Ijerph 19 10145

International Journal of

Environmental Research
and Public Health

Systematic Review
Biopsychosocial Factors for Chronicity in Individuals with
Non-Specific Low Back Pain: An Umbrella Review
Emilia Otero-Ketterer 1,2, * , Cecilia Peñacoba-Puente 3 , Carina Ferreira Pinheiro-Araujo 4 ,
Juan Antonio Valera-Calero 5 and Ricardo Ortega-Santiago 6,7

1 Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
2 Physiotherapy Department, Mutua Universal Mugenat, 28001 Alcalá de Henares, Spain
3 Department of Psychology, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
4 Motor Science Institute, Federal University of Alfenas, Alfenas 37130-000, Brazil
5 Valtradofi Research Group, Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela,
Villanueva de la Cañada, 28692 Madrid, Spain
6 Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation,
Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
7 Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual,
Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
* Correspondence: [email protected]; Tel.: +34-676-547-902
Abstract: Low back pain (LBP) is a global and disabling problem. A considerable number of
systematic reviews published over the past decade have reported a range of factors that increase the
risk of chronicity due to LBP. This study summarizes up-to-date and high-level research evidence
on the biopsychosocial prognostic factors of outcomes in adults with non-specific low back pain at
follow-up. An umbrella review was carried out. PubMed, the Cochrane Database of Systematic
Citation: Otero-Ketterer, E.; Reviews, Web of Science, PsycINFO, CINAHL Plus and PEDro were searched for studies published
Peñacoba-Puente, C.; Ferreira between 1 January 2008 and 20 March 2020. Two reviewers independently screened abstracts and
Pinheiro-Araujo, C.; Valera- full texts, extracted data and assessed review quality. Fifteen systematic reviews met the eligibility
Calero, J.A.; Ortega-Santiago, R.
criteria; all were deemed reliable according to our criteria. There were five prognostic factors with
Biopsychosocial Factors for
consistent evidence of association with poor acute–subacute LBP outcomes in the long term (high
Chronicity in Individuals with
levels of pain intensity and disability, high emotional distress, negative recovery expectations and
Non-Specific Low Back Pain: An
high physical demands at work), as well as one factor with consistent evidence of no association (low
Umbrella Review. Int. J. Environ. Res.
Public Health 2022, 19, 10145. https://
education levels). For mixed-duration LBP, there was one predictor consistently associated with poor
doi.org/10.3390/ijerph191610145 outcomes in the long term (high pain catastrophism). We observed insufficient evidence to synthesize
social factors as well as to fully assess predictors in the chronic phase of LBP. This study provides
Academic Editor: Paul B. Tchounwou
consistent evidence of the predictive value of biological and psychological factors for LBP outcomes
Received: 15 July 2022 in the long term. The identified prognostic factors should be considered for inclusion into low back
Accepted: 14 August 2022 pain explanatory models.
Published: 16 August 2022
Keywords: chronic pain; prognosis; humans; low back pain; pain; risk factors; umbrella review
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
1. Introduction
Low back pain (LBP) is a common health condition with important implications for
individuals, public health systems and economies [1]. It has been increasing worldwide
Copyright: © 2022 by the authors.
since 1990 with the rise and aging of the population, with a higher prevalence among
Licensee MDPI, Basel, Switzerland.
people between the ages of 40 and 80 [2,3]. In 2017, low back pain was the leading cause of
This article is an open access article
years of disability, with over 570 million people affected at any one time [3], and it is likely
distributed under the terms and
to increase in low-income and middle-income countries in the next few decades [4]. Low
conditions of the Creative Commons
back pain generates an impact on the quality of life of individuals [5,6] and on the economy,
Attribution (CC BY) license (https://
with direct healthcare costs [7] comparable to those of cardiovascular disease, cancer or
creativecommons.org/licenses/by/
4.0/).
mental health [8], as well as indirect costs related to the potential loss of work status [4,9].
Int. J. Environ. Res. Public Health 2022, 19, 10145. https://doi.org/10.3390/ijerph191610145 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 10145 2 of 25
Most people who experience LBP have non-specific low back pain (NSLBP), a hetero-
geneous presentation with variable prognosis, defined as low back pain not attributable to
a recognizable and known specific pathology (e.g., infection, tumor, osteoporosis, lumbar
spine fracture, structural deformity, inflammatory disorder, radicular syndrome or cauda
equina syndrome) [2]. Currently, NSLBP is understood as a neurobiological and behavioral
response to individual threat perception, rather than a disease [1]. The biopsychosocial
model was embraced in 1977 [10], providing a framework to explain the complexity of dis-
abling LBP and its multidimensional clinical reasoning up to the present day, incorporating
the interaction between the social, psychological and biological dimensions of pain [11],
context and behavioral conditioning [12].
Prognostic factors inform us about the likely course or outcome of a health condition
over time and, thus, guide health professionals in decision-making and patient health
education [13], in preventing the development and maintenance of chronic pain [14].
Since the publication of the last overview of systematic reviews on prognostic factors in
individuals with LBP in 2009 [15], a considerable number of primary studies and systematic
reviews on LBP predictors have been published, and, in turn, there has been substantial
progress in search methods. However, most of these available systematic reviews have
either focused on the analysis of a single prognostic factor or have done so regarding a
specific outcome domain.
Therefore, the objective of this umbrella review is to display an up-to-date overview
of high-level research evidence providing longitudinal data on biopsychosocial prognostic
factors of outcomes in individuals with non-specific low back pain.
2. Materials and Methods

One reviewer (EO) screened the titles identified by removing ineligible studies and,
subsequently, two reviewers (EO and CP) independently examined all abstracts and full
texts. Two other reviewers (CF and JV) extracted information using a standardized data
extraction form and assessed the reliability of the reviews. Disagreements were discussed
until consensus, and if consensus was not reached, a third reviewer (RO) was available.
2.1. Protocol and Registration

We followed the Umbrella Review Methodology Working Group [16] and considered
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) rec-
ommendations [17] (Supplementary Table S1: PRISMA checklist). The protocol of the study
was registered on PROSPERO 2020: CRD42020155081.
2.2. Criteria for Considering Reviews for the Overview

2.2.1. Literature Search
PubMed, the Cochrane Database of Systematic Reviews, Web of Science, PsycINFO,
CINAHL Plus and PEDro were searched electronically for studies published between
1 January 2008 and 20 March 2020. Our search was limited to 2008 onwards, given that
the previous “review of reviews” on LBP prognosis conducted a literature search until
2007 [15]. No restrictions were applied regarding the follow-up duration or language. The
search strategy included low back pain (Cochrane Back and Neck Group recommended
strategy) [18] and prognostic study method terms [19] (Supplementary Table S2: Search
strategy for PubMed). The electronic search was implemented in several grey literature
databases (NHS Evidence, Explore the British Library, Open Dissertations, TESEO, Open-
Grey, CNCS-ISCiii, JBI COnNECT+, New York Academy of Medicine, New York, NY, USA).
In addition, manual searches were also performed by tracking citations from the reference
lists of all included reviews and relevant reviews in musculoskeletal (MSK) pain, as well as
by contacting authors of included reviews.
2.2.2. Review Selection

We selected systematic reviews, with or without meta-analysis, summarizing longi-
tudinal observational studies that involved adult participants (≥18 years) at any point in
the course of LBP (acute, subacute or chronic) or with mixed pain (i.e., other conditions
such as neck or thoracic pain), only if most of the population (≥75%) underwent NSLBP or
subgroup data were available for this condition, with baseline measures of at least one bio-
logical, psychological or social factor, as well as one predicating the primary outcomes (pain
intensity, functional status, work participation and recovery) and, additionally, secondary
outcomes (health-related quality of life, emotional distress, satisfaction with treatment and
healthcare utilization); we included only those written in English or Spanish.
We excluded reviews involving a majority of individuals with LBP caused by specific
pathologies or conditions (such as surgery or pregnancy); those assessing factors as media-
tors, moderators or their impact on treatment; those reporting only secondary outcomes;
those based on a cross-sectional design; and narrative or methodological reviews.
2.2.3. Data Extraction and Management

We recorded complete information about citations, populations, methods, prognostic
factors and outcomes assessed. The results of the reviews were extracted separately for
each duration of LBP symptoms: acute–subacute (≤3 months), chronic (>3 months) and
mixed duration [20].
Likewise, results data were extracted for each primary outcome, according to the Inter-
national Classification of Functioning, Disability and Health (ICF) framework [21]—pain
intensity, functional status and work participation and recovery—which were considered
together to synthesize the evidence of our outcomes of LBP results at follow-up. For the in-
terpretation of the best available evidence, the secondary outcomes of health-related quality
of life, emotional distress, satisfaction with treatment as well as healthcare utilization were
collected and considered narratively. We categorized the results according to the follow-up
time period—short-term (<3 months) and long-term (≥3 months)—along with the evi-
dence that most improvements in pain, activity limitation and return to work occur within
3 months and thereafter recovery is lesser [20]. Moreover, since an unadjusted finding does
not control for confounding factors, unlike the adjusted finding, we extracted all adjusted
data, apart from the unadjusted data for a separately planned analysis, when possible [22].
When a systematic review presented data from several primary studies for the same
factor, we reported the range (i.e., the lowest and highest value reported). In the event that
the review described a meta-analysis, we presented the pooled estimate. Where several
measurement instruments were reported for the same outcome, we selected the measure
with greater evidence of validity and reliability for synthesis. Likewise, all dichotomous
measures with more than one cut-off point were extracted, but the one showing the most
significant association was used. In addition, the overlap of primary studies among the
included reviews was recorded using citation matrices and excluded from our synthesis.
The degree of overlapping studies was calculated using the Corrected Covered Area
(CCA) method [23].
2.3. Methodological Quality Assessment of Included Reviews

We used the criteria developed by the SUPPORT and SURE collaborations, reported in
a recent review published in The Cochrane Library [24]. It rates 14 criteria grouped under
Section A—Identification, selection and critical appraisal of studies; Section B—Analysis;
and Section C—Overall. Each item can be rated as follows: +, yes; ?, can’t tell/partially;—,
no; NA, not applicable (e.g., no studies or data). In the last item, and considering the prior
assessments of the criteria, the review is categorized as having (1) only minor limitations;
(2) limitations that are important enough that it would be worthwhile to search for another
systematic review and to interpret the results of this review cautiously, if no better review
is available; (3) limitations that are important enough to compromise the reliability of the
findings of the review and to prompt the exclusion of the review.
2.4. Data Synthesis

The characteristics of the included reviews were summarized descriptively. We also
conducted a descriptive quantitative analysis (summary measure with a precision estimate)
for each systematic review, according to the duration of LBP symptoms (acute, subacute,
chronic and mixed duration) as well as length of follow-up (short and long term).
To adequately compare findings across the reviews, we used odds ratio (and beta coef-
ficients) statistics for synthesis. Results of a systematic review were considered consistent if
≥75% of the primary studies reporting on a factor rated the same direction of association
with the outcome [25]. Thus, a factor was judged consistently associated with low back
pain outcomes when it demonstrated a uniform association in the same direction by at least
two reliable reviews, or at least half of them, and not contradicted by any other review [15].
The strength of association with outcomes was deemed weak (OR 1.01–1.49), moderate
(OR 1.50–1.99) or strong (OR ≥ 2.0) [26], with moderate and strong strengths considered
clinically relevant.
Thus, a qualitative synthesis was performed given that the main purpose of this
study was to present a summary of the current body of evidence based on systematic
reviews of biopsychosocial prognostic factors in patients with LBP and also considering
the heterogeneity of the data collected. In this way, we have described and discussed the
extent of the main differences found in the results reported by the included reviews, as well
as the aspects considered as probable explanatory factors for such heterogeneity, without
performing additional subgroup or sensitivity analyses.
3. Results
3.1. Review Selection
A total of 2.721 citations were identified: 1.846 through electronic databases, 744 from
grey literature databases and 131 from tracking citations and contact with authors. We
evaluated 72 full-text publications, and 15 systematic reviews were eligible (see Figure 1).
References from excluded full-text citations (n = 57) are reported in Supplementary Table S3.
The conflicts of interest of the review authors are displayed in Supplementary Table S4.
Disagreements were resolved by consensus among reviewers twice during the selec-
tion process, four times during data extraction and twice during quality assessment, with
non-intervention of the third reviewer.
3.2. Review Characteristics

Fifteen systematic reviews (257,208 participants) reported data on biopsychosocial
prognostic factors and low back pain outcomes at follow-up, with four being general
reviews [27–30] and 11 reviews focused on a single prognostic factor [31–41] (Table 1).
The reviews included studies performed in North America (15 reviews), South Amer-
ica (1 review), Europe (15 reviews), Oceania (11 reviews) and Asia (4 reviews). Most of the
populations contained in the reviews displayed acute and subacute (57%, 146 studies from
10 reviews) and mixed-duration low back pain (39%, 100 studies from 7 reviews) from a
clinical (61%, 156 studies) and occupational setting (36%, 93 studies).
The publication date of the included reviews ranged from 2008 to 2019 and that of
the included primary studies varied from 1981 to 2017 (Supplementary Table S5: Primary
studies referenced in tables). Twelve reviews (80%) were published over 5 years ago (before
2015). The sample size in the reviews ranged from 219 [41] to 112.797 [29], with a mean of
17.147 (interquartile range (IQR): 3.535 to 11.330).
Regarding our outcome of LBP results, all primary outcomes were widely assessed
across the 15 included reviews: work participation (60%, 9 reviews), functional status (60%,
9 reviews), pain intensity (60%, 9 reviews) and aspects of recovery (53%, 8 reviews). For
secondary outcomes, only satisfaction with treatment and healthcare utilization results were
reported by two primary studies, using p-values in two reviews [37,39], with insufficient
evidence for interpretation. Only 5% of the primary studies included in the systematic
reviews reported results within 3 months of follow-up (short term).
The main reasons for the review authors not pooling the results were the heterogeneity
of the population, measures of prognostic factors, outcomes assessed and outcome mea-
sures, as well as the variety of statistical analyses. The most common estimates used to
report the results across the reviews were odds ratios (OR), but beta coefficients (β), risk
ratios (RR), prevalence ratios (RP), hazard ratios (HR), likelihood ratios (LR+/LR-) and
p-values were also reported. Data from RR/RP, HR, LR+/LR- and p-values are provided in
Supplementary Table S6.
3.3. Methodological Quality Assessment of Included Reviews

The results of our appraisal of the methodological quality (reliability) of the included
reviews are shown in Supplementary Table S7. We judged all 15 included reviews to have
only minor limitations. In general, there were few failures with regard to the selection
criteria and critical appraisal of the risk of bias of the primary studies from the system-
atic reviews, with thirteen reviews partially meeting the comprehensive search strategy
criterion. Likewise, there were few flaws regarding the analysis of the results, with three
Int. J. Environ. Res. Public Health 2022,reviews
19, x showing limitations in the reporting of the characteristics and results and5 one of 26
review explaining the differences in the results.
Figure1.1.Flow
Figure Flowchart
chartof
oflow
lowback
backpain
painprognosis
prognosissystematic
systematicreviews.
reviews.
Disagreements were resolved by consensus among reviewers twice during the

selection process, four times during data extraction and twice during quality assessment,
with non-intervention of the third reviewer.
Table 1. Characteristics of the included low back pain prognosis systematic reviews.
Research Question Data Extraction

Prognosis
Study Selection
Outcome(s)/ Prognostic Factor Quality
Review Population/ Prognostic Literature Search Criteria (Stud- Synthesis Main Conclusions
Review Follow-Up: Associations Categorization: Assessment
Quality Setting Factor(s) (Citations Found) ies/Publications)/ Strategies of the Authors
Minimum Number and Type Criteria
Total Participants
Criteria; Result
RQ; English;
prospective cohort
studies; reporting
MEDLINE, statistical association
1. psychosocial
CINAHL, Embase, information;
Adults with 2. history It remains
PsycINFO and excluding studies
recent-onset 3. pain uncertain which
Pain intensity, AMED from with participants
non-specific low 1. SS+, SS−, NS 4. physical List of 6 quality factors are
Biopsychosocial activity limitation inception to with specific diseases,
back pain 2. Effect sizes and impairment criteria Count of associated with
prognostic and participation February 2007; pregnancy or more
Kent PM et al., (<3 months), not CIs calculated; 5. activity recommended significant specific outcomes,
Reliable factors of restriction/S/T: reference lists of than 15% with
2008 [27] necessarily first bivariate and limitation by Hudak et al., results; the strength of
screening <3 months and included studies compressive
episode/ multivariate 6. participation 1996 [42] with a meta-analysis those associations
instruments L/T: >3 months; and relevant symptoms,
clinical and results restriction score from 0 to 6 and the degree of
NA reviews; citation cross-sectional, inci-
occupational 7. clinical confusion among
tracking of authors dence/prevalence
population 8. therapeutic prognostic factors.
of relevant studies or describing
response
studies (3881) clinical course
without prognostic
factor data
(50–54)/33,089
The most useful
components for
predicting
persistent
Adults with low Chronic low back
RQ; English; adults; 1. demographic disabling NSLBP
back pain <8 disability (pain, MEDLINE
prospective cohort and work-related were lower levels
weeks/clinical disability, work (1966–January
studies of individual characteristics Individual of fear avoidance
(primary care, status, mixed 2010) and Embase 1. SS+, SS−, NS
Chou R et al., Biopsychosocial risk factors or risk 2. health status at List of study results and low basal
Reliable specialty or results)/S/T: 3 to (1974–February 2. multivariate
2010 [28] factors predictors of the beginning of 8 quality criteria described; functional
physical therapy 6 months and 2010); reference results mainly
persistent disabling the LD meta-analysis impairment, along
clinics) and L/T: ≥1 year; lists of collected
DL (14–16)/ 3. signs and with non-organic
occupational ranged from 3 studies (11,841)
10,842 participants symptoms signs, general
population months to 2 years
health status and
the presence of
psychiatric
co-morbidities
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
Workers’
expectations of
recovery are
International
RQ; cohort studies important factors
Classification of
MEDLINE (prospective, in predicting a
Functioning,
Adults with (1966–April 2011), retrospective) and Individual return to work.
Disability and
acute non- Embase and secondary RCT List of 6 quality study results Pain and disability
1. SS+, SS−, NS Health (ICF)
specific low Return to PsycINFO (from analyses; results criteria based on described; factors remain
2. Effect sizes and 1. factors related to
Steenstra IA et al., back pain Biopsychosocial work/NR; inception to April measured in absolute existing lists with levels of important barriers
Reliable CIs; univariate the LD
2011 [29] (<6 weeks)/ factors varies from 2011); reference terms (rate), relative a classification of evidence to recovery.
and multivariate 2. to the worker, 3.
clinical and 2 to 264 months lists of relevant terms (OR, RR, HR), high, moderate (strong, Offering modified
results to the work and
occupational and recently survival curve or or low quality moderate and tasks clearly helps
the workplace
population published studies duration of sick leave insufficient) workers return to
4. to the
(4449) (25–30)/112,797 work. However,
psychosocial
participants job physical
environment
demands prevent
workers from
returning to work.
RQ; English and
The ability of the
Recovery French; subjects aged Adapted tool by
female gender to
Adults with (presence or not MEDLINE, 18–65 years with Walton et al.,
Individual predict the outcome
acute of pain or CINAHL, Embase radiated or 1. SS, NS 2009 [43] of
study results is not yet clear. Pain
non-specific work-related or and PsycINFO non-radiated pain; 2. Effect sizes 17 criteria, with
described; radiating to the leg
Agnello A et al., low back pain Biopsychosocial non-work-related from inception to occupational setting; and CIs a maximum
Reliable NR meta-analysis and a history of
2010 [30] (≤6 weeks)/ factors disability)/ November 2007; minimum follow-up calculated; score of
with adequate back pain have no
clinical and 6 months; reference lists of 6 months; excluding univariate 34 points and a
graphical statistical evidence
occupational ranged from relevant studies fractures and results high, moderate
representation to support their
setting 6 months to (2341) dislocations or low quality
isolated application
1 year (7–10)/2484 rating
in clinical practice.
participants
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
MEDLINE,
RQ; English;
Embase,
prospective cohort
PsycINFO,
and case–control List of 16 quality Work-related
CINAHL, IBSS,
studies; excluding criteria based on Individual social support had
Adults with Recovery results AMED and BNI
Work social studies addressing the combination study results a weak prognostic
mixed duration (pain intensity, from inception to 1. SS+, SS−, NS
support informal family or of assessments described; effect on NSLBP
from acute to disability) and 18 November 2011; 2. Effect sizes
(general work social support, of several recent count of outcomes and may
Campbell P et al., chronic return to reference lists of and CIs;
Reliable support, specific health NR reviews and results based be subject to the
2013 [31] non-specific low work/NR; recent relevant univariate and
co-worker and problems, specific guidelines for on direction influence of
back pain/ ranged from studies and multivariate
supervisor pregnancy or DL, quality effect with broader concepts
occupational 6 weeks to reviews; citation results
support) cross-sectional assessment in ranges of related to the
setting 4 years search for
findings and small systematic effect sizes employment
validated social
case series reviews in LBP context.
support measures;
(<30 persons)
databases of local
(13)/8091
experts (447)
List of 14 criteria
MEDLINE, Embase, RQ; English; derived from
Expectations of
PsycINFO, published in 2 systematic Individual
recovery when
Adults with CINAHL, AMED, peer-reviewed reviews on study results
Activity measured with a
non-chronic The Cochrane journals; baseline 1. SS, NS prognosis of described;
limitation and specific,
non-specific low Library, PEDro cohorts with >75% 2. Effect sizes NSLBP, with a count of
participation time-based
Iles RA et al., back pain Recovery from inception to participants with and CIs; classification of significant
Reliable restriction NR measure within the
2009 [32] (<3 months)/ expectations September 2007; DLNS; reporting univariate and high quality results with
(ICF)/NR; first 3 weeks of
clinical and reference lists of predictive strength multivariate (if 10 or more ranges of
ranged from 6 NSLBP are a
occupational included studies data; excluding results criteria were effect sizes;
weeks to 2 years strong predictor of
population and relevant retrospective studies satisfied) and graphical
people at risk of
systematic reviews (10)/4038 lower quality presentation
poor outcomes.
(111) participants (less than 10
criteria satisfied)
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
IP; English;
prospective cohort
studies and
secondary RCT List of 9 quality
Individual Consistent
Adults with analyses; adults criteria (AHRQ),
PubMed, 1. SS, NS study results evidence that
acute and 18–65 years; living in with scores
MEDLINE, 2. Effect sizes described; negative
subacute Absence from Western below 4
Hallegraeff Embase, PEDro and Cis meta-analysis expectations
non-specific low Recovery usual work/NR; (industrialized) indicating low
JM et al., Reliable since 1999; calculated; NR with ranges of regarding early
back pain expectations ranged from 3 to country; OR or HR risk of bias,
2012 [34] reference lists of univariate and effect sizes recovery are a
(<12 weeks)/ 24 months analyses; excluding between 4 and 6
studies included multivariate and adequate strong predictor of
occupational studies with medium risk
(591) results graphical future absence
setting participants with and 7 or more
representation from usual work.
rheumatic disease, high risk of bias
cancer or trauma
(10)/4683
participants
Individual recovery
MEDLINE, expectations are
Work Embase, CINAHL, probably strongly
participation, PsycINFO from associated with
Adults with important inception to Individual future work
acute recovery, 12 March 2019; RQ; prospective or study results participation
1. SS+, SS−, NS
(<6 weeks), functional reference searches retrospective studies, described; (moderate-quality
2. Effect sizes Quality In
subacute or Recovery limitations, pain of relevant reviews; secondary RCT meta-analysis evidence) and may
and CIs Prognosis
chronic expectations intensity; global reference lists of analysis and with ranges of be associated with
Hayden calculated; Studies (QUIPS)
(≥6 weeks) and (general, improvement, included studies; associations from effect sizes clinically important
JA et al., Reliable univariate and NR tool with
mixed-duration self-efficacy and health-related citation searches of moderate analysis; and adequate recovery outcomes
2019 [35] multivariate 6 domains, rated
non-specific low treatment quality of life, recovery excluding specific graphical rep- (low-quality
results; as low, moderate
back pain/ expectations) satisfaction with expectation pathologies or resentation; evidence). The
adjusting factors or high risk of bias
clinical and treatment, mood measurement tools; conditions (60–85)/ GRADE association of
noted
occupational and healthcare personal files of 30,530 participants quality levels recovery
setting use/3 months; recovery of evidence expectations with
ranged up to expectation functional
>16 months investigators limitations and pain
(7235) intensity outcomes
is less certain.
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
RQ; no language or
BIOSIS, CINAHL,
setting limits; using
The Cochrane
FABQ and TSK Evidence suggests
Adults with Work-related Library, Embase,
scales; cohort studies that fear avoidance
acute, acute– (days off, return OTSeeker, PEDro,
(prospective, Individual beliefs are
subacute, to work, etc.) PsycINFO,
retrospective) and 1. SS, NS Methodological study results predictive of poor
subacute, and non-work- PubMed/MEDLINE,
Wertli and secondary RCT 2. Effect sizes checklist SING described; outcome in
chronic and related measures Scopus and Web of
Rasmussen- Fear avoidance analyses; at least and CIs; with a high (++), count of patients with
Reliable mixed-duration (pain, perceived Science from 1990 NR
Barr, 2014 beliefs moderate quality and univariate and moderate (+) or significant subacute NSLBP
non-specific low disability, etc.)/ to October 2011;
[36] 100 subjects; multivariate low (−) quality results; and should be
back pain/ 3 months; reference lists of
minimum follow-up results grading graphical addressed in this
clinical and ranged from collected studies
3 months; excluding presentation population to
occupational 3 months to and manual
conference avoid delay in
setting 2 years electronic search of
proceedings recovery.
6 relevant journals
(21)/5467
(2070)
participants
BIOSIS, CINAHL,
The Cochrane RQ; no language or
Library, Embase, setting limits; cohort
Work-related OTSeeker, PEDro, studies (prospective,
Adults with There is some
measures (days PsycINFO, retrospective) and
acute, acute– Individual evidence that
off, return to MEDLINE, Scopus secondary RCT
subacute, 1. SS, NS List of SING study results catastrophism as a
work, etc.) and and Web of Science analyses; at least
chronic and 2. Effect sizes criteria for described; coping strategy
Wertli and non-work- from January 1980 moderate quality;
mixed-duration and CIs; cohort studies count of can lead to a delay
Eugster, 2014 Reliable Catastrophism related measures to September 2012; minimum NR
non-specific low univariate and with a high, significant in recovery. The
[37] (pain, perceived reference lists of 100 patients and
back pain/ multivariate moderate or low results; influence of
disability, etc.)/ included studies, minimum follow-up
clinical and results quality rating graphical catastrophism on
3 months; reviews and 3 months; excluding
occupational presentation DL patients is not
ranged from treatment conference
setting fully established.
90 to 2160 days guidelines; proceedings
handsearching of (16–19)/11,330
6 relevant journals participants
(1528)
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
BIOSIS, CINAHL,
The Cochrane
Work-related Library, Embase, RQ; no language or
Adults with (days off, etc.) OTSeeker, PEDro, setting limits; 1. SS, NS Catastrophism
Individual
mixed-duration and non-work- PsycInfo, MEDLINE, secondary RCT 2. Effect sizes List of SING predicted
study results
Wertli and from acute to related (pain, Scopus and Web of analyses with a and CIs; criteria for RCTs outcomes for pain
described;
Burgstaller, Reliable chronic Catastrophism perceived Science from January minimum of univariate and NR with a high, and disability at
count of
2014 [38] non-specific low disability, etc.) 1980 to September 30 patients per group; multivariate moderate or low follow-up in
significant
back pain/ measures/NR; 2012; reference lists excluding conference results, if quality rating patients with
results
clinical setting ranged from of included studies proceedings (6–7)/ available NSLBP.
7 days to 1 year and handsearching 1049 participants
of 6 relevant journals
(1528)
AMED, CINAHL, RQ; no limits on
Work-related Embase, Health & language, setting,
Adults with measures, pain Society Database, length of follow-up 1. SS+, SS−, NS
Individual
acute or intensity, LILACS, or type of 2. Effect sizes
List of 8 criteria study results
subacute disability, MEDLINE, publication; with CIs; Depression might
based on recom- described;
Pinheiro non-specific low self-perceived PsycINFO, Scopus prospective cohort univariate and have an adverse
mendations for count of
MB et al., 2016 Reliable back pain Depression recovery and and Web of Science studies; excluding multivariate NR effect on the
systematic significant
[39] (<3 months)/ mixed/ from inception to pregnancy-specific or analysis; prognosis of low
reviews and the results;
clinical and unrestricted; 10 October 2014; pregnancy-related adjusting factors back pain.
STROBE guide graphical
occupational ranged from reference lists of LBs and secondary noted and
presentation
setting 2 weeks to included studies analyses of RCTs detailed
>12 months and systematic (13–17)/5396
reviews (10,541) participants
OVID, CINAHL,
MEDLINE, AMED,
Embase, Biomed,
PubMed—
The results
Pain, disability National Library
RQ; English; >18 provide moderate
Adults with and number of of Medicine, Individual
Physical activity years; cohort studies, 1. SS, NS Modified Down evidence that
mixed-duration health Proquest and The study results
Hendrick in daily life secondary RCT and 2. Effect sizes and Black list of activity or change
from acute to treatments Cochrane Library described;
P et al., 2011 Reliable (occupational, case–control and CIs; NR 23 items, with a in activity in
chronic results in from 1990 to count of
[40] sports and analyses; excluded multivariate maximum score patients with
non-specific low 1 year/NR; January 2009; significant
leisure activities) retrospectives results mainly of 27 points NSLBP is not
back pain/NR ranged from reference lists of results
(7)/3535 participants predictive of LBP
1 to 5 years included studies;
outcomes.
experts and
authors of
included studies
contacted (405)
Table 1. Cont.

Prognosis
Study Selection
Total Participants
Criteria; Result
MEDLINE,
Individual There was
Adults with Results for pain Embase, CINAHL, 1. SS+, SS−, NS Quality In
RQ; English, Spanish, study results low-quality
acute, subacute intensity, SPORTDiscus and 2. Effect sizes Prognosis
Portuguese; described; evidence that
and chronic disability and Web of Science and CIs; Studies (QUIPS)
prospective cohort GRADE physical activity
Oliveira CB non-specific low Physical activity recovery mea- from inception to univariate and tool with
Reliable studies; excluding NR quality levels may not be a factor
et al., 2019 [41] back pain/ (any type) sures/unrestricted; February 2018; multivariate 6 domains, rated
secondary RCT of evidence in predicting pain,
clinical and ranged from reference lists of analysis; as low, moderate
analyses (12)/ (high, disability or
general 3 months to included studies adjusting factors or high risk of
8455 participants moderate, low recovery outcomes
population 5 years and systematic noted bias
and very low) in NSLBP.
reviews (12,681)
MEDLINE,
There was
Embase, PEDro,
conflicting evidence
Adults with SPORTDiscus, RQ; English, Chinese,
Individual regarding the
acute, subacute CINAHL and The French, Portuguese; Adapted criteria
study results dynamic
and chronic Characteristics Cochrane Library cohort studies list with
1. SS, NS described; morphometry of
non-specific low of TrA and LM from inception to (prospective, 7 potential bias
Pain and 2. Effect sizes levels of TrA/LM when
back pain/ assessed by December 2012; retrospective), areas with a
function and CIs; evidence predicting low-back-
Wong AY clinical (hospital, dynamic ClinicalTrials.gov, secondary RCT maximum score
Reliable results/NR; multivariate NR (strong, pain-related
et al., 2013 [33] general practice morphometry, NIH Clinical analyses, case series of 26 points and
ranged from analysis only; moderate, disability or pain
clinics and histology and Center Clinical with 10 or more a cut-off point of
1 week to 1 year adjusting factors limited, reduction in patients
physical muscle Research Studies subjects, systematic 50% of the total
noted conflicting with chronic
therapy) and activation and Current reviews or score indicating
and non-specific low
general Controlled Trials meta-analyses high quality
non-evidence) back pain after
populations Register; contact (5)/219 participants
various conservative
with investigators
treatments.
or authors (2325)
NSLBP = non-specific low back pain; NR = not reported; RQ = review search question; SS = statistically significant; NS = not statistically significant; CI = confidence interval;
S/T = short term; L/T = long term; TrA: transversus abdominis; LM: lumbar multifidus.
3.4. Synthesis of Results

Overall, forty-nine factors were reported across the included systematic reviews. The
degree of overlap of the primary studies through the reviews was slight (CCA = 2.6%).
3.4.1. Acute–Subacute Phase of LBP

For most factors collected, there was insufficient evidence to synthesize the unadjusted
data, so our summary of results was mainly based on adjusted results. Besides this, there
were three factors (gender, previous history of LBP and pain radiating to the leg) for which
there was also insufficient evidence to perform synthesis from adjusted data. In order to
include as much evidence as possible [22], we combined both types of results (adjusted and
unadjusted) to analyze the consistency of these variables.
Thus, there were 10 prognostic factors of outcomes at long-term follow-up provided by
two or more systematic reviews with sufficiently similar data for comparability (OR/Beta),
derived from seven systematic reviews (Tables 2 and 3) [27,29,30,32,33,35,38]. Of these,
five prognostic factors showed consistent evidence supporting their ability to predict poor
long-term outcomes: high levels of pain intensity and disability, high emotional distress,
negative recovery expectations and high work physical demands (Table 4). Another factor
showed consistent evidence of no association with poor outcomes: low education levels.
Each of these variables showed strengths of association ranging from weak to strong and
outcomes reflecting clinical relevance (OR ≥ 1.50). Moreover, four factors demonstrated
no consistent evidence supporting their predictive ability for long-term outcomes: high
fear avoidance beliefs (from adjusted data) and female gender, the presence of previous
history of LBP and pain radiating to the leg (from adjusted and unadjusted data) (Tables 2
and 3). These variables did not reflect relevant disagreements of inverse association. On
the other hand, there were 35 prognostic factors reported by a single systematic review,
with insufficient evidence for synthesis (Supplementary Table S8).
3.4.2. Chronic Phase of LBP

There were four variables reported by a single systematic review and, therefore,
with insufficient evidence for synthesis [35,36,40,41]: physical activity, abdominal muscle
function, fear avoidance beliefs and pain catastrophism. The evidence in all of them ranged
from non-association to association with the results (Supplementary Table S9). There was
only one finding indicating that high fear avoidance beliefs predicted better low back pain
outcomes. However, the sample size of this study was small and the follow-up short, so
this may be a potentially biased finding.
3.4.3. Mixed-Duration LBP

Pain catastrophism was reported by two reviews based on individuals with acute
to chronic LBP [36,37], reflecting that high catastrophic thinking showed a consistent as-
sociation with poor long-term outcomes and clinically relevant strengths of association
(from adjusted data) (Table 4). Moreover, there were three factors in acute to chronic
LBP [31,35,40] and one factor in the subacute–chronic population [34] reported by a sin-
gle systematic review: physical activity, fear avoidance beliefs, work social support and
recovery expectations, respectively. Once again, the evidence ranged from association to
no significant association with outcomes in each one of them (Supplementary Table S10).
On the other hand, only four factors were analyzed in the acute, subacute and chronic
low back pain phases. Recovery expectations were systematically associated with outcomes
regardless of the duration of symptoms, and pain catastrophism showed a trend towards
association in all phases, although not always significantly. Physical activity showed a
tendency of non-association in the different phases, and fear avoidance beliefs were more
significant in the subacute phase of LBP.
The considerable clinical and methodological heterogeneity of the collected data
(prognostic factors, outcomes and their measurements, as well as the wide range of time in
the long-term follow-up) precluded the use of a meta-analysis.
Table 2. Results of prognostic factors for LBP outcomes at long term, reported by two or more systematic reviews using OR/beta coefficients.
Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Factor Definition Author, Year [Ref] Outcome Adjusted OR/Beta Crude OR/Beta
Domain Factor Included (N) Ref. Q Statistic (p) Bias
Acute and Subacute LBP (≤3 months)
Pooled OR = 1.28,
Q = 14.6 The failsafe
Agnello A, 2010 [30] * 6 studies (N = 2306) 1–6 Ra 95% CI = 1.03–1.58
(p = 0.01) N = 4 (ss)
(p = 0.02)
Pooled OR = 1.97,
Gender Gender (Female) 2 studies (N = 334) 7,8 P NR NR
95% CI = 0.98–3.97 ***
Kent PM, 2008 [27] Pooled OR = 1.38,
Factors related to 3 studies (N = 833) 8–10 FS NR NR
95% CI = 0.64–2.99
the individual Pooled OR = 0.61,
2 studies (N = 1154) 6,11 WP NR NR
95% CI = 0.30–1.24
OR = 0.92,
Lower education level Steenstra IA, 2011 [29] * 2 studies (N = 2739) 11,12 WP NA NA
Education 95% CI = 0.55–1.54
Pooled OR = 0.99,
Lower education level Kent PM, 2008 [27] 2 studies (N = 1.114) 11,13 WP NR NR
95% CI = 0.63–1.55
Pooled OR = 0.91,
Q = 1.64 The failsafe
Agnello A, 2010 [30] * 3 studies (N = 382) 3,4,6 Ra 95% CI = 0.52–1.60
(p = 0.44) N (ns)
Factors related to Previous history of (p = 0.75)
Prior episodes Pooled OR = 2.98,
the episode low back pain (yes/no) 2 studies (N = 818) 10,14 FS NR NR
95% CI = 1.42–6.23
Kent PM, 2008 [27]
Pooled OR = 0.99,
95% CI = 0.39–2.53
Table 2. Cont.

Pooled OR = 1.37,
Pain radiating to the Q = 5.99 The failsafe
Agnello A, 2010 [30] * 4 studies (N = 502) 3,4,6,15 Ra 95% CI = 0.79–2.39
leg (yes/no) (p = 0.11) N (ns)
(p = 0.26)
OR ranged from 4.9,
Pain radiating to leg OR = 2.5,
3 studies (N = 1421) 16–18 WP 95% CI = 2.8–8.4 to 6.25, NA NA
(yes/no) 95% CI = 1.1–5.8
95% CI = 4.42–8.96
Severity of leg pain
(ref. mild sprain/
Steenstra IA, 2011 [29] * OR = 3.72,
strain: major 1 study (N = 1885) 12 WP NA NA
95% CI = 1.83–7.58
sprain/strain—
Pain radiating radiculopathy)
to the leg Intensity of leg pain OR = 1.92,
1 study (N = 854) 11 WP NA NA
(7–10) 95% CI = 1.11–3.33
Largest significant
1 study (N = 219) 7 P OR = 2.45, NA NA
95% CI = 1.20–4.99
Largest significant
Leg pain (yes/no) Kent PM, 2008 [27] 3 studies (N = 938) 9,10,15 FS OR = 3.30, NA NA
Pain
95% CI = 1.10–9.60
Pooled OR = 2.10,
95% CI = 0.96–4.62
Largest significant
1 study (N = 542) 9 FS OR = 2.84, NA NA
Greater pain intensity Kent PM, 2008 [27] 95% CI = 1.70–4.80
Pooled OR = 1.45, 95%
3 studies (N = 1334) 6,11,19 WP NR NR
CI = 1.10–1.91
OR ranged from 1.57,
Pain interference with
Pain intensity 2 studies (N = 532) 16,20 WP 95% CI = 1.27–1.94 NA NA
daily activities
to 4.7, 95% CI = 1.8–12.5
Number of sites with OR = 1.71,
pain (0–2/3–4/≥5) Steenstra IA, 2011 [29] * 95% CI = 1.01–2.92
Pain change (bet- OR = 1.47,
ter/unchanged/worse) 95% CI = 0.98–2.20
Greater pain intensity OR = 1.47,
(mild/moderate/severe) 95% CI = 0.74–2.91
Table 2. Cont.

High self-reported
4 studies 95% CI = 1.05–6.63
disability (RMDQ, Steenstra IA, 2011 [29] * WP Unclear NA NA
(N = 3247) 11,12,20,21 to 7.01,
ODI, others)
Functional 95% CI = 3.44–14.29
Disability Largest significant
limitation
High score on Oswestry 1 study (N = 130) 19 FS OR = 3.35, NA NA
Kent PM, 2008 [27]
Disability Index 95% CI = 1.42–2.37
Pooled OR = 2.69,
3 studies (N = 1334) 6,11,19 WP NR NR
95% CI = 1.01–7.15
Largest significant
1 study (N = 138) 22 P OR = 28.70, NA NA
Depression 95% CI = 3.52–233.91
Kent PM, 2008 [27]
(high scores) Pooled OR = 1.50,
95% CI = 0.48–4.71
OR = 1.03,
1 study (N = 315) 23 P NA NA
95% CI = 0.98–1.08
OR = 1.06,
95% CI = 1.02–1.11
Symptoms of 2 studies (N = 573) 24,25 FS NA NA
Psychological– Emotional and β = 0.20,
depression (presence/ Pinheiro MB, 2016 [39]
emotional distress 95% CI = 0.04–0.36
higher scores)
OR = 1.10,
4 studies (N = 1909) 11,26–28 WP Unclear NA NA
95% CI = 1.04–1.17
OR = 1.06,
1 study (N = 439) 29 Rb NA NA
95% CI = 1.03–1.09
Largest significant
2 studies (N = 2712) 7,30 P OR = 2.68, NA NA
Anxiety (high scores) Kent PM, 2008 [27] 95% CI = 1.28–5.58
Largest significant
1 study (N = 854) 11 WP OR = 2.08, NA NA
95% CI = 1.50–2.89
Table 2. Cont.

High fear avoidance
Steenstra IA, 2011 [29] * 2 studies (N = 2953) 5,12 WP Unclear NA NA
beliefs (FABQ)
3 studies (N = 637) 4,31,32 Ra Unclear NA NA
High fear avoidance
Wertli MM, 2014 [36] * OR = 1.71,
beliefs (FABQ and TSK) 1 study (N = 940) 12 WP NA NA
95% CI = 0.88–3.3
OR = 1.73,
High fear avoidance 1 study (N = 171) 33 FS NA NA
beliefs—Physical 95% CI = 0.6–4.99
OR = 1.58,
Fear activity (FABQ-P) 1 study (N = 171) 33 Ra NA NA
Wertli MM, 2014 [36] 95% CI = 0.7–3.53
avoidance High fear avoidance OR ranged from 3.13
beliefs beliefs—Work 2 studies (N = 1507) 5,34 WP (NR), p = 0.00 to 4.64, NA NA
(FABQ-W) 95% CI = 1.57–13.71
High fear avoidance Largest significant OR =
Kent PM, 2008 [27] 1 study (N = 300) 6 WP NA NA
beliefs (FABQ) 2.77, 95% CI = 1.02–7.55
Low fear avoidance OR = 0.38,
1 study (N = 258) 35 NA
beliefs (FABQ-W) Wertli MM, 2014 [36] ** WP 95% CI = 0.25–0.58 NA
High fear avoidance OR = 1.05,
Psychological– 1 study (N = 346) 20 NA
beliefs (FABQ) 95% CI = 1.02–1.09
cognitive
Low recovery
expectations (how
likely it is that they OR ranged from 1.14, OR ranged from 1.22,
5 studies
will return to Steenstra IA, 2011 [29] * WP 95% CI = 1.04–1.25 to 95% CI = 1.02–1.45 to NA NA
(N = 2326) 5,16,20,36–38
work/how long it will 3.8, 95% CI = 1.46–6.48 4.6, 95% CI = 2.1–10.3
be before they are able
to return)
OR = 2.21,
Negative recovery 1 study (N = 156) 39 FS NA NA
Recovery 95% CI = 1.54–2.89
expectations expectations (general Iles RA, 2009 [32] OR ranged from 2.3,
expectations of recovery OR ranged from 1.21,
7 studies 95% CI = 1.4–3.8
WP 95% CI = 1.01–1.45 to NA NA
and self-efficacy) (N = 2321) 5,36,37,40–42 p = 0.001 to 9.18,
3.9, 95% CI = 1.77–5.38
95% CI = 5.00–16.8
Negative recovery
expectations (general Hallegraeff JM, 10 studies Pooled OR = 2.17, Q = 96.23
WP NA
expectations of recovery 2012 [34] (N = 4649) 5,36–38,40–45 95% CI = 1.61–2.91 *** (p < 0.0001)
and self-efficacy)
Table 2. Cont.

High work physical
2 studies (N = 3605) 20,46 WP 95% CI = 1.12–3.17 to NA NA
demands (occupation) Steenstra IA, 2011 [29] *
2.27, 95% CI = 1.21–3.92
High work physical
demands— OR = 3.23, OR = 1.98,
2 studies (N = 1016) 11,21 WP NA NA
self-reported (lift, 95% CI = 1.50–6.97 95% CI = 1.30–3.04
Occupational Work physical bend, twist)
demands
Largest significant
1 study (N = 120) 15 FS OR= 4.00, NA NA
Job physically 95% CI = 1.10–14.00
Kent PM, 2008 [27]
demanding Largest significant
1 study (N = 854) 11 WP OR= 2.04, NA NA
95% CI = 1.41–2.96
Acute to chronic LBP
Standardized β ranged
OR = 1.77,
from 0.25;
Wertli MM, 2014 [38] 2 studies (N = 474) 47–49 FS NA 95% CI = NA
95% CI 0.12–0.35 to 0.43,
Pain catastrophism 1.13–2.75
Psychological– Pain 95% CI = 0.25–0.61
(High) (CSQ,
cognitive catastrophism OR ranged from 0.64,
PRSS, PCC)
95% CI = 0.4–0.96 (for
Wertli MM, 2014 [37] 3 studies (N = 3423) 48,50,51 FS NA
decrease RMQ ≥ 30%) to
7.63, 95% CI = 3.69–15.7
LBP = low back pain; N = sample size; ref. = references provided in Supplementary Table S5; OR = odds ratio; NR = not reported; NA = not assessable; ss = significant result;
ns = non-significant result. Outcome: P = pain; FS = functional status; WP = work participation; R (a, b, c, d): recovery a = recovery of pain or disability, b = self-reported recovery,
c = slightly better” or “worse” score on two or more follow-up measurements, d = recovery and/or return to work. * Sample of individuals in acute phase of low back pain. ** Sample of
individuals in subacute phase of low back pain. *** Meta-analysis combining adjusted and adjusted data. Bold results are statistically significant.
Table 3. Prognostic factors for LBP outcomes reported by two or more systematic reviews at long term.
Associated
Kent PM, Steenstra Agnello A, Pinheiro MB, Wertli MM, Wertli MM, Wertli MM, Iles RA, Hallegraeff Not Associated Unclear Consistent
Prognostic Factor Total with Poor
2008 [27] IA, 2011 [29] 2010 [30] 2016 [39] 2014 [36] 2014 [37] 2014 [38] 2009 [32] JM, 2012 [34] with Outcome (Ø) Evidence Conclusions
Outcome (+)
ACUTE AND SUBACUTE LBP
Adjusted data
Level of education Ø Ø 0 2 0 4
Pain intensity + + 2 0 0 4
Disability + + 2 0 0 4
Emotional distress + + 2 0 0 4
Fear avoidance
+ Unclear Unclear 1 0 2
beliefs
Recovery
+ + + 3 0 0 4
expectations
Work physical
+ + 2 0 0 4
demands
Adjusted and unadjusted data
Gender Ø + 1 1 0
Previous history
Unclear Ø 0 1 1
of LBP
Pain radiating to
Unclear + Ø 1 1 1
the leg
ACUTE TO CHRONIC LBP
Adjusted data
Pain catastrophism + + 2 0 0 4
LBP = low back pain. “+”: prognostic factor with consistent association with LBP outcome; “Ø”: factors not associated with outcome; unclear: conflicting or insufficient evidence;
4: Factor consistently associated with LBP outcomes.
Table 4. Predictor variables of an explanatory model in patients with LBP.
Prognostic Factor Domain Prognostic Factor

ACUTE AND SUBACUTE LBP
Pain Pain intensity
Functional limitation Disability
Psychological Emotional distress
Recovery expectations
Occupational Work physical demands
ACUTE TO CHRONIC LBP
Psychological Pain catastrophism
LBP = low back pain.
4. Discussion
This umbrella review provides a summary of up-to-date and high-level research
evidence about biopsychosocial predictors in individuals with NSLBP. We included 15 sys-
tematic reviews, showing primary research spanning the last three decades.
A variety of biopsychosocial prognostic factors have been investigated but, in accor-
dance with the evidence derived from the present umbrella review, only high levels of
pain intensity and disability, high emotional distress, negative recovery expectations, high
pain catastrophism and high work physical demands are predictors of poor low back pain
outcomes at long term, and low levels of education have no prognostic ability.
4.1. Factors with Consistent Evidence of Association with Poor Outcomes at Long Term
4.1.1. Acute–Subacute LBP
In the present umbrella review, the factors found to be associated with poor out-
comes in this phase of LBP are largely in line with the literature on LBP [15,44–48] and
MSK [49–51] prognosis. In spite of this, we consider that the results suggesting that high
baseline pain intensity and disability levels predict LBP outcomes should be understood
from the perspective of their interactions with the factors that we discuss below. We found
that individuals with high levels of emotional distress are at a greater risk of developing
chronic pain and disability, with depression being the predictor with the greatest strength
of association. However, its predictive capacity for the maintenance of chronic low back
pain, beyond its association derived from cross-sectional studies, has been less reported in
longitudinal studies, as this umbrella review shows. Nevertheless, a recent review with
qualitative data on chronic LBP showed that depression had moderate evidence of no
association with work-related outcomes at follow-up [52]. Moreover, recovery expectations
were the most consistently reported predictor in the current umbrella review, regardless of
the different outcome domains considered, as well as the phase of low back pain analyzed.
Similar results have been reported in individuals with conditions other than back pain,
including chronic shoulder pain [53] and major orthopedic trauma [54]. In addition, we
mainly found strong association strengths with poor outcomes for high work physical
demands, indicating the clinical relevance of this factor in individuals with acute–subacute
LBP, in line with the previous overview of LBP prognostic factors [15]. However, two
recent reviews in populations with MSK pain found insufficient evidence for physical
workload [49,51] that may suggest the greater relevance of these aspects for the low back
region specifically.
4.1.2. Mixed Duration of LBP

Despite our results reflecting consistent evidence that high pain catastrophism predicts
a delay in the functional recovery of individuals with acute to chronic LBP, as well as a
trend of association with poor outcomes in the other phases of LBP, the role of catastrophic
thinking remains controversial. A systematic review and meta-analysis of mediation studies
suggested that “catastrophism may not explain the development of disability from back
and neck pain” [55]. Moreover, it has been recently reported that pain-related acceptance is
a significant mediator both between pain and catastrophism and between catastrophism
and fear avoidance beliefs in chronic pain patients [56]. Thus, more studies are needed to
understand the cognitive processes in the experience of pain.
4.2. Factors with Consistent Evidence of No Association with Poor Outcomes at Long Term in
Acute–Subacute LBP
We found that a lower level of education was not associated with worse work-related
outcomes, being in line with the evidence provided by previous reviews in LBP [15,48,52]
and musculoskeletal populations [49].
4.3. Factors with Inconsistent Evidence of Association with Poor Outcomes at Long Term in
Acute–Subacute LBP
The inconsistent evidence found for the female gender was mainly due to the findings
reported by Agnello et al., but whose significant heterogeneity was explained by the
compensation status of the individuals to participate in the study [30]. Considering this,
our findings are consistent with the non-association evidence reported by other authors
in LBP and MSK pain [15,49,51]. On the other hand, sciatica or nerve root exam results
showed consistent evidence of association with poor acute–subacute LBP outcomes in a
previous overview [15]. Our findings of inconsistent evidence for pain radiating to the leg
could be related to the fact that the included reviews did not provide an explicit definition
and their measurements ranged from LBP assessment with or without radiating pain to the
assessment of neurocompressive radiculopathy. Moreover, in both the current umbrella
review and the prior overview of prognostic factors in LBP [15], having previous episodes
of low back pain showed inconsistent evidence of association with acute–subacute low
back pain outcomes. The lack of consensus in the definition of recurrence versus new
episodes of LBP [57] could explain in part the lack of consistency in these findings. Finally,
the predictive role of fear avoidance beliefs (FABs) in the development and perpetuation of
chronic pain has been systematically reviewed in samples of LBP [15] and musculoskeletal
pain patients [44,58], with some conflicting results between them as well as with the present
umbrella review. The concepts of fear and avoidance encompass a series of complex
processes that interact over time, and this may suggest that they are linked. However,
pain-related fear and avoidance behaviors are context-dependent and do not always co-
occur [11]. Thus, an individual can both prioritize the goal of avoiding pain for protection,
even without reporting fear [59], and can prioritize other valued life goals and confront the
threat whilst self-reporting fear [11]. This confusing conception of fear related to pain and
avoidance behaviors, evidenced in turn through the measurement instruments available
so far [60], may partially explain the conflicting evidence found in this umbrella review,
reflecting the complexity of these mechanisms.
4.4. Other Factors with Insufficient Evidence of Association with LBP Outcomes at Long Term
In the current umbrella review, low work social support [31] and low social activity [27]
were reported by one systematic review, showing predictive ability for poor outcomes in
individuals with mixed-duration and acute–subacute LBP, respectively. A recent systematic
review among individuals with chronic pain found that the most frequent aspect in explain-
ing the effect of social support on the experience of pain was the stress-buffering effect [61].
More studies analyzing the mechanisms of interaction between social factors and disabling
LBP are needed. In addition, older age is considered a common predictor of poor outcomes
in LBP, musculoskeletal pain and sciatica [15,51,62]. We believe that age may influence the
natural course of low back pain and more studies are needed to determine its predictive
value in these individuals.
4.5. Strengths and Weaknesses

We developed and registered a specific overview protocol in PROSPERO, minimiz-
ing reporting bias and giving transparency to the review process. Our search strategy
was implemented in a sufficiently inclusive manner through relevant and grey literature
databases, along with additional strategies such as manual searches and contact with
authors (accounting for 14% of the reviews included), reflecting the evidence from original
studies over the last 35 years and including a large number of participants (N = 257,208).
The weaknesses of the present overview depend not only on the risk of bias and
selective reporting of results by the primary studies, as reflected the publication biases
shown in the findings derived from meta-analyses, but also on the quality of the included
reviews, all of them being assessed to have minor limitations. Additionally, there was a
modification from the initial protocol recorded in PROSPERO. For our outcome of LBP
results at follow-up, we planned to synthesize the evidence for each primary outcome
separately, but, due to insufficient evidence, we considered pain intensity, functional status,
work participation and recovery outcomes together. Furthermore, at the level of this
overview, the English and Spanish languages were considered as inclusion criteria, and
therefore some reviews of interest may have been excluded. Moreover, the heterogeneity
derived from the variability in adjustment models for confounders must be recognized.
Our synthesis is also limited by the fact that we only included quantitative research studies;
for this reason, several systematic reviews with qualitative data have been considered in
our discussion.
4.6. Implications for Clinicians and Policymakers

This umbrella review presents a synthesis of prognosis evidence on individuals with
acute and subacute LBP in North America, Europe and Oceania in clinical and occupational
settings. An enhanced understanding of the role of the psychosocial factors provides
the opportunity for prevention, identifying patients at risk of chronicity and targeting
treatments for modifiable factors [63–65]. Treatments in low back pain may consider
the factors consistently reported in this umbrella review. Policymakers should include
multidimensional interventions through public health systems [66].
4.7. Future Research

The factors presented in the present umbrella review, with consistent evidence of a
prognostic association with LBP outcomes derived from adjusted data, can be taken into
consideration for the development of low back pain causal explanatory models and for
intervention trials in these patients. In view of the evidence collected, further research
in the later phase of LBP and regarding social and socio-occupational factors is required.
Future reviews that include a meta-analysis could gain a better estimate of prognostic effect
sizes, assess and account for heterogeneity in the effects of prognostic factors and perform
additional subgroup and sensitivity analyses.
Overall, we still need a better understanding of the complex dynamic relationships
between biopsychosocial factors.
5. Conclusions
The current umbrella review has identified consistent findings of up-to-date and high-
level research evidence that support the ability of several biopsychological factors to predict
LBP outcomes in the long term. Such factors are levels of pain intensity and disability,
emotional distress, recovery expectations, pain catastrophism and physical demands at
work. These variables deserve attention for inclusion in the development of low back pain
explanatory models. More research on social and socio-occupational factors, as well as
predictors, in the chronic phase of LBP is required in order to add potential prognostic
information to this condition. Our findings implicate a multidimensional approach in
dealing with these individuals.
Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/ijerph191610145/s1, Table S1: PRISMA checklist; Table S2: Search
strategy for PubMed; Table S3: References from excluded full-text citations; Table S4: Conflicts of
interest of included studies; Table S5: Primary studies referenced in tables; Table S6: Other statistics
(RR, RP, HR, LR+LR- and p values); Table S7: Reliability of included reviews; Table S8: Prognostic
factors reported by only one review; Table S9: Prognostic factors in chronic LBP; Table S10: Prognostic
factors in mixed-duration LBP.
Author Contributions: Conceptualization, E.O.-K. and C.P.-P.; methodology, E.O.-K., C.P.-P. and
R.O.-S.; formal analysis, E.O.-K.; investigation, E.O.-K., C.P.-P., C.F.P.-A. and J.A.V.-C.; data curation,
E.O.-K., C.F.P.-A. and J.A.V.-C.; writing—original draft preparation, E.O.-K.; writing—review and
editing, R.O.-S., C.P.-P., C.F.P.-A. and J.A.V.-C.; visualization, E.O.-K.; supervision, R.O.-S. and
C.P.-P.; project administration, R.O.-S. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.
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International Journal of

2. Materials and Methods

2.1. Protocol and Registration

2.2. Criteria for Considering Reviews for the Overview

2.2.2. Review Selection

2.2.3. Data Extraction and Management

2.3. Methodological Quality Assessment of Included Reviews

2.4. Data Synthesis

3.2. Review Characteristics

3.3. Methodological Quality Assessment of Included Reviews

Disagreements were resolved by consensus among reviewers twice during the

Research Question Data Extraction

Research Question Data Extraction

Research Question Data Extraction

Research Question Data Extraction

Research Question Data Extraction

Research Question Data Extraction

Research Question Data Extraction

3.4. Synthesis of Results

3.4.1. Acute–Subacute Phase of LBP

3.4.2. Chronic Phase of LBP

3.4.3. Mixed-Duration LBP

Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Prognostic Factor Prognostic Nº Primary Studies Heterogeneity Publication

Table 4. Predictor variables of an explanatory model in patients with LBP.

Prognostic Factor Domain Prognostic Factor

4.1.2. Mixed Duration of LBP

4.5. Strengths and Weaknesses

4.6. Implications for Clinicians and Policymakers

4.7. Future Research

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