Finding the right time point for treatment
Bearing in mind that although a substantial number of acute low back pain (ALBP) patients will recover with little or no medical care, close to one-third of these patients tend to develop continuous or recurrent pain one year after an initial episode (Waddell 2004). As the duration of pain is one of the most important predictors of the development of severely chronic pain states, this leads to the conclusion that an effective treatment should start as early as possible. One of the first interventional strategies that focused on primary prevention was aimed at the prevention of the occurrence of back pain in healthy people at the workplace, since a number of risk factors for the occurrence of LBP have been shown to be work-related (see Chapter 19). However, despite the reduction of several ergonomic stressors at the workplace, the effects of these interventions on the development of pain and disability in healthy workers remained more than marginal (Shaw et al. 2006). The concept of secondary prevention—starting treatment in a phase of acute LBP with a duration of not more than 4 weeks—should be more cost-effective, because interventions are offered to fewer patients with a potentially greater effect. Within this context, it is less likely that a person who is healthy and who may have no risk of developing LBP or chronic states will receive an intervention that causes no effect but does cause costs. As described in more detail in the second section of this chapter, a number of randomized trials have been published during the past 10 years which aimed at secondary prevention of a recurrence of pain, pain-related disability, and work-related issues, conducted at the workplace, within primary care, and also on a population-based level. Although the results of these trials indicate that acute and subacute LBP is an optimal time point for starting multidisciplinary treatment, we recognize that there is substantial room for improvement of treatment offers.