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 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) Seven million adults in the United States have been estimated to have activity limitations as a result of chronic low back pain (Chou 2010).

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 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 (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)

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Multidisciplinary Teams for Chronic Pain Management

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. (Demoulin article 2009) “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 (Samwell article 2009). Therefore a team is needed to address all the extra extraneous effects that are produced by living with chronic low back pain from months to years. The multidisciplinary team usually consists of psychologists, phsycians, and physical and occupational therapists. There are multidisciplinary clinics patients can go to 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 co-morbidities produced by the chronic pain.

Surgical Approaches

Spinal surgery is recommended for certain conditions and can be beneficial to some patients. These conditions which are evidence-based practice indicators for spinal fusion surgery are disorders such as spondylolisthesis and only rare cases of disk herniation or spinal stenosis without spondylolisthesis. However, it has been shown that spinal stenosis patients can benefit from physical therapy especially with manual therapy, exercise and walking programs implemented. (The Whitman article 2006).  It has also been shown that structured behavior therapy may yield better results than the implementation of surgery. With that being stated the rate of spinal surgeries continues to rise each year unnessassarly for unwarranted conditions. Also there are inherited risks that occur with each spinal surgery especially with spinal fusion. 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 (Deyo article 2004 NEJ). 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.

Medical Management (current best evidence)

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)

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 (Chou 2010).

·       Acetaminophen: The American Pain Society/American Chronic Pain 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 (Chou 2010).

·       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 (Chou 2010).

·       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 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 (Chou 2010, Deshpande 2010)

·       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 (Kuijpers 2011).  Although, depression is common in patients with chronic low back pain and should be treated appropriately (Chou 2007).

·       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 (Chou 2010).

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)

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.    (sync website/article)

Graded Exposure: 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 the activities the patient 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. (Nicholas and George 2011)

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:

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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) 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

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

Find Your Physical Therapist

The American Physical Therapy Association

The National Institute of Health

American Chronic Pain Association

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

see adding references tutorial.