Chronic Low Back Pain: Difference between revisions

No edit summary
mNo edit summary
 
(106 intermediate revisions by 13 users not shown)
Line 2: Line 2:
'''Original Editors - '''[[User:Bryan Jacobson|Bryan Jacobson]], [[User:Tori Westcott|Tori Westcott]], [[User:Ashley Bohanan|Ashley Bohanan]], [[User:Alisha Lopez|Alisha Lopez]]  
'''Original Editors - '''[[User:Bryan Jacobson|Bryan Jacobson]], [[User:Tori Westcott|Tori Westcott]], [[User:Ashley Bohanan|Ashley Bohanan]], [[User:Alisha Lopez|Alisha Lopez]]  


'''Lead Authors '''-  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} <br>
</div>  
</div>  
== Search Strategy  ==
== Introduction ==
[[File:Back pain image.jpg|thumb|CLBP: common in society.]]


Pubmed, Web of Science, Pedro
Chronic low back pain (CLBP) is defined as lower back pain lasting for longer than 12 weeks or 3 months, even after an initial injury or underlying cause of acute [[Low Back Pain|low back pain]] has been treated.


<br>
Key Points


== Description/Description  ==
# CLBP develops in roughly 5.0% to 10.0% of low back pain cases.<ref name=":18">Meucci RD, Fassa AG, Faria NM. [https://doi.org/10.1590/S0034-8910.2015049005874 Prevalence of chronic low back pain: systematic review]. Revista de saude publica. 2015 Oct 20;49:73.</ref><ref>NIH Low Back Pain Fact Sheet Available: https://www.ninds.nih.gov/low-back-pain-fact-sheet<nowiki/>(accessed 17.11.2022)</ref>
# CLBP represents the second leading cause of disability worldwide and is a major health and economic problem.
# CLBP has a significant impact on functional capacity and occupational activities, and can also be influenced by psychological factors, such as stress, depression and/or anxiety.<ref name=":0">Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research. 2016;5. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926733/ (accessed 17.11.2022)</ref>
# Patients often have unrealistic expectations of total pain relief, being a large gap between a patient's desired amount of pain reduction and the minimum percentage of improvement that makes a treatment worthwhile. <ref name=":2">AFP Chronic Low Back Pain: Evaluation and Management Available;https://www.aafp.org/pubs/afp/issues/2009/0615/p1067.html (accessed 18.11.2022)</ref>


[[Image:Lumbar region.png|right|300px]]
== Epidemiology /Aetiology  ==


Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. Low back pain that has been present for longer than three months is considered chronic, although there is still no consensus about the definition of CLBP. Specific causes of LBP are uncommon, and in approximately 90% of patients a specific generator cannot be identified with certainty. (1) More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode. It is estimated that seven million adults in the United States have activity limitations as a result of chronic low back pain (31). <br>  
# The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the ageing population, affecting both men and women in all ethnic groups.<ref name=":0" />
 
# CLBP prevalence varies according to age, prevalence was 4.2% for individuals aged between 24 and 39, and 19.6% for people aged between 20 and 59<ref>Meucci RD, Fassa AG, Faria NM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ Prevalence of chronic low back pain: systematic review]. Rev Saude Publica. 2015;49:1. doi: 10.1590/S0034-8910.2015049005874. Epub 2015 Oct 20. PMID: 26487293; PMCID: PMC4603263.</ref>.
Chronic low back pain (CLBP) has been associated with neurochemical, structural, and functional cortical changes (28) of several brain regions including the somatosensory cortex. (3) Complex processes of peripheral and central sensitization may influence the evolution of acute to chronic pain. (4)<br><br>
# Higher prevalence in females, people of lower economic status, those with less schooling, and smokers compared to males, people with higher economic status, those with more schooling, and non-smokers, respectively.<ref>Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ (accessed 17.11.2022)</ref>
 
== Clinically Relevant Anatomy  ==
 
The lumbar region is situated under the thoracic region of the spine. The lower back consists of five vertebrae (L1- L5). It has a slight inward curve known as lordosis. The fifth lumbar vertebrae is connected with the top of the sacrum. The vertebrae of the lumbar spine are connected in the back by facet joints, which allow for forward and backward extension, as well as twisting movements.The two lowest segments in the lumbar spine, L5-S1 and L4-L5, carry the most weight and have the most movement, this makes the area prone to injury. In between vertebrae are spinal discs, they provide support. Discs in the lumbar region of the spine are most likely to herniate or degenerate, which can cause pain in the lower back, or radiating pain to the legs and feet. The spinal cord travels from the base of the skull to the joint at T12-L1, where the thoracic spine meets the lumbar spine. At this segment, nerve roots branch out from the spinal cord, forming the cauda equina. Some lower back conditions may compress these nerve roots, resulting in pain that radiates to the lower extremities, known as radiculopathy. The lower back region also contains large muscles that support the back and allow for movement in the trunk of the body. These muscles can spasm or become strained, which is a common cause of lower back pain. (Prometheus)
 
<br>
 
== Epidemiology /Etiology  ==
 
5-10% of all low back pain patients will develop CLBP. CLBP prevalence rates are lower in individuals aged 20-30 years, increasing from the third decade of life, and reaching the highest prevalence between 50-60 years. However the prevalence rates stabilize in the seventh decade of life. There’s no difference in CLBP prevalence at different periods of the year or in different places.(38)<br>  
 
There is higher CLBP prevalence in females, people of lower economic status, people with less schooling and smokers. There’s indication that prevalence has doubled over time. This may be due to important changes in lifestyle (obesity) and in the work industry. Factors as a family history of disabling back pain, radiating pain, advice to rest upon back pain consultation, occupational LBP or LBP caused by traffic injury are all associated with chronic disabling back pain over lifetime.(39) Job satisfaction and psychosocial factors also play a role in the development of CLBP.(40)
 
Musculoskeletal disorders are a comorbid condition strongly linked to CLBP. A moderate association was found when considering the whole musculoskeletal chapter, a stronger association was found when considering the somatoform symptoms related to the musculoskeletal cluster. (41)
 
In patients with low back pain (LBP), alterations in fiber typing in Multifidus and erector spinae are assumed to be possible factors in the etiology and/or recurrence of pain symptoms as it negatively affects muscle strength and endurance. In case of the latter, type I fibers have been argued to be more affected by pain and immobilization than type II fibers. (4)<br><br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Most patients that suffer from CLBP experience pain in the lower area of the back (lumbar and sacroiliac regions) and mobility impairment. Pain can also radiate in the lower extremities, or generalized pain can be present. Patients with CLBP can also experience movement and coordination impairments. This could affect the control of voluntary movements of the patient. <br>It can be challenging for the patient to maintain the neutral position, malalignment of the body can occur. It can also be found difficult to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities. Carrying things in the arms, or bending can also provoke complaints. Daily activities, such as cleaning, sports and other recreational occupations can become a big task for people with CLBP. <br>On the occasion of generalized pain, sensory experiences of the patient can also become altered; fear-avoidance beliefs, pain catastrophizing and depressive thoughts can appear. (17) If symptoms like these occur, central sensitisation can be present. It is important to monitor these yellow flags, as well as it is important to monitor blue flags and black flags.
CLBP refers to LBP occurring for longer than three months, and possibly occurring episodically. Social contact and work environment will suffer from the impact on the patient's health and wellbeing.  
 
The complaints are recurring and occur longer than three months. It is possible that CLBP passes in episodes. Some episodes are more severe than others, but overall the patient is affected by the impairments. Eventually, social contact and work environment will suffer from this great impact on the patient's health and wellbeing.  
 
<br>
 
== Differential Diagnosis  ==
 
Lower back pain is a frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom lower back pain may be related to underlying pathological conditions.
 
Table 1 gives a list of differential diagnosis. (13)
 
[[Image:Po.jpg]]<br><br>


For back pain associated with specific spinal cause, such as radiculopathy or spinal stenosis, magnetic resonance imaging (MRI) or CT (computed tomography) may establish diagnosis. (13)<br>In some differential diagnosis, immediate intervention is required.
Presentation includes: 


Table 2 shows a list of “red flags”: Red flags in spinal conditions, specific for lower back pain. These are signs or indicators of possible (severe) underlying pathology. (13) When these signs are found present, further screening is required and patients should be checked out as soon as possible.  
* [[Pain Assessment|Pain]] in the lower area of the back, which may radiate into the lower extremities.
* Movement and [[Coordination Exercises|coordination]] impairments
* Difficulty maintaining the neutral position and/or to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities. 
* Carrying objects in the arms, or bending can also provoke complaints.
* [[Activities of Daily Living|Daily activities]] such as household tasks, sports and other recreational activities can be challenging for people with CLBP.
* When pain is generalized, sensory experiences of the patient can also become altered
* Fear-avoidance beliefs, pain catastrophizing (see [[Pain Catastrophizing Scale|Pain Catastrophizing]] ) and depressive thoughts can appear (monitor these [[Yellow Flags]], [[The Flag System|blue flags]] and [[The Flag System|black flags]]).<ref name=":1">Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. [https://www.jospt.org/doi/10.2519/jospt.2012.42.4.A1 Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association]. J Orthop Sports Phys Ther. 2012;42(4):A1-A57. </ref>


[[Image:8455.jpg]]&nbsp;<br>(13)&nbsp;
'''[[Red Flags in Spinal Conditions|Red Flags]]:''' Although uncommon, serious spinal conditions (such as those listed below) may present as chronic LBP in approximately 5% of patients presenting to primary care office:
* [[Cauda Equina Syndrome|Cauda equina syndrome]]
* [[Cancer Pain|Cancer]]
* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]]
* [[Lumbar Spinal Stenosis]]
* Lumbar [[Disc Herniation|disc herniations]]
* [[Lumbar Spine Fracture]]
* [[Spondylodiscitis]]
* [[Abdominal Aortic Aneurysm]]<ref>[[Lumbar Assessment]]</ref>


== Diagnostic Procedures  ==
== Diagnosis ==
In most cases, causes for CLBP are not found using traditional investigations.


Chronic lower back pain is difficult to diagnose on one hand, but on the other hand the definition is very simple. In fact, if the back pain continues to be present for 3 months or more, we can consider it “chronic lower back pain”. Generally, patients are diagnosed based on their history. The specific diagnosis is then formulated based on the examination and clinical outcomes. Questionnaires can be used, as well as a body pain diagram, on which the patient locates his pain and pain distribution. (7)
* Fewer than 10% of cases are diagnosed with radiography and magnetic resonance imaging (MRI).  
 
* Degenerative changes and conditions such as spondylolysis and spondylolisthesis are not reliable diagnoses for CLBP, as they are no more common in patients with pain than in asymptomatic individuals.<ref name=":13" />
In case of specific lower back pain, other diagnostic procedures are required to confirm diagnosis. Magnetic Resonance Imaging (MRI) and Computed Tomography (CT-scan) may put these diseases forward (radiculopathy, discopathy …). Nevertheless, patients are frequently misdiagnosed. Normal age-related degenerative changes in the spine can be misinterpreted as an initiator of pain, although we can see the same changes in people with no complaints. For this reason, radiological pictures differ according to age, even in patients with no chronic low back pain (2,3,8)
 
It is also important to check for any presence of red flags.  
 
<br>
 
== Outcome Measures  ==
 
Validated self-report questionnaires, such as the Oswestry Disability Index and the [[Roland‐Morris_Disability_Questionnaire]]&nbsp;should be used at baseline and throughout the course of treatment to monitor a change in a patient’s status. (17) The Modified Somatic Perceptions Questionnaire (MSPQ) is used to assess pain intensity, disability and somatic pain perception respectively.The MSPQ is relevant and appropriate for use in a CLBP study as it was devised and evaluated specifically for CLBP and an MSPQ score &gt; 13 is one of the clinical predictors of lumbar facet syndrome. (45)


Generally, patients are diagnosed based on their history. The specific diagnosis is then formulated based on the examination and clinical outcomes.
== Examination  ==
== Examination  ==


Research has shown that the patient history and biopsychosocial evaluation are crucial to establish chronic LBP. Patient history and self-report forms help rule out serious pathologies such as cauda equina,&nbsp;[[Ankylosing_Spondylitis]], nerve compromise and cancer. The [[Fear‐Avoidance_Belief_Questionnaire]]&nbsp;(FABQ) self-report form has been shown to predict chronicity and psychosocial factors influencing patient prognosis (32) The focus of the physical examination is to confirm the hypothesis of chronic LBP by eliminating other pathologies or mechanisms (30)
# Research has shown that patient history and biopsychosocial evaluation are crucial to establish CLBP<ref>McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA. [https://www.tandfonline.com/doi/abs/10.1179/108331904225003955 The biopsychosocial classification of non-specific low back pain: a systematic review.] Physical Therapy Reviews. 2004 Mar 1;9(1):17-30.</ref>.
 
# The focus of the physical examination is to confirm the hypothesis of CLBP by eliminating other pathologies or mechanisms, such as the aforementioned red flags.<ref name=":3">Chou R, Qaseem A, Snow V, Casey D, Cross Jr JT, Shekelle P, Owens DK. [https://doi.org/10.7326/0003-4819-147-7-200710020-00006 Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.] Annals of internal medicine. 2007 Oct 2;147(7):478-91.</ref>
There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with (sub)acute low back pain. The best predictor is the lumbar spine flexion test. Other differences might be seen in functional tests, sensation in the feet, and in the different pain provocation tests. (18)<br><br>
# There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with subacute LBP. The best predictor is the lumbar spine flexion test. Other differences might be seen in functional tests, sensation in the feet, and in the different pain provocation tests.<ref>Paatelma M, Karvonen E, Heiskanen J. [https://doi.org/10.1179/106698109790818197 Clinical perspective: how do clinical test results differentiate chronic and subacute low back pain patients from" non-patients"?]. Journal of Manual & Manipulative Therapy. 2009 Jan 1;17(1):11-9.</ref>  
 
== Prevention<br>  ==
 
Identifying risk factors allows development of healthcare strategies (and prevention) to reduce the burden of chronic pain. Some risk factors cannot be changed, but others can be modified. Risk factors include socio-demographic, clinical, psychological and biological factors. For example anxiety, depression and catastrophizing beliefs (yellow flags) are associated with chronic pain and with a poor prognosis. (15)
 
Operant treatment approaches can be integrated into standard pain management for acute/subacute low back pain. Graded activity and behavioural education are promising treatment approaches for the prevention of CLBP and explaining the physiology of pain can also work preventive. (16,17) <br><br>
 
== Medical managment  ==
 
'''Pharmacology''': For chronic low back pain, pharmacological management can be used on a continuous basis or as needed. (31) (level of evidence 2c) However it’s important to advise patients to use it as a tool to stay active and to engage in treatment, rather than as a solution itself.<br><br>- ''Acetaminophen'': The American Pain Society/American College of Physicians guidelines recommend that acetaminophen be used as a first-line option with any duration of low back pain. Acetaminophen is an antipyretic and analgesic medication without anti-inflammatory properties. Risk of hepatotoxicity is the main complication, therefore dosing instruction must be followed carefully.(31) (level of evidence 2c)<br><br>Recent research states that there are a lot of uncertainties about the effect of paracetamol so there is a need for further research. There is only low-quality evidence for no effect on immediate pain reduction.(44) (level of evidence 1a)<br><br>- ''NSAIDS'': Non-steroidal Anti-Inflammatory drugs are another medication recommended as a first-line medication for short-term use. They are pain relieving and anti-inflammatory medications that block the cyclo-oxygenase (COX)-2 enzyme. Side-effects include gastrointestinal and renal complications, such as bleeding ulcers and perforation. NSAIDS are slightly effective for the improvement of disability. (31, 42) (level of evidence 2c) (level of evidence 1a)<br><br>- ''Opioids'': Opioids are considered an option in patients with moderate or severe pain.<br>Research has found opioids moderately effective for pain relief, although effects on functional outcomes were small. Slow-release opioids are recommended when compared to immediate-release opioids to prevent adverse effects, and should be given regularly rather than as needed. Due to the addictive nature of opioids, long-term use should be carefully monitored for misuse (31,35) (level of evidence 2c)(level of evidence 1a)<br><br>- ''Antidepressants'': Tricyclic antidepressants (TCA) are commonly used to treat numerous chronic pain syndromes. However, there is conflicting evidence on whether there are significant changes in pain relief or disability with CLBP. A recent systematic review found that there is evidence of moderate quality indicating that there is no difference in pain relief between antidepressants and placebo for patients with chronic LBP. (36) (level of evidence 1a) Depression is common in patients with chronic low back pain and should be treated appropriately (30) <br><br>- ''Other medications'': Skeletal muscle relaxants, benzodiazepines, and antiepileptic medications are not recommended because of the insufficient evidence towards their effectiveness for chronic low back pain. (31) (level of evidence 2c)
 
<br><u>Multidisciplinary approach&nbsp;</u><br><u><br></u>When treating patients with chronic LBP it has been shown that having been treated by a multidisciplinary team yields improvements. The multidisciplinary approach includes treating the physical, psychological, emotional, and socio professional aspects of the disorder (33) (level of evidence 2b) "Fear of pain in turn is supposed to initiate worrying about the consequences of pain and hence increases avoidance behavior, leading in the long term to increased pain, functional disability, and depression." (34) (level of evidence 4)<br><br>In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment. (14) (level of evidence 1a)<br>For more information: <u>&nbsp;[[Behavioral_pain_management_of_chronic_low_back_pain]]<br></u>
 
== Physical Therapy Management<br>  ==
 
[[Image:Physi.jpg]]<br>
 
'''Interventions:'''<br>- ''Advice'': For nonspecific low back pain the general advice on self-management is to remain active. This is also the case in CLBP. (30, 17) (resource - guideline based on level 1a and level 1b evidence)<br>It is frequently assumed that a firm mattress has beneficial effects on low back pain. In fact, for patients with chronic nonspecific low back pain (with no referred pain), a medium-firm mattress is found to be superior. Patients experience less pain and disability during the day and overnight. (43) (level of evidence 1b)<br>Giving advice only will probably not suffice. It is important to combine multiple treatment means to avoid recurrency. (17) <br> <br>- ''Stretching and flexibility exercises'': are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion. (10) (level of evidence 2b) The aim is to reduce pain, improve movement, and improve functional limitations of movement.
 
<u>Exercise therapy:</u><br>Exercise therapy has been shown to have beneficial effects for the management of chronic low back pain. (11) (level of evidence 1b)
 
Utilisation of trunk coordination, strengthening, and endurance exercises reduces low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments. (17) (resource - guideline based on level 1a and level 1b evidence)
 
Moderate- to high-intensity exercise will be considered for patients with CLBP without generalized pain. For patients with CLBP with generalized pain incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies will be considered. (17)
 
-''Core strengthening exercises'': are used to restore the coordination and control of the trunk muscles to improve control of the lumbar spine and pelvis. These exercises aim to restore the strength and endurance of the trunk muscles to meet the demands of control. Core exercise may be more effective than general exercise in relieving pain and improving back-specific function for patients with CLBP in the short term. No significant differences were found in the long term. (19) (level of evidence 1a)
 
- ''Motor control exercise'': motor control exercise protocols have been shown to be an effective treatment of chronic low back pain. Common targeted muscles include transversus abdominis, multifidus, the diaphragm and pelvic floor muscles.The focus of motor control exercises is to improve neuromuscular control of trunk segments involved in movement of the spine.(26, 27, 29, 37) (level of evidence 1a) (27 = resource) (level of evidence 1b) (level of evidence 1b)<br><br><br>Instructions: An independent contraction of the deep stabilizing muscles, such as the transversus abdominis and multifidus, facilitated by pelvic floor contraction, which leads to their co-contraction, whilst instructing to control breathing by maintaining resting tidal volumes throughout deep trunk activation maneuvers. Progression is achieved when mastery of contraction in static tasks is achieved. Then move on to implementation of deep muscle contraction during dynamic tasks. Daily practice at home for 30 minutes is instructed. (11) (level of evidence 1b)
 
Motor control exercises seem to be superior to several other treatments, such as general exercise (with regard to disability in the short-, intermediate, and long-term and pain in the short- and intermediate term), spinal manual therapy (with regard to disability during all time periods) and minimal intervention (during all time periods with regard to pain and disability). (20) (level of evidence 1a)
 
- ''Sensory discrimination training'': cortical reorganization presents a barrier to successful recovery; however the plasticity that underpins cortical reorganization also suggests that it might be responsive to targeted treatments, such as sensory discrimination training (SDT). SDT comprises tactile discrimination and sensorimotor retraining approaches, which involve the recognition of the location and the type of the stimuli by the patient (localization training). However, these approaches are not fully developed from a pathoanatomical perspective, since the processes involved in cortical reorganization in CLBP are not fully understood . (3) (level of evidence 1a)


- ''Traction:'' Summary evidence concludes that mechanical lumbar traction is not effective for treating acute or chronic nonspecific low back pain (LBP) Few trials evaluated the effectiveness of treatments for radicular low back pain, but the available evidence showed traction and spinal manipulation were not effective or were associated with small effects. (22) (level of evidence 2b)
== Outcome Measures ==
Can be used at baseline and throughout the course of treatment to monitor a change in a patient’s status.<ref name=":1" />
*[[STarT Back Screening Tool|STarT Back]]
*[[Oswestry Disability Index]]
*[[Roland‐Morris Disability Questionnaire]]&nbsp;
*[[Patient Specific Functional Scale|Patient-specific functional scale (PSFS)]]
* The loaded forward-reach test
*[[Pain Self-Efficacy Questionnaire (PSEQ)|Pain self-efficacy questionnaire (PSEQ)]]
== Medical Management ==
All the guidelines currently available stress the importance of a multimodal and multidisciplinary approach in order to determine a strategy to solve CLBP, not simply alleviate symptomatic pain.<ref name=":0" />  See [[Multidisciplinary Care in Pain Management]]


- [[Mckenzie Method]]: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises. This obviously might differ across different groups of patients. (11) (level of evidence 1b)
Treatment for chronic low back pain is grouped into into three wide categories: monotherapies, multiidisciplinary therapy, and reductionism.


- Massage and modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. (30) Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain. (29) (level of evidence 1b)
* Monotherapies: do not work or have limited effectiveness (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery).
* Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on CLPB.
* The reductionist approach, meaning the pursuit of a pathoanatomical diagnosis with the view to target-specific treatment, should be implemented when a specific diagnosis is essential. Searching a pathoanatomical diagnosis has been criticised on the grounds that it ignores the psychosocial aspects of chronic pain. However advocates of reductionism have persisted, as monotherapies and multidisciplinary therapy to date, have not provided a good solution to chronic low back pain.


- ''Pilates'': there is inconclusive evidence that pilates is effective in reducing pain and disability in people with CLBP. More research is necessary. (21) (level of evidence 1a)  
Imaging: Conventional investigations often do not reveal the cause of pain however joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.<ref name=":13">MJA Management of CLBP Available:https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain (accessed 17.11.2022)</ref>


- ''Yoga'': may be an efficacious adjunctive treatment for CLBP. Strongest and most consistent evidence is there for the short-term benefits on functional disability. More research is necessary. (24) (level of evidence 1a)
'''Multidisciplinary Approach'''


'''Biopsychosocial rehabilitation (cognitive behavioural therapy)'''<br>For patients with nonspecific chronic low back pain, more specifically patients who have already had full conservative treatment, a biopsychosocial rehabilitation program might result in positive long term effects on pain and disability. (14) (level of evidence 1a) For more information see: <u>[[CBT approach to Chronic Low Back Pain]]</u>  
In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment.<ref name=":4">Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, Van Tulder MW. [https://doi.org/10.1136/bmj.h444 Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis]. Bmj. 2015 Feb 18;350.</ref>  For more information see - <u>&nbsp;[[Behavioral pain management of chronic low back pain]]</u>


<u></u>Also pain education and graded exercise therapy could play an important role. There has not been found a significant difference between the effect of motor control exercises and graded exercise therapy, but subgroups of patients might respond better to one of these interventions. (23) (level of evidence 1b) <br><br>
== Physical Therapy Management  ==
[[File:Core activation 4point kneeling alternate arms.jpeg|thumb|Core activation ]]
Patients with CLBP should receive information about effective self-care options and should be advised to remain active (because muscles that do not move can eventually become hypersensitive to pain). Assessing the response to therapy is focused on improvements in pain, mood, and function.<ref name=":2" /> A multidisciplinary approach in treating chronic low back pain is advised. See also [[Communication in Chronic Pain Conditions]]


== Key Research  ==
Therapy consists of:


[https://connect.regis.edu/p20273804/ Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain], Bill Garcia, Evidence in Motion, OMPT Fellowship, 2009
* '''''Stretching and flexibility exercises'':''' are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion.<ref>Maddalozzo GF, Kuo B, Maddalozzo WA, Maddalozzo CD, Galver JW. [https://doi.org/10.1016/j.jcm.2016.07.001 Comparison of 2 multimodal interventions with and without whole body vibration therapy plus traction on pain and disability in patients with nonspecific chronic low back pain.] Journal of chiropractic medicine. 2016 Dec 1;15(4):243-51.</ref>  The aim is to reduce pain, improve movement, and improve functional limitations of movement.
* '''Strengthening and stabilizing the back and abdominal core muscles:''' produces small improvements in pain and functioning in patients with chronic low back pain. Few however studies (i.e., six of the 43 studies included in a Cochrane review)  demonstrated clinically important and statistically significant differences between intervention and control groups.<ref name=":2" />See [[Core Strengthening]]  and [[The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain]]
* Massage is now recommended in both the acute and chronic stages of back pain but modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain.
* [[Cognitive Behavioural Therapy]]: For patients with nonspecific chronic low back pain, more specifically patients who have already had full conservative treatment, a biopsychosocial rehabilitation program might result in positive long term effects on pain and disability.  For more information see: [[CBT Approach to Chronic Low Back Pain]]
* [[Pain Neuroscience Education (PNE)]]: Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view pain. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. PNE aims to increase pain thresholds during exercise, decrease fear related to movement and decreased brain activity in brain regions associated with pain.
[[File:Pain knowing-neurons.jpg|thumb|399x399px]]
Other Options Include:


== Resources <br> ==
* '''Manipulative therapy''': found in the latest meta-analysis to be slightly more effective than sham therapy however no more effective than other forms of care, for example care by a general practitioner, physiotherapy or exercises,<ref name=":13" />
* [[McKenzie Method]]: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises. This obviously might differ across different groups of patients.<ref name=":5">Halliday MH, Pappas E, Hancock MJ, Clare HA, Pinto RZ, Robertson G, Ferreira PH. [https://www.jospt.org/doi/10.2519/jospt.2016.6379 A randomized controlled trial comparing the McKenzie method to motor control exercises in people with chronic low back pain and a directional preference]. Journal of Orthopaedic & Sports Physical Therapy. 2016 Jul;46(7):514-22.</ref>
* Acupunture is no longer supported by the UK and Belgian guidelines but is still supported by the American guidelines state that acupuncture massage and pressure point massage are minimally helpful for reducing CLBP, with benefits lasting for up to one year.<ref name=":14">Qaseem A, Wilt TJ, McLean RM, Forciea MA. [https://doi.org/10.7326/M16-2367 Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.] Annals of internal medicine. 2017 Apr 4;166(7):514-30.</ref>
* Pilates:There is inconsistent evidence that [[pilates]] is effective in reducing pain and disability in people with CLBP, with a lack of long term follow up information.<ref>Wells C, Kolt GS, Marshall P, Hill B, Bialocerkowski A. [https://doi.org/10.1186/1471-2288-13-7 Effectiveness of Pilates exercise in treating people with chronic low back pain: a systematic review of systematic reviews.] BMC medical research methodology. 2013 Dec;13(1):1-2.</ref> The use of Pilates was found to improve ongoing Low Back Pain (LBP) in patients who received conventional physiotherapy treatment, the improvement was most obvious in the female population group.<ref>Pilates [[Pilates]]</ref>
* Yoga: Evidence in recent years has suggested [[yoga]] to be an efficacious adjunctive treatment for chronic low back pain <ref>Holtzman S, Beggs RT. [https://doi.org/10.1155/2013/105919 Yoga for chronic low back pain: a meta-analysis of randomized controlled trials]. Pain Research and Management. 2013 Oct;18(5):267-72.</ref>. Yoga has had a positive impact on pain and function outcomes in patients with CLBP. It has been found to have a statistically significant difference compared to minimal intervention. However, results comparing to exercise and usual physiotherapy are inconsistent. Yoga should be considered as an adjunct to usual physiotherapy until further higher quality studies have been produced.<u></u>
== Resources    ==


https://www.youtube.com/watch?v=DBh4_7YtLaA<br>
https://www.youtube.com/watch?v=DBh4_7YtLaA  
 
[http://www.ampainsoc.org/]


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


<span style="font-size:10.0pt;font-family:Helvetica; mso-bidi-font-family:Helvetica;color:#1A1718">A multidisciplinary approach in treating chronic low back pain is advised. Especially in patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments.  
A multidisciplinary approach in treating chronic low back pain is advised. Especially in patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programs result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Physical therapy should consist of exercise therapy (and no manual therapy). The exercise therapy might be general exercise therapy, the Mckenzie method, or motor control exercises. Pilates and yoga could be used if the patient has interest in this. Biopsychosocial rehabilitation is advised in patients with nonspecific chronic low back pain, education and graded exercise could also play an important role for these patients. Above all, it’s important to choose a therapy that fits the individual patient.
Physical therapy should consist of exercise therapy (and no manual therapy). The exercise therapy might be general exercise therapy, the Mckenzie method, or motor control exercises. Pilates and yoga could be used if the patient has interest in this.  
Biopsychosocial rehabilitation is advised in patients with nonspecific chronic low back pain, education and graded exercise could also play an important role for these patients. Above all, it’s important to choose a therapy that fits the individual patient.
 
</span>
 
 
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br> ==
 
== References  ==
== References  ==


<references />  
<references />  


<br>  
<br>
 
[[Category:Texas State University EBP Project]]
[[Category:Lumbar]] [[Category:Low_Back_Pain]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Texas_State_University_EBP_Project]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Conditions]]
[[Category:Lumbar Spine]]  
[[Category:Lumbar Spine - Conditions]]
[[Category:Mental Health]]
[[Category:Mental Health - Conditions]]

Latest revision as of 10:38, 3 March 2024

Original Editors - Bryan Jacobson, Tori Westcott, Ashley Bohanan, Alisha Lopez

Top Contributors - Bryan Jacobson, Meg Howitt, Cindy John-Chu, Nele Kiekens, Kim Jackson, Lucinda hampton, Laura Ritchie, Admin, Chloe Johnson, Tori Westcott, Jonathan Wong, Judith Vrydag, Rachael Lowe, Jeremy Brady, Joshua Samuel, Evi Van Cauwelaert, Simisola Ajeyalemi, Eric Robertson, Ashley Bohanan, Aminat Abolade, Evan Thomas, Scott Buxton and George Prudden

Introduction[edit | edit source]

CLBP: common in society.

Chronic low back pain (CLBP) is defined as lower back pain lasting for longer than 12 weeks or 3 months, even after an initial injury or underlying cause of acute low back pain has been treated.

Key Points

  1. CLBP develops in roughly 5.0% to 10.0% of low back pain cases.[1][2]
  2. CLBP represents the second leading cause of disability worldwide and is a major health and economic problem.
  3. CLBP has a significant impact on functional capacity and occupational activities, and can also be influenced by psychological factors, such as stress, depression and/or anxiety.[3]
  4. Patients often have unrealistic expectations of total pain relief, being a large gap between a patient's desired amount of pain reduction and the minimum percentage of improvement that makes a treatment worthwhile. [4]

Epidemiology /Aetiology[edit | edit source]

  1. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the ageing population, affecting both men and women in all ethnic groups.[3]
  2. CLBP prevalence varies according to age, prevalence was 4.2% for individuals aged between 24 and 39, and 19.6% for people aged between 20 and 59[5].
  3. Higher prevalence in females, people of lower economic status, those with less schooling, and smokers compared to males, people with higher economic status, those with more schooling, and non-smokers, respectively.[6]

Characteristics/Clinical Presentation[edit | edit source]

CLBP refers to LBP occurring for longer than three months, and possibly occurring episodically. Social contact and work environment will suffer from the impact on the patient's health and wellbeing.

Presentation includes:

  • Pain in the lower area of the back, which may radiate into the lower extremities.
  • Movement and coordination impairments
  • Difficulty maintaining the neutral position and/or to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities.
  • Carrying objects in the arms, or bending can also provoke complaints.
  • Daily activities such as household tasks, sports and other recreational activities can be challenging for people with CLBP.
  • When pain is generalized, sensory experiences of the patient can also become altered
  • Fear-avoidance beliefs, pain catastrophizing (see Pain Catastrophizing ) and depressive thoughts can appear (monitor these Yellow Flags, blue flags and black flags).[7]

Red Flags: Although uncommon, serious spinal conditions (such as those listed below) may present as chronic LBP in approximately 5% of patients presenting to primary care office:

Diagnosis[edit | edit source]

In most cases, causes for CLBP are not found using traditional investigations.

  • Fewer than 10% of cases are diagnosed with radiography and magnetic resonance imaging (MRI).
  • Degenerative changes and conditions such as spondylolysis and spondylolisthesis are not reliable diagnoses for CLBP, as they are no more common in patients with pain than in asymptomatic individuals.[9]

Generally, patients are diagnosed based on their history. The specific diagnosis is then formulated based on the examination and clinical outcomes.

Examination[edit | edit source]

  1. Research has shown that patient history and biopsychosocial evaluation are crucial to establish CLBP[10].
  2. The focus of the physical examination is to confirm the hypothesis of CLBP by eliminating other pathologies or mechanisms, such as the aforementioned red flags.[11]
  3. There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with subacute LBP. The best predictor is the lumbar spine flexion test. Other differences might be seen in functional tests, sensation in the feet, and in the different pain provocation tests.[12]

Outcome Measures[edit | edit source]

Can be used at baseline and throughout the course of treatment to monitor a change in a patient’s status.[7]

Medical Management[edit | edit source]

All the guidelines currently available stress the importance of a multimodal and multidisciplinary approach in order to determine a strategy to solve CLBP, not simply alleviate symptomatic pain.[3] See Multidisciplinary Care in Pain Management

Treatment for chronic low back pain is grouped into into three wide categories: monotherapies, multiidisciplinary therapy, and reductionism.

  • Monotherapies: do not work or have limited effectiveness (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery).
  • Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on CLPB.
  • The reductionist approach, meaning the pursuit of a pathoanatomical diagnosis with the view to target-specific treatment, should be implemented when a specific diagnosis is essential. Searching a pathoanatomical diagnosis has been criticised on the grounds that it ignores the psychosocial aspects of chronic pain. However advocates of reductionism have persisted, as monotherapies and multidisciplinary therapy to date, have not provided a good solution to chronic low back pain.

Imaging: Conventional investigations often do not reveal the cause of pain however joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.[9]

Multidisciplinary Approach

In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment.[13] For more information see -  Behavioral pain management of chronic low back pain

Physical Therapy Management[edit | edit source]

Core activation

Patients with CLBP should receive information about effective self-care options and should be advised to remain active (because muscles that do not move can eventually become hypersensitive to pain). Assessing the response to therapy is focused on improvements in pain, mood, and function.[4] A multidisciplinary approach in treating chronic low back pain is advised. See also Communication in Chronic Pain Conditions

Therapy consists of:

  • Stretching and flexibility exercises: are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion.[14] The aim is to reduce pain, improve movement, and improve functional limitations of movement.
  • Strengthening and stabilizing the back and abdominal core muscles: produces small improvements in pain and functioning in patients with chronic low back pain. Few however studies (i.e., six of the 43 studies included in a Cochrane review) demonstrated clinically important and statistically significant differences between intervention and control groups.[4]See Core Strengthening and The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain
  • Massage is now recommended in both the acute and chronic stages of back pain but modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain.
  • Cognitive Behavioural Therapy: For patients with nonspecific chronic low back pain, more specifically patients who have already had full conservative treatment, a biopsychosocial rehabilitation program might result in positive long term effects on pain and disability.  For more information see: CBT Approach to Chronic Low Back Pain
  • Pain Neuroscience Education (PNE): Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view pain. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. PNE aims to increase pain thresholds during exercise, decrease fear related to movement and decreased brain activity in brain regions associated with pain.
Pain knowing-neurons.jpg

Other Options Include:

  • Manipulative therapy: found in the latest meta-analysis to be slightly more effective than sham therapy however no more effective than other forms of care, for example care by a general practitioner, physiotherapy or exercises,[9]
  • McKenzie Method: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises. This obviously might differ across different groups of patients.[15]
  • Acupunture is no longer supported by the UK and Belgian guidelines but is still supported by the American guidelines state that acupuncture massage and pressure point massage are minimally helpful for reducing CLBP, with benefits lasting for up to one year.[16]
  • Pilates:There is inconsistent evidence that pilates is effective in reducing pain and disability in people with CLBP, with a lack of long term follow up information.[17] The use of Pilates was found to improve ongoing Low Back Pain (LBP) in patients who received conventional physiotherapy treatment, the improvement was most obvious in the female population group.[18]
  • Yoga: Evidence in recent years has suggested yoga to be an efficacious adjunctive treatment for chronic low back pain [19]. Yoga has had a positive impact on pain and function outcomes in patients with CLBP. It has been found to have a statistically significant difference compared to minimal intervention. However, results comparing to exercise and usual physiotherapy are inconsistent. Yoga should be considered as an adjunct to usual physiotherapy until further higher quality studies have been produced.

Resources[edit | edit source]

https://www.youtube.com/watch?v=DBh4_7YtLaA

Clinical Bottom Line[edit | edit source]

A multidisciplinary approach in treating chronic low back pain is advised. Especially in patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programs result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Physical therapy should consist of exercise therapy (and no manual therapy). The exercise therapy might be general exercise therapy, the Mckenzie method, or motor control exercises. Pilates and yoga could be used if the patient has interest in this. Biopsychosocial rehabilitation is advised in patients with nonspecific chronic low back pain, education and graded exercise could also play an important role for these patients. Above all, it’s important to choose a therapy that fits the individual patient.

References[edit | edit source]

  1. ↑ Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.
  2. ↑ NIH Low Back Pain Fact Sheet Available: https://www.ninds.nih.gov/low-back-pain-fact-sheet(accessed 17.11.2022)
  3. ↑ 3.0 3.1 3.2 Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research. 2016;5. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926733/ (accessed 17.11.2022)
  4. ↑ 4.0 4.1 4.2 AFP Chronic Low Back Pain: Evaluation and Management Available;https://www.aafp.org/pubs/afp/issues/2009/0615/p1067.html (accessed 18.11.2022)
  5. ↑ Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015;49:1. doi: 10.1590/S0034-8910.2015049005874. Epub 2015 Oct 20. PMID: 26487293; PMCID: PMC4603263.
  6. ↑ Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ (accessed 17.11.2022)
  7. ↑ 7.0 7.1 Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42(4):A1-A57.
  8. ↑ Lumbar Assessment
  9. ↑ 9.0 9.1 9.2 MJA Management of CLBP Available:https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain (accessed 17.11.2022)
  10. ↑ McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA. The biopsychosocial classification of non-specific low back pain: a systematic review. Physical Therapy Reviews. 2004 Mar 1;9(1):17-30.
  11. ↑ Chou R, Qaseem A, Snow V, Casey D, Cross Jr JT, Shekelle P, Owens DK. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine. 2007 Oct 2;147(7):478-91.
  12. ↑ Paatelma M, Karvonen E, Heiskanen J. Clinical perspective: how do clinical test results differentiate chronic and subacute low back pain patients from" non-patients"?. Journal of Manual & Manipulative Therapy. 2009 Jan 1;17(1):11-9.
  13. ↑ Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, Van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj. 2015 Feb 18;350.
  14. ↑ Maddalozzo GF, Kuo B, Maddalozzo WA, Maddalozzo CD, Galver JW. Comparison of 2 multimodal interventions with and without whole body vibration therapy plus traction on pain and disability in patients with nonspecific chronic low back pain. Journal of chiropractic medicine. 2016 Dec 1;15(4):243-51.
  15. ↑ Halliday MH, Pappas E, Hancock MJ, Clare HA, Pinto RZ, Robertson G, Ferreira PH. A randomized controlled trial comparing the McKenzie method to motor control exercises in people with chronic low back pain and a directional preference. Journal of Orthopaedic & Sports Physical Therapy. 2016 Jul;46(7):514-22.
  16. ↑ Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine. 2017 Apr 4;166(7):514-30.
  17. ↑ Wells C, Kolt GS, Marshall P, Hill B, Bialocerkowski A. Effectiveness of Pilates exercise in treating people with chronic low back pain: a systematic review of systematic reviews. BMC medical research methodology. 2013 Dec;13(1):1-2.
  18. ↑ Pilates Pilates
  19. ↑ Holtzman S, Beggs RT. Yoga for chronic low back pain: a meta-analysis of randomized controlled trials. Pain Research and Management. 2013 Oct;18(5):267-72.


Retrieved from "https://www.physio-pedia.com/index.php?title=Chronic_Low_Back_Pain&oldid=351053"