20The shift from acute pain to chronic pain and disability is a dynamic process that evolves over time. The original symptom of back pain arises from a physical process in the back and nociception. As pain becomes chronic (and this process may start within 3-8 weeks), attitudes and beliefs, distress and illness play an increasing part in its development. This all occurs within a social context involving interactions with health professionals, work colleagues and health care. The passing of time and in particular the duration of sickness absence are key to this process. Frank et al (1996, 1998) and Krause & Ragland (1994) describes the clinical and occupational stages by which a patient progresses seamlessly from the acute stage to chronic disability. The table below also reflects increasing difficulty in clinical management, rehabilitation and return to work.

Table 2: Progression of LBP

Stages of Disability

Acute : 0-4 weeks ( a medical condition with a social implication)

  • Natural progression is benign and self limiting.
  • Prognosis is good irrespective of health care.
  • 90% of acute attacks settle within 6 weeks, at least sufficient to return to work, even if many people still have some persistent or recurrent symptoms
  • Minimise health care, avoid medicalisation, avoid iatrogenic disability.
  • Avoid labelling and culture of disability and incapacity.

Sub-acute 4-12 weeks (the critical stage for intervention)

  • Most people have returned to work, even if they still have some residual pain.
  • Those still off work now have 10-20% risk of going on to chronic pain and incapacity.
  • Psychosocial factors become more important.
  • Active interventions to control pain and improve activity levels are effective and cost effective.
  • The opportunity for timely health care, rehabilitation and administrative interventions.

Chronic >12 weeks (a disability problem with medical elements)

  • This 10% of patients account for 80% of healthcare use and 90% of social costs.
  • Non-specific low back pain has now become a source of chronic incapacity.
  • Major impact on every aspect of their lives, their families, and their work.
  • Psychosocial issues are always important.
  • Poor prognosis: likelihood of return to work diminishes with time.
  • Medical treatment, rehabilitation, and vocational rehabilitation are difficult and the success rate is low.
  • Many patients lose their jobs. Retraining and replacement becomes much more difficult.

Adapted from Frank et al (1996) and Krause & Ragland (1994)