Back Pain Again? Why Me?
Back pain once is a painful nuisance. But it usually goes away quickly. Then it's back to business as usual. Back pain that recurs is much more than a minor inconvenience. It can be chronic, disabling, and costly. In fact, it's estimated that recurrent back pain is one of the most expensive health conditions being treated in health care today.

Studying back pain recurrence has been a bit difficult. For one thing, when is back pain a recurrence of the old problem and when is it a new and different problem? Is a second (or third) bout of back pain a recurrent episode if less than six weeks has gone by? Six months? Does the patient have to be pain free for any particular length of time (or at all) before the episode is considered a recurrence?

How do we draw the line? Maybe it should be based on the patient's pain duration, location, and intensity. Maybe recurrence of back pain should only be counted as an episode if the person loses time off work or goes to see a healthcare or other back care specialist.

The authors of this study acknowledge all of these difficulties in defining back pain recurrence or back pain disorder (BPD). Their task (given the challenges of defining back pain recurrence) was to find individual indicators that back pain is likely to recur. There is probably more than one indicator but the first step was to identify any factor(s) already existing.

They relied on three ways to study this problem. The first was an overview of the available studies already published. The second was the opinion and consensus of an expert panel. The third involved discussions at workshops held at the International Classification Forum on Primary Care Research and Low Back Pain.

In the overview step, they looked at research on back-related recurrence to find any indicators that might point to recurrence. They used the same research publications to look for a model of health and disability that might work to classify patients. They chose the newly adopted World Health Organization's ICF model.

ICF stands for International Classification of Impairments, Disabilities, and Handicaps. The ICF works well to describe patients in terms of abilities rather than just disabilities. It provides a more accurate way to see patients' function and restrictions in the everyday world.

Both the expert panel and the workshop discussion groups discussed the current definitions of back pain as a health condition. They said that when using the ICF model, back pain disorder couldn't just be defined by pain. Back pain is a health condition if any one of three conditions is met:

  • There is impaired body function or structure with pain AND pathology of the nerve or other pain producing structures
  • There are activity limitations; in other words, the person has difficulty performing certain tasks or actions
  • There are participation restrictions meaning that the activity limitations affect function within the patient's social, family, or work environment

    When looking at indicators of back pain recurrence, there were two main groups reported in the literature: direct and indirect. Four measures were used as indicators of possible back pain recurrence including 1) return of pain, 2) time off from work, 3) seeking health care services, and 4) filing a worker's compensation claim. Each of these four indicators was either direct or indirect.

    For example, recurrence of pain or other symptoms is a direct indicator. Pain intensity, duration, and frequency can be individually measured and reported. In some studies, patients filled out a pain questionnaire, while others completed a daily diary. There was not a consensus as to what constituted a pain-free period in between back pain episodes. Another direct indicator of back pain recurrence was the time away from work, also referred to as repeated absences.

    The indirect indicators of back pain recurrence included recurrence of (health) care (for back pain) and recurrence of compensation claims. Using the presence of any indicator always raises the question, Within what time frame? Some experts suggest recurrence be defined as seeking care for back pain within the first 45 days after the initial episode. Others use 45 to 90 days as a more appropriate time period to provide acceptable bounds for identifying a recurrence vs. a new episode.

    But when using compensation claims, the agency must decide when to file a new workers' compensation claim versus reopening the old claim. If benefits have been suspended, how much time can elapse before it becomes a new episode?

    Using the ICF model doesn't solve all of these dilemmas, but it goes a long way toward keeping the focus on function. Using the model to classify patients helps include those who don't necessarily have recurring back pain but still have activity or participation restrictions because of fear avoidance behaviors (FABs). FAB refers to patients avoiding movements or activities because these might increase their pain.

    The ICF model also smoothes out the bumps in assessing repeated time away from work. Instead of just measuring complete absences from work, the ICF puts the worker's efforts in the more functional context of participation restrictions. In this way, light or partial-duty, on-the-job productivity, and failed efforts to return-to-work help indicate recurrence status.

    Likewise, when pain isn't the issue but rather, there is a restriction in the ability to work or a limitation in activity present, the ICF helps identify such as part of the health condition known as back pain disorder. The authors suggest that using this type of model guides intervention. Areas of participation restrictions and activity limitations can be addressed even when pain is not the key factor in reducing function.

    Using this approach, new research can be done to track how often back pain recurrence develops with more targeted treatment. This feature makes it possible to see just how effective each treatment approach is for the various areas of dysfunction. Studying recurrence of activity limitations may be more accurate than just looking at repeat episodes of back pain.
    Radoslaw Wasiak, PhD, et al. Back Pain Recurrence. An Evaluation of Existing Indicators and Direction for Future Research. In Spine. April 20, 2009. Vol. 34. No. 9. Pp. 970-977.