Transition from acute to chronic low back pain: A biopsychosocial perspective

Introduction: Low back pain (LBP) is the most costly and the most common musculoskeletal condition in industrialised countries, and is the most common cause of disability particularly for those under the age of 45. Most of disability and the associated costs relate to the condition when it becomes chronic. It is therefore necessary to study the factors that lead to chronicity, and the clinical predictors that can be used to warn clinicians against such an outcome. This review explores these predictors, as well as the beliefs and perceptions of practitioners about these predictors that inform their clinical decision-making that could impact on the patients' transition to chronicity. A number of these predictors of chronicity in LBP are beginning to be established, they include: Pain predictors: earlier literature categorises these predictors into three levels, primary or preinjury, secondary or pre chronicity and tertiary or chronic outcome predictors. Literature in recent times has pointed to psychological factors as being clearly associated with the development of chronicity. Disease related factors: Few associations have been identified between the disease related factors and chronicity. Occupational factors: have been found to contribute significantly to the risk of chronicity. Workers with subacute LBP receiving workers compensation reported that stress, fear and beliefs about work correlated strongly with progression to chronicity. Psychological factors: with adverse bearing on prognosis have been identified in most studies, psychological profile at presentation has a much stronger influence on outcome than does conventional clinical information and Psychosocial factors: the way people "deal with the demands and challenges of everyday life" in a number of studies these have been reported to be associated with development of chronicity and have been defined as "yellow flags". Practitioners' beliefs and perceptions: each profession dealing with chronic pain has its own knowledge base and beliefs about the causes and treatment of chronic LBP that are based on training, group perceptions, clinical experience and memory. These factors can have an impact on the progression to chronicity. Decision making: the literature on decision making processes has demonstrated that there are many factors that may bias a decision; these include accommodation bias, past experience and cognitive biases, the decisions as to which strategy to use in the treatment of LBP may be similarly wrought with these factors. Conclusion: According to much of the literature, chronicity in LBP is more closely related to demographic, psychological and occupational factors. It is important to have an understanding of these factors in order to manage LBP patients more effectively. In addition it may be instructive to examine the sources and content of continuing education that are available to practitioners.