Introduction And Edidemiology Of Low Back Pain

Prevalence and Natural Course

Fifty to eighty percent (Frymoyer, 1988) of adult population will experience back pain at some point in their life. 40 percent have back pain in any one year. Back pain may be considered normal (Croft et al, 1997, Klaber-Moffett et al, 1995, Evans & Richards 1996, Waddell 1994, Shekelle 1997, Papageorgiou & Rigby 1991, Papageorgiou et al 1995, Linton et al 1998, Brown et al 1998, Leboeuf_Yde et al 1996, McKinnon et al 1997, Szpalski et al 1995, Heliovaara et al 1989, Toroptsova et al 1995, Cassidy et al 1998). There is also considerable variability in natural history (Carey et al 1995a, Cherkin et al 1996, Croft et al 1998, Phillips and Grant 1991). Some have suggested that resolution of symptoms typically occurs in 4 to 8 weeks (Coxhead et al 1981, Evans et al 1987, Berquist-Ullman & Larsson 1970). Another source reported one third of a population reporting back pain had symptoms less than a month, whereas another third reported pain lasting 1 to 5 months, and the remaining third reported pain lasting more than 6 months (Dey & Tsui-Wu, 1994). Recurrent episodes and persistent symptoms are common (Croft et al, 1997). Recurrence rates have been estimated to range between 60 and 85 percent (Troup et al 1987, Troup et al 1981, Valkenburg & Haanen 1982)


There are direct and indirect health care costs associated with low back injury. Direct costs include money spent on hospitalization, outpatient visits, medication, rehabilitation, emergency room visits, home health visits, and laboratory procedures. Indirect costs, or psychosocial costs, are those related to lost work output, wage losses, work time lost by other family members caring for injured worker, and loss of professional opportunities (Porterfield & Derosa, 1998).
Back pain is one of the commonest causes of disability is working population (Waddell 1994). Total costs of back pain are larger than for any other disease for which economic analysis is available (Maniadakis & Gray 2000). Medical costs represent 7% to 34% of total societal costs (van Tulder et al 1995, Maniadakis &Gray 2000). 25% to 40% of those with back pain seek healthcare (Croft et al 1997, Papagerorgiou & Rigby 1991, McKinnon et al 1997, Carey et al 1996). Back pain accounts for 3% to 5% of primary care physician consultations (Walsh et al 1992)
Episodes of back pain are responsible for 25 percent of all lost workday in the United States, and represent 25 percent of all workers’ compensation claims. It has also been estimated that chronic low back pain results in 225,000 to 300,000 lumbar surgeries and an estimated direct and indirect medical cost of $75 to $100 billion (Frymoyer & Cats-Baril, 1991). In addition, it appears as though relatively few patients are responsible for the majority of the costs. In Spengler et al. (1986), the authors noted that 10 percent of the claimants for low back injury accounted for nearly 70 percent of the total costs (Spengler et al, 1986). Leavitt et al (1972) noted that only 25% or workers’ compensation claimants accounted for 87 percent of medical and disability claims.

Risk and prognostic factors for current and future back pain and disability

Identification of factors that put individuals at risk of sustaining a low back injury or that may prolong recovery has long been a objective of clinicians and researchers. The premise being that identification of these variable will allow early multidisciplinary intervention in a effort to return the patient back to prior status and reduce overall medical costs. Increased risk to low back pain has been associated with a variety of factors including heavy or frequent lifting (Frymoyer et al, 1983; Frymoyer et al, 1980; Garg & Moore, 1992; Magnusson et al, 1996; Macfarlane et al, 1997), prolonged sitting or standing (Macfarlane et al 1997, Clark et al, 1988, Skov et al, 1996), hours in a vehicle (Levangie 1999, Frymoyer et al 1983, Frymoyer et al 1980, Skov et al, 1996, Kelsey & White 1980, Masset & Malchaire 1994), smoking (Levangie 1999, Frymoyer et al 1983, Frymoyer 1980, Lebouef-Yde et al, 1996, Boshuizen et al, 1993), vibration exposure (Frymoyer et al 1983, Frymoyer et al 1980, Magnusson eta l, 1996, Masset & Malchaire, 1994, Levangie 1999), activity level (Frymoyer et al, 1983, Kelsey & White 1980, Leboeuf)Yde et al, 1997), pregnancy (Levangie 1999, Frymoyer 1980, Kelsey & White 1980, Harreby et al, 1996, Silman et al, 1995), and oral contraceptive use (Grieve, 1981, Wreje et al, 1997).
Low job satisfaction, lower income, leg pain, sciatica, previous back pain, and lack of centralization have been associated with poor prognosis (Adams et al, 1999, Bombardier et al, 1994, Bongers et al 1993, Burdorf 1992, Burdorf et al 1997, Frank et al 1996, Hoogendoorn et al 1999, Hoogendoorn et al 2000, Linton 2000, Mannion et al 1996, Pincus et al 2002, Vlaeyen et al 2000, Winkel et al 1994)

There are generally three classes of risk factors:
1. Individual and lifestyle:
a. History of low back pain
b. Smoking
c. Physical fitness (Nachemson, 1985)
2. Physical or biomechanical
a. Heavy or frequent lifting
b. Whole body vibration (as when driving)
c. Prolonged or frequent bending or twisting
d. Postural stresses (High spinal load or awkward postures)
3. Psychosocial
a. Fear avoidance behavior
b. Depression
c. Job satisfaction

Cigarette smoking has been recognized as an important risk factor as smokers tend to report symptoms as more sever than nonsmokers (Kelsey 1984). Vibration appears to hasten fatigue failure of collagenous structures (Seidel & Heide, 1986). Work relationships and interactions that the employee has with the employer and co-workers also significantly affect recovery (Bergenudd & Nilsson, 1988, Bigos et al, 1992). The fewer personal-, job-, or family-related problems and individual has the greater chance that the injured worker with low back pain will return to work following acute low back injury.

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