Chronic Low Back Pain

Welcome to Texas State University's Evidence-based Practice project space. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors- Bryan Jacobson, SPT

Lead Authors- Tori Westcott, SPT

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

Search Criteria

Chronic pain, low back pain, biopsychosocial, spinal manipulation, opioids, multidisciplinary management

Description

Low back pain is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. People that suffer from low back pain longer than 3 months are considered chronic, and can be attributed to more than 80% of all health care cost. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for 1 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.

Clinical Presentation

Low back pain is a common complaint in adults of all ages. Its clinical presentations can vary, but most patients' will likely experience pain that is centralized or radiates into the lower extremities. When patients don’t exclusively fit into a specific type of treatment based on clinical prediction rules, and they are predicted to suffer from chronicity from self-report forms, a multi-disciplinary approach is best suited to treat these patients.

Differential Diagnosis

Low 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 low back pain may be related to underlying pathological conditions. Some other possible conditions that could be attributing to the low back pain that are not physical therapy related include: Abdominal Aneurysm, Appendicitis, Ectopic Pregnancy, Endometriosis, Neoplasms, Ovarian Cyst, Pelvic Inflammatory Disease, Prostatitis, Renal Calculi, and Urinary Tract Infections. In the event that these conditions could be present, either a physician referral, or immediate attention is required.

Examination

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

File:Low Back Pain Eval.png

Surgical Approaches

Spinal surgery is recommended for certain conditions. However, the rate of spinal surgeries continues to rise each year unnecessarily for unwarranted conditions. There are inherited risks that occur with each spinal surgery especially with spinal fusions. Such risks include: increase chance of blood transfusion, postoperative mortality, instrumentation failure, infection, chronic pain, neural injuries, pulmonary embolus, pseudarthrosis, a high reoperation rate and complications at the bone- donor site .

Patients should be well informed of the risk that occurs with these surgeries and work with their physician to decided what would yield the best possible outcome. According to Whitman et al. patients with lumbar spinal stenosis can benefit from physical therapy instead of opting for a surgical approach. It has been found that manual physical therapy, exercise and a progressive body weight supported treadmill walking program yield the most improvements. Structured cognitive behavior therapy has also been proven to be beneficial.

Multidisciplinary Teams

When treating patients with chronic low back pain it has been shown that having been treated by a multidisciplinary team yields improvements. The multidisciplinary approach includes treating the physical, psychological, emotional, and socioprofessional aspects of the disorder . "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." .

Therefore a team is needed to address all the extraneous effects that are produced by living with chronic low back pain from months to years. Psychologists, phsycians, and physical and occupational therapists tend to be the professionals involved in multidisciplinary teams. Multidisciplinary clinics are available to patients for this type of care, however, if a patient cannot get to a clinic their physician, physical therapist, and psychologist should all be working together in order to address all the patients impairments produced by the chronic pain.

Medical Management (current best evidence)

Pharmacology: According to Kuijpers et al, pharmacological interventions are the most frequently recommended intervention for back pain. Many factors, such as severity and duration of symptoms, adverse side-effects, prior response to medications and presence of co-morbidities determine which medication is best for the patient. For chronic low back pain, pharmacological management can be used on a continuous basis or as needed .

·       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.

·       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 .

·       Opioids: Opioids are considered an option in patients with moderate or severe pain.  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 .

·       Anti-depressants: Tricyclic anti-depressants (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 chronic low back pain.  A recent systematic review found that there is moderate quality evidence that there is no difference in pain relief between antideperessants and placebo for patients with chronic low back pain .  Although, depression is common in patients with chronic low back pain and should be treated appropriately.

·       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.

Behavioral Therapy: Evidence has shown the behavioral therapy has a positive effect on pain intensity, functional status, and behavior in patients with chronic low back pain. There are three approaches to behavioral therapy: operant conditioning, cognitive, and respondent.

• Operant treatments uses positive reinforcement of healthy behavior to minimize focus on pain, and spouse support.

• The focus of the cognitive approach is on modifications of thoughts and feelings toward their pain and disability.

• The respondent approach focuses on reducing muscular tension by methods of relaxation. 

The cognitive approach is the most commonly used technique in pain management.  Nicholas and George explain basic cognitive-behavior methods that may be beneficial for chronic low back pain patients. Basic Cognitive-Behavioral Methods Appendix

Graded exposure is a behavioral treatment recommended for patients with chronic pain and high fear-avoidance behaviors.  The focus of the treatment is on gradually exposing the patient to activities he or she actively avoids.  A recent systematic review of randomized control trials found no advantage when physical therapy was supplemented with graded exposure. However, only 5 of the 15 trials in the systematic review involved patients who had high levels of fear avoidance. Therefore, more randomized trials need to be performed on patients with high fear-avoidance levels to adequately test graded exposure..

Biopsychosocial 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).  

Another important consideration for therapist is the possibility of the patient developing a depressive mood.  Low back pain epidemiological literature suggest that it could be a strong prognostic indicator for chronicity.  Those that are more depressed are more likely to experience back pain symptoms when compared to people whose moods are not affected. (Hill and Fritz, 2011)

Physical Therapy Management

Intervention:

File:Low back pain 2.png

Spinal Manipulation: There has been conflicting evidence on whether spinal manipulation is beneficial for chronic low back pain patients.  Ferreira et al., Cecchi et al., and Aure et al. found significant short term and long term improvements in functional capabilities, debilitating pain and return to work.  Contrastingly, a Cochrane review published in 2011 reviewing 26 articles found no benefit.

Even though there is conflicting evidence, spinal manipulation has minimal risk of harm and is cost effective.  The decision to use spinal manipulation in treatment must focus on these factors and patient preference (Rubinstein 2011, UK BEAM Trial Team).

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, Macedo 2009)

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.

Modalities: Electrical nerve stimulation (TENS and interferential), low-level laser therapy, shortwave diathermy, and ultrasonography have not been shown to be an effective treatment option due to insufficient evidence .

Traction: Evidence has shown no benefit to continuous or intermittent traction.

Massage: Massage has not been shown to be an effective intervention for chronic low back pain.

Key Research

TBD

Resources

Find Your Physical Therapist

The American Physical Therapy Association

The National Institute of Health

American Chronic Pain Association

American Pain Society

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

Kuijpers T, Middelkoop M, Rubinstein S, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. European Spine Journal [online]. 2011;20:40-50.Available from: MEDLINE with FULL TEXT. Accessed April 21, 2011.

Chou R. Pharmacological Management of Low Back Pain. Drugs [online]. 2010;70 (4):387-402. Available from MEDLINE with FULL TEXT. Accessed April 30, 2011.

Nicholas M, George S. Psychologically Informed Interventions for Low Back Pain: An update for Physical Therapists. Physical Therapy. 2011;91 (5): 765-777. http://ptjournal.apta.org/content/91/5/765.abstract?etoc .Accessed April 29, 2011.

Hill J, Fritz J. Psychosocial Influences on Low Back Pain, Disability, and Response to Treatment. Physical Therapy. 2011;91 (5): 712-721. http://ptjournal.apta.org/cgi/content/extract/91/5/735 . Accessed April 29, 2011.

Tulder M, Ostelo R, Johan W, et al. Behavioral Treatment for Chronic Low Back Pain: A Systematic Review Within the Framework of the Cochrane Back Review Group. Spine [online].2000; 26(3): 270-281. Available from MEDLINE with FULL TEXT. Accessed April 21, 2011.

Deyo RA, Nachemson A, Mirza SK. Spinal fusion: the case for restraint. NEJM 2004;350:722-726.

Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion & surgery to nonoperative care for treatment of chronic back pain. 2007;32:816-823.

Whitman JM, Flynn TW, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis. Spine 2006;31:2541-2549.

Martin B, Mirza S, Comstock B, Gray D, Kreuter W, Deyo R. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine [serial online]. Febuary 2007; 32(3): 382-387. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 30, 2011.

Demoulin C, Grosdent S, Vanderthommen M, et al. Effectiveness of a semi-intensive multidisciplinary outpatient rehabilitation program in chronic low back pain. Joint Bone Spine [serial online]. 2010; 77 (1): 58-63. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 30, 2011. 

Samwel H, Kraaimaat F, Crul B, van Dongen R, Evers A. Multidisciplinary allocation of pain treatment: long term outcome and correlates of cognitive-behavioral processes. Journal of Musculoskeletal Pain [serial online]. March 2009; 17(1): 26-36. Available from: CINAHL plus with Full Text, Ipswich, MA. Accessed April 30, 2011. 

UK BEAM Trial Team. United Kingdom Back Pain Exercise and manipulation (UK BEAM) Randomised Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care. BMJ. December 2004; 329 (7479):1381-1385.

Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.

Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.

Chou R, Qaseem A, Snow V, Casey D, Cross TJ, 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. Ann Intern Med. 2007;147:478-491.

Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Physical Therapy. 2009;89:9-25.

Akbari A, Khorashadizadeh S, Abdi G. The Effect of Motor Control Exercise Versus General Exercise on Lumbar Local Stabilizing Muscle Thickness: Randomized Controlled Trial of Patients with Chronic Low Back Pain. Journal of Back and Musculoskeletal Rehabilitation. 2008;21:105-112.

Costa LOP, Majer CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, McAuley JH, Jennings MD. Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial. Physical Therapy. 2009;89(12):1275-1286.

Cecchi F, Molino-Lova R, Pasquini G, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clinical Rehabilitation. [online]. 2010;24:26-34. Available from: Medline with FULL TEXT. Accessed April 21, 2011.

Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low back pain. The Cochrane collaboration. [online] 2011;2: 1-178. Available from: The Cochrane Library. Accessed on April 21, 2011.