Patterns in Back Pain Over Time: Who Recovers and Who Persists?

Peer Reviewed

A study following patients with back pain identified four distinct trajectories: one-in-five people recover over time, almost one-in-five experience persistent back pain, nearly one-third are likely to develop back pain over time, and one-third report occasional back pain, according to a population-based longitudinal study reported online ahead of print in Arthritis Care & Research.

Canada map demographics concept, population, people on map.Researchers analyzed data from a representative sample (n=12,782) of the Canadian population enrolled in the National Population Health Survey Results. Photo Source:


“The examination of the identified groups merits further attention as they may represent different diagnoses or distinct clinical presentations (ie, phenotypes),” co-authors Mayilee Canizares, PhD, and Y. Raja Rampersaud, MD, FRCSC, told SpineUniverse. “These trajectory groups may provide key insights to the selection of stratified treatments and aid designing early prevention and management strategies in the population.”

“The study showed that persistent back pain is associated with persistent symptoms such as pain and disability as well as increased healthcare and medication use,” the researchers said. “The recovery trajectory group had increased use of opioids and antidepressants over time, suggesting that those recovering from back pain need further monitoring as they continue using medication over time.” Dr. Canizares is a Scientific Associate and Dr. Rampersaud is an orthopaedic spine surgeon and clinician scientist at the University Health Network’s Krembil Research Institute in Toronto, Canada.

Study Design

The researchers analyzed data from a representative sample (n=12,782) of the Canadian population enrolled in the National Population Health Survey. The participants were followed from 1994 to 2011, were surveyed every two years, and provided data on factors including comorbidities, pain, disability, opioid and other medication use, and healthcare visits.

During the 16 years of follow-up, almost half (45.6%) of participants reported back pain at least once. Four trajectories of back pain emerged among these participants: those with persistent back pain (18%), those who developed back pain over time (28.1%), those who recovered (20.5%), and those who occasionally reported back pain (33.4%).

The persistent and developing groups tended to have more pain, disability, healthcare visits, and medication use (eg, opioids and antidepressants) than those in the recovery and occasional trajectory groups.

Participants who were obese were more likely to have persistent, developing, or occasional back pain than their non-obese counterparts. Participants who engaged in physically demanding daily activities were more likely to be in the developing, recovery, or occasional back pain groups. Smoking and comorbidities were also linked to a greater risk for all back pain trajectory groups.

What Does the Back Pain Developing Group Represent?

“It is unclear what the back pain developing group represents,” the authors told SpineUniverse. “It is likely that a portion of this group may represent people who would transition to a more persistent stage, particularly as the trajectories over time of the outcomes for this group were similar to those for the ‘persistent’ group. Given the high impact of back pain on both the individual and healthcare system, there is a need for further research to understand the characteristics of this group.”

“Future long-term studies recording back pain from onset and assessing back pain in short time intervals (eg, monthly) would help to fully understand the dynamics of back pain over time,” they concluded.

How to Taper or Stop Unnecessary Opioid Use

All groups showed an increase in opioid use over time, with the increase being more marked in the persistent and developing groups compared with the other groups. Notably, the recovery group showed increased use of opioids and antidepressants over time.

“One possible explanation for this is that some people in the ‘recovery’ group may be using these medications several years after their back pain has resolved,” Drs. Canizares and Rampersaud said. “If this is the case, there are potentially secondary long-term consequences of back pain, such as opioid dependence and persistent mood dysfunction, pointing to the key importance of clinical intervention as the back pain recovers to modify or stop medication use.”

“Another possibility is that the continued recovery is related to the ongoing drug intervention, however, it is unlikely that the long-term opioids use is justifiable,” the authors told SpineUniverse. “Ongoing opioids use is not likely to be related to co-occurring conditions, as our analyses took comorbidities into account. It is also possible that the continued opioid use in the ‘recovery’ and ‘occasional’ groups is related, at least partially, to the increase in opioid use (medical and nonmedical) in the general population that has been previously reported.”

“As per recent guidelines, opioid use for low back pain should be avoided and if deemed necessary for severe pain, should only be used for a short period of time to enable optimal non-pharmacological management,” Drs. Canizares and Rampersaud said. “Long-term opioid use has not been shown to be beneficial for the management of back pain.”

People With Back Pain Are a Heterogeneous Group

Overall, the findings suggest that people with back pain are a heterogeneous group that may benefit from different approaches to management rather than a traditional one size fits all approach, the authors concluded. “The distinct groups identified in the study may represent opportunities for more individualized treatment and preventative strategies,” they said.

Dr. Canizares and Dr. Badley have no financial disclosures.
Dr. Rampersaud reports personal consulting and royalty fees from Medtronic, which have no relationship or impact on the findings of this study.

Updated on: 07/31/19
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Mayilee Canizares, PhD
Scientific Associate
University Health Network
Y. Raja Rampersaud, MD
Orthopaedic Spine Surgeon
Clinician Investigator
Krembil Research Institute

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