Detailed guides to painful problems, treatments & more

Chronic Low Back Pain Is Not So Chronic

The prognosis for chronic low back pain is better than you think

Paul Ingraham • 15m read

Photo of a man holding his stiff back.

Good news! Chronic low back pain is less chronic than many people probably thought — probably less than anyone thought — according to the British Medical Journal.

Famously, most back pain doesn’t last long: most people get better fairly soon. Specifically, at least half of people with back pain will improve or even recover completely within just a month.1 But then what?

What happens when back pain doesn’t go away within a few weeks? When does acute pain become chronic… and how long does chronic low back pain last? The duration that conventionally distinguishes “acute” from “chronic” cases is 6-12 weeks (depends who you ask). It’s an arbitrary number, not a data-based one — and it comes with the insidious, confidence-nuking insinuation that those who do not recover by that deadline are doomed to a much longer battle with chronic pain.

You do not disastrously become an impossible case the moment you hit week thirteen. In fact, if you’ve had chronic low back pain for less than a year, I’ve got great news for you: your ordeal may soon be over, no matter what you do about it. Or don’t do about it. There is good evidence about this, which this article will explore in detail.23

Obviously low back pain can last for many years, sometimes constant, and other times coming and going (chronic episodic back pain). But these are a worst-case scenarios, and here’s the good news is that chronic low back pain is:

The pseudo-myth of back pain chronicity

The pseudo-myth is that chronic back pain is common, severe, and rarely ever lets up. It’s not quite a full-strength myth for two reasons:

  1. Chronic back pain is real and serious. The pseudo-myth is an exaggeration of the truth, not total departure from it.
  2. No one is really out there “promoting” the myth, or erroneously defending it. You’re not likely to catch a doctor actually saying that you’re doomed after twelve weeks of back pain — but it might be implied.

Back pain is generally over-treated and over-medicalized with lots of medical drama with minimal benefit for patients (exhibit A: the infamous overprescription of imaging, too often and too soon). Part of that drama is a pervasive attitude of defeatism and alarmism about the prognosis of chronic low back pain. Most healthcare professionals know enough to reassure their patients that a new episode of back pain is likely to resolve quickly, but many of those same professionals simply postpone their pessimism and alarmism, defeating the purpose of their reassurances, and often undermining patient confidence long before chronicity actually arrives.

It is not at all reassuring to be told that “most cases go away with two or three months” if it’s accompanied by the strong implication that “you’re screwed if it doesn’t!” Patients given these conflicting messages are likely to start worrying that their pain might not go away in time to avoid the spectre of chronicity.

Diagram showing acute pain giving way to chronic around the uncertain border of 12 weeks.

There is no clear transition from acute to chronic pain, but pain that persists beyond 9–12 weeks is usually deemed chronic. The surprising thing? Most chronic low back pain doesn’t stay “orange” for a whole year.

Good news: credible evidence that plenty of chronic back pain backs off!

If you’ve had chronic low back pain for less than a year, I’ve got great news for you: your ordeal may soon be over. A good Australian study by Costa et al. showed that “prognosis is moderately optimistic for patients with chronic low back pain.”

“Many studies provide good evidence for the prognosis of acute low back pain,” the authors explain. “Relatively few provide good evidence for the prognosis of chronic low back pain.”

And the prognosis is better than most people would expect.

This research is different from other studies of chronic low back pain, which often focus on patients who already have a well-established track record of long-term problems: in other words, the people who had already drawn the short straw before they were selected for study, and are therefore much more likely to carry right on feeling rotten. But what if you studied fairly new cases of chronic low back pain? How many of them fade away, and how many of them drag on?

And isn’t that what low back pain patient most want to know? Especially after suffering for 3-4 months? Just how chronic is chronic back pain? No so chronic after all…

More than a third of chronic cases recover within a year — which isn’t very chronic

Costa et al. followed patients who had not yet recovered from their new cases of chronic low back pain, and found that “more than one third” recovered within nine more months. That’s a quite a happy number.

Yes, of course, that does still leave almost two thirds of patients who do continue to suffer past the year-mark — and that’s not such a happy number. This is chronic low back pain we’re talking about here, after all — it’s not nothing! But the surprising and promising thing is that so many patients in this study — almost 40% — actually did recover by the one-year anniversary of their pain. These are people who didn’t get better in the first three months … and who would have been told by many doctors that they were officially “chronic” at that point.

This evidence is a great foundation for more substantive and lasting optimism about back pain. But wait, there’s more!

How did it go for 11,000 more people with chronic low back pain?

Sure, it’s great that a third of people recover entirely, but there’s still something important missing here: what happens to everyone else? Do they improve? Or do they get stuck with just as much back pain at a year as they had at three months? Obviously that does happen to a few unlucky souls.

But definitely not most people.

There’s surprisingly little hard evidence on the prognosis of chronic low back pain: as of 2023, there’s still just one other good study … and it also came from Costa et al. Busy researchers!

In 2012, they pooled a whole bunch of data about the progression of both acute and chronic back pain, generally validating their 2009 finding that chronic pain improves, and some of it resolves — further debunking the idea that chronic is permanent. Yes, lots of people still have significant pain and disability a year after being stuck with the “chronic” label… but not everyone, and almost everyone improves quite a bit. Costa et al. crunched the numbers on over 11,000 patients in 33 different studies of back pain patients, and split them up into acute and chronic (pain for less/more than 12 weeks). Here’s how pain in those groups changed in the year after their trouble started:

Progression of acute vs chronic back pain (Costa et al.)
acute chronic
onset 69/100 60–80?4
6 weeks 28 55
26 weeks 12 29
1 year 4 17
Chart of key data from Costa et al. 2012.

Whether pain was acute or chronic to begin with, pain declines in very similar way over a year. Although chronic is clearly worse than acute on average, it also declines slowly & significantly over the months — a striking contrast to the pattern that people fear about back pain chronicity.

Risk factors: who did well or poorly in the Costa trial, and why?

Did the people who didn’t recover in Costa et al.’s 2009 trial have anything in common? The study also looked at risk factors, and found some patterns. The patients whose pain just kept going were those who had worse pain, more disability, and more fear (“perceived risk of persistent pain”) — no surprise there. They were also the patients with a history of previous sick leave — not for back pain, but for other things, people who may be generally unwell.

A little more surprising was that they had less education: better educated people recovered better.

And (my favourite) the patients with persistent pain also tended to be non-Australian. That’s right: native Australians in Australia get less chronic back pain than non-Australians in Australia! Not sure what to do with that information — don’t move to Australia and get low back pain, I guess? Sound medical advice.


EXCERPT This article is an excerpt of PainScience.com’s extremely detailed guide to low back pain. Who are we kidding? It’s a full-on book. It’s huge, actually.

Who does poorly with low back pain? Known risk factors for chronicity

Back pain chronicity is impossible to predict reliably, but there are some signs to be alert for. Although very complex, the oversimplified truth is so obvious it almost feels silly to say it: the worst and most intimidating cases of back pain are the most likely to last! But we can get more specific…

  1. Anxiety and pessimism. Obviously more severe back pain tends to be more emotionally challenging, but there are other critical factors too, like how the pain menaces work and fun. (It is not clear whether anxiety and pessimism are a cause of chronicity, or merely a natural consequence of the severity that leads to chronic back pain. More on this below.)
  2. Leg pain, pain in the neck and shoulders, and difficulty walking or getting dressed.
  3. No position or movement eases the pain. This can change with time, so the more and sooner you can get relief from some movement or position, the better. This is the phenomenon of “centralization” — relief in response to specific repeated movements or sustained postures. We see this in roughly 40% of people with back pain, and it is quite strongly linked to better outcomes.5 It’s possible, maybe even likely, that centralization is just a sign of a milder case of back pain,6 but I’m including it because it’s such a famous signal.

Back pain chronicity risk quiz

The STarT back pain questionnaire is a nine-question quiz that does a good job of identifying low, medium, and high risk of poor outcomes for people with back pain.7 The first points questions above are an extreme simplification of its implications. The full questionnaire is intended to be used by clinicians with patients, but it can be understood and used by anyone, and there’s an online calculator.

But scoring the official version is a bit tortuous (there’s literally a flow-chart for it, and worse8) — so I think the world could use a simpler version. This is my own slightly simplified self-serve quiz for patients. While the full quiz is scientifically validated, and that matters, it’s clearly not an exact science, and a simplified version is just fine for getting a rough sense of your risk level.

The more of these statements apply to you, the higher your risk of chronicity, and the more likely you are to benefit from skilled and personalized care. Most people scoring three or less probably need no professional help at all, as long as the situation doesn’t get worse. If you score low initially, but then much higher three weeks later, you should seek out help.

The relationship of back pain and anxiety and/or depression

Knowing that your chronic back pain probably won’t be as chronic as you fear is inherently valuable. But could that kind of reassurance actually help? And does being afraid of a bad outcome actually make it more likely?

Anxiety, pessimism, and depression might cause exactly what we fear — a self-fulfilling prophecy. And reassurance might actually scare the back pain away and, all other things being equal, produce a better prognosis than if you were freaked out.

That’s a very tempting idea, but No one actually knows that anxiety causes or exacerbates back pain, or vice versa, because the right evidence simply does not exist (despite some strong expert opinions to the contrary in both directions). All anyone can do is speculate. All we do know is that there is some kind of relationship,9 and that there are indeed psychological risk factors for back pain … but correlations and risk factors are not “causes.”

It is plausible that anxiety and depression can make back pain worse (at least). And if that’s the case, then reassurance and correction of the misinformation might be very valuable.10

More articles about back pain

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

What’s new in this article?

2023 — Rewrite and major upgrade. The previous reassurance-is-good-for-back-pain slant has been replaced with a much more nuanced perspective on the relationship between back pain and psychological factors. And there are useful new sections on risk factors.

2023 — Added a new section with more recent and detailed follow-up evidence, a new table, and two diagrams. Edited the whole thing.

2009 — Publication.

Notes

  1. Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ. 2003 Aug;327(7410):323. PubMed 12907487 ❐ PainSci Bibliography 51326 ❐

    Many studies over the years that have shown roughly the same thing: most people recover relatively quickly and well. This old review of 15 such studies calculated an average of 58% reduction both pain and disability within a month, and then some more within another month.

  2. Costa LCM, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009 Oct;339:b3829. PubMed 19808766 ❐ PainSci Bibliography 55422 ❐
  3. Costa LCM, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012 Aug;184(11):E613–24. PubMed 22586331 ❐ PainSci Bibliography 51296 ❐
  4. 51 was the pain level when these patients joined a study, but they had already been in pain for a while. We can guess that it was probably higher at the beginning.
  5. May S, Runge N, Aina A. Centralization and directional preference: An updated systematic review with synthesis of previous evidence. Musculoskelet Sci Pract. 2018 Dec;38:53–62. PubMed 30273918 ❐
  6. Kilpikoski S, Suominen EN, Repo JP, et al. Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers. J Man Manip Ther. 2023 Feb:1–10. PubMed 36756675 ❐ This study showed that centralization occurs in somewhat milder cases, while non-centralizers have a bit more pain/disability. It’s not a dramatic difference, but it’s consistent with the rather obvious idea that it’s easier to find relieving movements and positions in less severe cases.
  7. The Keele STarT Back Screening Tool was developed by Keele University, and originally validated in a trial published in The Lancet in 2008 (Hill 2008). Hill went on to study the cost-effectiveness of care customized for patients with low, medium, or high risk of poor outcomes (Hill 2011) — basically, more and better care for people with worse back pain, rather than “one size fits all.” Low-risk patients were reassured and not treated, while medium-risk patients received typical physical therapy, and high-risk patients got more and better physical therapy that was “psychologically informed” with attention to “psychosocial obstacles to recovery.” This approach resulted in better bang-for-buck results. Care stratification has been extensively studied since then, and even extended to other kinds of pain (see van den Broek).
  8. Although the Keele calculator tallies up your score, it doesn’t interpret it for you, and half the scoring table is devoted to highly cryptic codes for each result, thinks like “SNOMED codes, Concept ID: 945621000000107, Description ID: 2418721000000118.” Really, Keele?
  9. Stubbs
  10. Cremers T, Zoulfi Khatiri M, van Maren K, et al. Moderators and Mediators of Activity Intolerance Related to Pain. J Bone Joint Surg Am. 2021 Feb;103(3):205–212. PubMed 33186001 ❐ This is a better-than-nothing citation. Cremers *et al.* over-interpret their moderator/mediator analysis of cross-sectional data, overconfidently “concluding” that fearful misconceptions increases pain-related disability, and more so with greater symptoms of depression or anxiety. That conclusion is actually more like a reasonable hypothesis, partially supported by their experiment. But at least the data doesn’t seem to undermine their hypothesis

Permalinks

https://www.painscience.com/articles/chronic-low-back-pain-is-not-so-chronic.php

PainScience.com/chronic_not_so_chronic

linking guide

3,500 words

PainSci Member Login » Submit your email to unlock member content. If you can’t remember/access your registration email, please contact me. ~ Paul Ingraham, PainSci Publisher