Chronic Low Back Pain
Original Editors- Bryan Jacobson, SPT
Lead Authors- Tori Westcott, SPT
Evidence Based Researchers- Ashley Bohanan, SPT, Alisha Lopez, SPT. Read more.
Search Strategy[edit | edit source]
Chronic, low back, pain, biopsycosocial
Definition/Description[edit | edit source]
Low back pain can be a disabling condition that is the fifth most common reason for physician visits. It affects nearly 60-80% of people. 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. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for 1 year after an acute episode (Aure 2003, Ferreira 2007, Chou 2007).
Characteristics/Clinical Presentation[edit | edit source]
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Differential Diagnosis[edit | edit source]
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Examination[edit | edit source]
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 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. (European Guidelines)
Surgical Approaches[edit | edit source]
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Medical Management (current best evidence)
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Pharmacology: Opioids, both weak and strong, have been shown to be an effective pain reliever in chronic low back pain. There is stronger evidence supporting the use of weak opioids in CLBP showing improvement in pain and disability. Strong opioids may be used although, if used for an extended period of time, the patient may become dependent on them. Therefore, slow-release opioids are recommended to immediate-release opioids and should be given regularly rather than as needed. Side effects of opioid use may include nausea and headache. (Deshpande 2010, European Guideline)
Behavioral Therapy: Evidence has shown the behavioral therapy has a positive effect on pain intensity, functional status, and behavior in patients with CLBP. 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. (Maurits 2000)
Biopsycosocial Approach[edit | edit source]
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)[edit | edit source]
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[edit | edit source]
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Resources
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The American Physical Therapy Association
The National Institute of Health
American Chronic Pain Association
Clinical Bottom Line[edit | edit source]
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[edit | edit source]
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