Chronic Low Back Pain

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Original Editors- Bryan Jacobson, SPT

Lead Authors- Tori Westcott, SPT

Evidence Based Researchers- Ashley Bohanan, SPT, Alisha Lopez, SPT. Read more.

Search Strategy

Chronic, low back, pain, biopsycosocial 

Definition/Description

Low back pain can be a disabling condition affecting nearly 60-80% of people.  These people that suffer from low back pain longer than 3 months are considered chronic, and can be attributed to more than 80% of all heath care cost. 

Epidemiology /Etiology

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Characteristics/Clinical Presentation

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Differential Diagnosis

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Examination

Research has shown that the patient history and biopsychosocial evaluation are crucial to establish CLBP. The patient history and self report forms help rule out serious pathologies such as cauda equine, anklysosing spondylosis, nerve root compromise, and cancer. The Fear-Avoidance Beliefs Questionnaire (FABQ) self report form has been shown to predict chronicity and psychosocial factors influencing patient prognosis (George 2003, Fritz 2002). The focus of the physical examination is to confirm the hypothesis of chronic low back pain by eliminating other pathologies or mechanisms.

Surgical Approaches

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Medical Management (current best evidence)

Pharmacology

Biopsycosocial Approach

Chronic low back pain threatens self-identity, as it can change coping patterns and the individual’s way of thinking, with people often reporting feelings of helplessness and a loss of self-esteem and experience of a hidden disability. When low back pain becomes chronic, it often does not respond to traditional biomedical treatments. Identification of psychosocial risk factors, or ‘yellow flags’, enable appropriate intervention to be incorporated into vocational rehabilitation treatment as a preventative measure against conditions such as chronic low back pain. Yellow flags are factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain. Assessment of these is encouraged in the early stages of intervention after work related injury (Ashby, 2010).

Physical Therapy Management (current best evidence)

Intervention:
Spinal Manipulation: Short term and long term improvements have been seen demonstrated after spinal joint manipulation performed to the spine or pelvis. Ferreira et al. and Aure et al. found significant improvements in functional capabilities, debilitating pain and return to work.

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. (Ferreira 2007, Costa 2009, Akbari 2008)

Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain. (Ferreira 2007)

Treatment of chronic low back pain is most effective when spinal manipulation and motor control exercises are used in combination. (Aure et al) In addition, treatment plans must be specific to the impairments of the patient.

Key Research

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Resources

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Clinical Bottom Line

Multidimensional treatment approaches that consider physical, cognitive, affective and behavioral components are increasingly used with individuals with chronic low back pain.  The impact of fear of movement on the lives of the participants is multi-faceted, and can have a considerable impact upon occupational functioning. A change of roles and relationships, social isolation, self doubt and interpretation of chronic low back pain impacted upon a person’s functioning, on the vocational rehabilitation process and on return to work outcomes (Ashby, 2010).

Recent Related Research (from Pubmed)

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References

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