decision about the treatment of patients with chronic LBP. This review is based on a search strategy using Medline and PsychINFO databases with the following key words: psychosocial, predictors, transition, chronicity, and low back pain. Information on decision-making was included on the basis that it was: directly relevant to the subject material; and made specifc reference to the key words. PAIN PREDICTORS The International Association for the Study of Pain (IASP), which was founded in 1973 and is the world's largest multidisciplinary organisation focused specifcally on pain research and treatment, has defned chronic pain as pain that persists beyond the normal time for healing. In practice, this may translate to less than one month to more than six months.9 This defnition has remained the benchmark for many studies, was reviewed in 2011 and has remained unmodifed from the 1994 publication. It is important to note that this defnition implies that pain should cease once the damaged area has healed. Unfortunately for many however, this does not occur. Identifying the reasons why one develops chronic pain is the dilemma that faces clinicians dealing with the assessment and treatment of the ever-increasing number of chronic LBP sufferers. Predicting what subpopulation of patients could develop chronic LBP after experiencing an acute episode of LBP is an area that has received some research attention in recent years. Earlier literature categorised these predictors into three groups: primary or pre-injury predictors, that identify the percentage of an uninjured population likely to develop a LBP incident; secondary, or pre-chronicity, predictors that identify those with an acute LBP incident likely to develop chronic diffculties; and tertiary, or chronic outcome predictors, which identify treatment success or failure in chronic patients.10,11 The literature in recent times has pointed to psychological variables as being clearly associated with the development of chronicity. Fransen and co-workers for instance, have found that, in contrast to acute back pain, individual and psychological factors are more highly associated with chronic back pain than objective physical or biomechanical measures.12 A number of reviews of the literature have concluded that particular psychosocial factors, such as fear and avoidance behaviours, are potent risk factors, especially in the transition from an acute to a chronic LBP. Linton suggested that these factors might be used for the early identifcation of patients at risk of developing persistent pain. Cats-Baril and Frymoyer4 established, through a consensus process, a group of 28 factors organised into 8 categories that were predictive of LBP disability. These categories were: injury; diagnosis; demography; anthropometric characteristics; medical history; job related factors; health behaviour; and psychosocial factors. This seminal work has provided a basis for subsequent studies, as the factors known to be associated with chronicity have been understood to be primarily patient related, occupational, or psychosocial. It is now widely accepted that a biopsychosocial model, rather than the traditional biomedical model, is needed to account for transition to chronicity in LBP.13 DISEASE RELATED FACTORS Few associations have been identifed between disease- related factors and a chronic course of LBP. Functional symptoms, physical fndings, and treatment methods have failed to predict chronicity in most studies. In fact, The Fourth International Forum for Primary Care Research on LBP has documented the paradigm shift in this feld from viewing LBP as a 'biomedical injury' to a multifactorial biopsychosocial pain syndrome.13 The initial severity of the pain for instance, is less closely related to chronicity than social demographic and occupational factors, and the extent of anatomic damage does not infuence the risk of chronicity.14 In addition, there is evidence that patients in whom the exact nature of the lesions is determined were more likely to have a favourable outcome, whereas those with doubtful diagnosis are more likely to experience recurrence and disability.15 This supports the notion that patients with greater degrees of personal control are less likely to develop LBP chronicity.16 In another study, the number of days of work lost was greater in those patients who failed to develop a clear understanding of their medical condition.17 This point in particular, stresses the need for uniform methods of assessment, diagnosis of, and decision-making for, LBP conditions that have the potential for chronicity. Hence, the importance for a general awareness of the beliefs and perceptions of practitioners involved in the initial assessment of these conditions, as it is in the initial stages of assessment that the transition from acute to chronic pain maybe prevented. An interesting caveat is that it has recently been demonstrated in a prospective cohort study that in the subpopulation of LBP suffers that present to chiropractors, general health and duration of LBP episode prior to consulting a chiropractor are predictors of chronicity rather than psychosocial factors.18 OCCUPATIONAL FACTORS Occupational factors contribute signifcantly to the risk of chronicity. While it has been reported that approximately 10% of LBP sufferers in a general practice setting progress to chronicity,8 this fgure has recently been reported to be as high as 23% in nurses working in small Greek hospitals.19 This may be due to heavy physical work placing signifcant stress on the spine thereby increasing the likelihood of a chronic course. However the risk of chronicity is not proportional to the frequency of LBP in specifc jobs.14 A low level of formal education seems to predict a chronic course, particularly in males, and this is independent of: age; pain severity; occupation; and the presence of sciatica.20 The level of educational attainment was among the four best predictors of chronicity in a prospective study conducted in the United States. In this study, predictors of future function, employment, and medical utilization were drawn from 21 clinical, demographic, and psychosocial variables using multivariate techniques. Education, previous episodes, and whether the patient "always feels sick" were independently associated with most outcome measures, but prescribed therapy and physical findings were not. These 3 items created a scale defning subgroups with 3-fold differences in outcomes (e.g., 35% functionally improved in the worst group vs 93% in the best, p less than 0.001). Data from a national survey supported the importance of education and self-rated health as correlates of back related disability.21 Educational underachievement has also been closely correlated with LOW BACK PAIN: BIOPSYCHOSOCIAL PERSPECTIVE DoNNolI • aZaRI
CJA June 2013
CJA December 2013