Behavioral pain management of chronic low back pain
Clinical relevant anatomyThe muscles which are responsible for movement and postural control are divided into 2 groups:
1. local muscle system
2. global muscle system
Patients with chronic low back pain will show a disturbed equilibrium between these two muscle systems. The local system described below will be affected and will have a loss of function while the global system will take over. This can cause problems with the sensorimotor control and stabilization of the trunk.
The function of the local system is to ensure stability in the lumbopelvic region. The fact that these muscles are attached to the lumbar vertebrae and pelvis, tells us they have an anatomical potential to stabilize these structures. From a biomechanical point of view the muscles have a favorable position towards the joint to stabilize it. They create compression without causing a shift or shear force. Also histological the muscles have a good composition of type I fibers, which mean they have a great aerobic endurance. So they can contract for a long time at a low level intensity.Some muscles of the local system do also have feed forward activation. So they catch up an expected force at the thorax. The lumbar musculus multifidus is crucial for the stabilization of the thorax.The smaller intersegmental muscles, like the musculii intertransversarii en musculii interspinales, have a more proprioceptic function and a less stabilizing.Together with the musculus transverses abdominis, some parts of the musculus quadrates lumborum and the posterior fibers of the musculus psoas major, they are classified as local stabilizing muscles.
The global muscle system exists of more superficial and bigger muscles, which don’t attach directly to the vertebrae but they bridge some segments. They ensure the strength and movements needed for daily life. Just like the local system they take care of the global stabilization and postural control. Unlike the local, the global system contains more type II muscle fibers for a fast and powerful contraction. They also don’t have a feed forward activation system. The muscles which belong to the global system are: musculus obliquus internus, musculus obliquus externus, musculus rectus abdominis, thoracal bundles of the erector spinea, lateral fibers of the musculus quadrates lumborum en anterior bundles of the musculus psoas.
One of the possible classifications for low back pain is a time based classification:
- acute pain; less than six weeks
- subacute; six to twelve weeks
- chronic pain; more than 12 weeks
Chronic low back pain is not only different in time scale, but it also becomes a completely different clinical syndrome from acute low back pain. Chronic low back pain will become a self-sustaining condition while acute pain is generally proportionate to physical findings. Treatments specific directed to the physical disorder will be highly effective in relieving acute low back pain.
A very important factor to mention is the psychosocial factor and its influence in chronic low back pain. Most of the chronic back pain patients tend to show psychosocial issues as; a reduced sense of self control, a disturbed mood, a negative self-efficacy, a high level of anxiety, mental health disorders and engaging into a catastrophizing tend. These issues can cause pain fixation and avoidance behavior which can make the patient build up an abnormal pattern to move and engage muscle spasms. On its turn this will cause disuse of these muscles, which then leads to an imbalance and loss of strength of the muscles, a limitation of motion, a reduced physical condition, a disturbed posture and movement.
The physical dysfunction will grow into a participation disorder. , Unlike acute low back pain physical or medical treatment directed to a supposed nociceptive source which is possibly nonexistant won’t be effective and even may cause more physical damage. A failed treatment could reinforce aforementioned psychosocial issues.
Physical therapy management
Exercise will be very important to help a patient with chronic low back pain, surely if anxiousness to move and avoidance behavior are present. Graded exposure is one of the strategies that could help, the therapist will gradually and in a progressive way, let the patient perform some exercises which frighten the patient and overcome the fear of movement. The daily life activities are disturbed due to the catastrophizing tend and avoidance behavior.
Exercises and aerobic training is useful to create endorphins. This hormonal substance will help defeat stress and even depression.  The patient will get a happy feeling, also known as the “runners high” that will inhibit the pain. As the therapy goes on the patient will get more body control and come out of their social isolation. Naturally the psychosocial factors which maintain the pain should get some follow up and possibly cognitive behavioral management. , Exercise will only help partially to tackle these psychosocial dysfunctions. , The daily life activities are disturbed due to the catastrophizing tend and avoidance behavior. Back schooling should be advised to help the patient using the correct techniques of movement during these daily life activities.
The enduring pain will be responsible for extensive cortical reorganization such as neurochemical and structural changes of the brain. It appears that these changes will lead to a disturbed body perception, decreased tactile acuity and a disruption of the working body schema.
So we can say that a graded sensorimotor retraining countering these dysfunctions would be beneficial for patients with chronic low back pain. To reeducate the neuromuscular system and its intrinsic characteristics there is a systematic order to follow.The beginning exists of proprioception and coordination exercises, these are fundamental for an efficient stabilization. After regaining stability, strength and endurance will be the following parts of the revalidation.
It is important to explore the sensorimotor control of the patient and facilitate the exercises verbally, tactile, with use of referential points or a mirror, etc. . The exercises could be given in different starting positions. The most important positions are hand-knee support, lying on the back, standing position and sitting position.
To retrain coordination, a lot of factors should be taken into account. The condition of the muscles and ratio between the different muscles and the present status of the osteoarticulare structures are some examples. In these exercises the focus is placed on the quality of the movement. They should be executed in the most efficient and ergonomic way. The most crucial factor will be to train the local muscle system to prevent too much activity and substitution strategies of the global muscle system, which causes degeneration and pain, loss of stability, disturbed respiratory system and limited physiological movement. Because of the anatomical changes caused by antalgic positions of the patient; it can be concluded that training the muscles described at the clinical relevant anatomy as local muscle system will be very important to gain muscle control and stability. These muscles can be named as the stabilizing muscle corset. Also the activation sequence and timing seems to be essential in the process of reeducating the functional movements. To reactivate and automate the feed forward system it is useful to always contract the muscle corset before executing the specific movement. The patients should train dynamic as well as static stability. Therapy concentrated to only one of these areas will miss its purpose.
Core Stability Exercises 
Pain education is needed to break through the negative thoughts about pain from the patient. The therapist has to control the emotional reaction to chronic pain and learning the patient to cope with pain and other stressors . While this is more a psychological approach of therapy, chronic low back pain are to be treated in a multi-layered manner. It could be helpful to refer to a psychologist. The physiotherapist’s role as counselor should help the patient change from a passive recipient of treatment to a more active treatment. The patient has to accept the responsibility for his/her progress. 
- Brumagne S, Cordo P, Lysens R, Verschueren S, Swinnen S. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine (Phila Pa 1976). 2000 Apr 15;25(8):989-94.
- DANNEELS L. VANTHILLO B.; Oefentherapie bij rugaandoeningen; Standaard Uitgeverij nv Antwerp; 2010
- Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine (Phila Pa 1976). 2002 Jan 15;27(2):E29-36.
- Nitz AJ, Peck D. Comparison of muscle spindle concentrations in large and small human epaxial muscles acting in parallel combinations. Am Surg. 1986 May;52(5):273-7.
- BOGDUK N. clinical anatomy of the lumbar spine and sacrum. Edinburgh: Churchill livingstone. 1997.
- Ebenbichler GR, Oddsson LI, Kollmitzer J, Erim Z. Sensory-motor control of the lower back: implications for rehabilitation. Med Sci Sports Exerc. 2001 Nov;33(11):1889-98.
- Waddell G.1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976). 1987 Sep;12(7):632-44
- Last AR, Hulbert K.Chronic low back pain: evaluation and management. Am Fam Physician. 2009 Jun 15;79(12):1067-74.
- Hampel P, Graef T, Krohn-Grimberghe B, Tlach L. Effects of gender and cognitive-behavioral management of depressive symptoms on rehabilitation outcome among inpatient orthopedic patients with chronic low back pain: a 1 year longitudinal study. Eur Spine J. 2009;18(12):1867–1880. doi:10.1007/s00586-009-1080-z
- Tlach L, Hampel P. Long-term effects of a cognitive-behavioral training program for the management of depressive symptoms among patients in orthopedic inpatient rehabilitation of chronic low back pain: a 2-year follow-up. Eur Spine J. 2011;20(12):2143–2151. doi:10.1007/s00586-011-1810-x
- STANNARD C,Kalso E, Ballantyne J. Evidence-Based Chronic Pain Management. John Wiley & Sons. BMJ Books 2011
- HAWKES C., Endorphins: the basis of pleasure?, Journal of Neurology, Neurosurgery, and Psychiatry 1992;55:247-250
- AKANDERE M. , DEMIR B., The Effect of Dance over Depression, Coll. Antropol. 2011.35(3):651–656
- Boecker H, Sprenger T, Spilker ME, Henriksen G, Koppenhoefer M, Wagner KJ, Valet M, Berthele A, Tolle TR. The runner's high: opioidergic mechanisms in the human brain. Cereb Cortex. 2008 Nov;18(11):2523-31
- FISHER J.E. , HAYES S.C. Cognitive behavior therapy: applying empirically supported techniques in your practice. John Wiley and Sons, 2003 Level of evidence: D
- VAN HOOFF et al. Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management. Spine, Springer. 2010 Level of evidence: B
- GERSHWIN M.E. , HAMILTON M.E. The pain management handbook: a concise guide to diagnosis and treatment. Humana Press, 1998, chapter 8 Level of evidence: D
- BUER N., LINTON SJ., Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population, Pain 99, 485–491, 2002 Level of evidence: C
- WAND et al. Managing chronic nonspecific low back pain with a sensorimotor retraining approach: exploratory multiple-baseline study of 3 participants. American physical therapy association. 2011. pp 535-546. Level of evidence: C
- DANNEELS et al. spierreëducatie bij lage rugklachten. Vlaams Tijdschrift voor Sportgeneeskunde en Wetenschappen,pp 32-39. 1999 Level of evidence: D
- COOLS et al. conservatieve behandeling bij schouderinstabiliteit: belang van functionele neuromusculaire training. Vlaams Tijdschrift voor Sportgeneeskunde en Wetenschappen.1999. pp 16-30 Level of evidence: D
- Inspired Journey Fit. 5 Core Stability Exercises You Need to Know. Available from: https://www.youtube.com/watch?v=PI9Kvk_HMO8 (last accessed 23/08/2015)
- Steve Cutler. PNF Core stability exercises. Available from https://www.youtube.com/watch?v=TMHgfqOUG8E (last accessed 23/08/2015
- MMA Surge. 5 Simple Exercises that Strengthen Your Lower Back. Accessed from https://www.youtube.com/watch?v=WDiHXt22jek (last accessed 23/08/2015)
- GATCHEL RJ. ET AL., Evidence-informed management of chronic low back pain with cognitive behavioral therapy, The Spine Journal 8 , 40–44, 2008 Level of evidence: B