Mend Physical Therapy Blog and Injury Information

Unwarranted Clinical Practice Variation Associated With Transition From Acute To Chronic Low Back Pain

February 17, 2021


Low back pain is the leading cause of disability in our country, costing billions of dollars per year, felt by both the healthcare system and taxpayers. Acute low back pain lasting less than 30 days is a very common condition experienced by up to 90% of us during our lifespans. Thankfully, there is a very low probability of any underlying serious condition (ex. cancer) and the majority of these cases resolve with little medical or Physical Therapy interventions. Conversely, 1 in 4 individuals will experience low back pain lasting > 3 months and/or pain interfering with activity more frequently than every other day.

Researchers have been interested in the transition of pain from an acute stage, where it is easier to manage, to a chronic condition when it is less successfully treated at a higher cost. Hill and colleagues in the mid 2000s created the the STarT (Subgroups for targeted treatment) Back Tool to help identify individuals at risk for the development of chronic low back pain. Clinicians can utilize their simple, 9 item tool, to classify their current patient with acute back pain into one of three risk groups. Researchers recommend providing medical interventions including Physical Therapy based on a patient’s level of risk for chronic symptoms.

A recent article in the Journal of the American Medical Association reported on the associations and risk factors which explain some of the transition from acute to chronic low back pain (Stevans et al. JAMA Open Network. 2021). Authors enrolled over 5,000 patients presenting to primary care offices across the country with acute low back pain and collected demographic and STarT Back tool findings. They then retrospectively analyzed the patient’s charts to determine if the care they received was consistent or inconsistent with our best practice guidelines on low back pain. Inconsistent care was defined as unnecessary or non indicated medication prescriptions (including opiods), early imaging, or early referral to specialty physicians (orthopedists, neurologists, or neurosurgeons).

Stevans and colleagues reported 34%, 41%, and 25% of patients were classified as low, medium, and high risk for chronic low back pain using the STarT Back tool. Surprisingly, 1/3 of patients received non recommended medications (65% received opioids) and 1/4 received an early MRI or CT scan. This unwarranted practice variation from clinical guidelines was independently associated with the transition of 1 in 3 patients from acute to chronic low back pain.

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