Nathalia Costa, Esther Smits, Jessica Kasza, Sauro Salomoni, Manuela Ferreira, Michael Sullivan, Paul W. Hodges

May 2021, Volume 30, Issue 5, pp 1089 - 1097 Original Article Read Full Article 10.1007/s00586-021-06730-6

First Online: 03 February 2021


Although risk factors for new low back pain (LBP) episodes and acute-to-chronic transition have been identified, risk factors for flares of LBP remain largely unknown. This case-crossover study aimed to identify: (1) risk factors LBP flares and (2) whether risk factors differed when flare is defined by pain increase (pain-defined flare: PDF) or identified by participants according to a broader flare definition that considered emotions and coping (self-reported flare: SRF).


One hundred and twenty-six participants with LBP for > 3 months were included. Candidate risk factors and flares (PDF/SRF) were assessed daily using a smartphone application for 28 days. Data on exposure to risk factors one, two and three days preceding PDF/SRF were compared to control periods. Conditional logistic regression estimated associations between risk factors and PDF/SRF.


Odds of PDF and SRF were increased by poor sleep quality and morning pain. Good sleep quality reduced odds of flare. Odds for increased pain (PDF), but not SRF, were increased after days with higher afternoon and evening pain, fatigue, fear of physical activity and leisure physical activity.


LBP flare has been largely ignored but is more reflective of the LBP experience than conventional definitions of acute, sub-acute and chronic LBP. This study highlights risk factors for flare and that these differ depending on whether flare is defined by pain alone (PDF) or a broad multidimensional definition (SRF). Potential targets to reduce the intensity/frequency of LBP flares are identified, with strong indication for the potential role of sleep intervention to mitigate LBP flare risk.

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