Chronic Low Back Pain

Original Editors - Bryan Jacobson, Tori Westcott, Ashley Bohanan, Alisha Lopez

Lead Authors -

Search Strategy

Pubmed, Web of Science, Pedro

Description/Description

Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. Low back pain that has been present for longer than three months is considered chronic, although there is still no consensus about the definition of CLBP. Specific causes of LBP are uncommon, and in approximately 90% of patients a specific generator cannot be identified with certainty. (1) More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one 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 (31).

Chronic low back pain (CLBP) has been associated with neurochemical, structural, and functional cortical changes (28) of several brain regions including the somatosensory cortex. (3) Complex processes of peripheral and central sensitization may influence the evolution of acute to chronic pain. (4)

Clinically Relevant Anatomy

The lumbar region is situated under the thoracic region of the spine. The lower back consists of five vertebrae (L1- L5). It has a slight inward curve known as lordosis. The fifth lumbar vertebrae is connected with the top of the sacrum. The vertebrae of the lumbar spine are connected in the back by facet joints, which allow for forward and backward extension, as well as twisting movements.The two lowest segments in the lumbar spine, L5-S1 and L4-L5, carry the most weight and have the most movement, this makes the area prone to injury. In between vertebrae are spinal discs, they provide support. Discs in the lumbar region of the spine are most likely to herniate or degenerate, which can cause pain in the lower back, or radiating pain to the legs and feet. The spinal cord travels from the base of the skull to the joint at T12-L1, where the thoracic spine meets the lumbar spine. At this segment, nerve roots branch out from the spinal cord, forming the cauda equina. Some lower back conditions may compress these nerve roots, resulting in pain that radiates to the lower extremities, known as radiculopathy. The lower back region also contains large muscles that support the back and allow for movement in the trunk of the body. These muscles can spasm or become strained, which is a common cause of lower back pain. (Prometheus)

Epidemiology /Etiology

5-10% of all low back pain patients will develop CLBP. CLBP prevalence rates are lower in individuals aged 20-30 years, increasing from the third decade of life, and reaching the highest prevalence between 50-60 years. However the prevalence rates stabilize in the seventh decade of life. There’s no difference in CLBP prevalence at different periods of the year or in different places.(38)
There is higher CLBP prevalence in females, people of lower economic status, people with less schooling and smokers. There’s indication that prevalence has doubled over time. This may be due to important changes in lifestyle (obesity) and in the work industry. Factors as a family history of disabling back pain, radiating pain, advice to rest upon back pain consultation, occupational LBP or LBP caused by traffic injury are all associated with chronic disabling back pain over lifetime.(39) Job satisfaction and psychosocial factors also play a role in the development of CLBP.(40)
Musculoskeletal disorders are a comorbid condition strongly linked to CLBP. A moderate association was found when considering the whole musculoskeletal chapter, a stronger association was found when considering the somatoform symptoms related to the musculoskeletal cluster. (41)

In patients with low back pain (LBP), alterations in fiber typing in Multifidus and erector spinae are assumed to be possible factors in the etiology and/or recurrence of pain symptoms as it negatively affects muscle strength and endurance. In case of the latter, type I fibers have been argued to be more affected by pain and immobilization than type II fibers. (4)

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.

The diagnostic process is mainly focused on the triage of patients with specific or non-specific low back pain. This triage is focused on identification of “red flags” as indicators of possible underlying serious pathology.

"Red Flags":

Onset age < 20 or > 55 years,(Level of evidence: 1B) Non-mechanical pain (unrelated to time or activity)(Level of evidence: 2B) Thoracic pain Previous history of carcinoma, steroids, HIV  Feeling unwell ,(Level of evidence: 2B) Weight loss  Widespread neurological symptoms  Structural spinal deformity  Saddle anesthesia (Cauda equina syndrome)  Recent onset of bladder dysfunction (Cauda equina syndrome)

Examination

Research has shown that the patient history and biopsychosocial evaluation are crucial to establish chronic LBP. Patient history and self-report forms help rule out serious pathologies such as cauda equina, ankylosing spondylitis, 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 LBP by eliminating other pathologies or mechanisms 

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 inherent risks that occur with each spinal surgery, particularly spinal fusions. These risks include: increased chance of blood transfusion, post-operative 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 LBP 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." .

A team is therefore needed to address all the extraneous effects that are produced by living with chronic LBP from months to years. Psychologists, physicians, physical therapists 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 be working together to address the impairments produced by the chronic pain.

Medical Management

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 LBP.  A recent systematic review found that there is evidence of moderate quality indicating that there is no difference in pain relief between anti-depressants and placebo for patients with chronic LBP .  Depression is common in patients with chronic low back pain and should be treated appropriately.

• Other medications: Skeletal muscle relaxants, benzodiazepines, and anti-epileptic medications are not recommended because of the insufficient evidence towards their effectiveness for chronic low back pain.

Behavioural Therapy: Evidence has shown the behavioural therapy has a positive effect on pain intensity, functional status and behavior in patients with chronic LBP. There are three approaches to behavioural 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 patients with chronic low back pain. Basic Cognitive-Behavioral Methods Appendix

Graded exposure is a behavioural treatment recommended for patients with chronic pain and high fear-avoidance behaviours. 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 LBP threatens self-identity because 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 LBP. 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.

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 . 

Physical Therapy Management

Intervention:

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.

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..

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

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

Modalities: Electrical nerve stimulation (TENS and interferential current), 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

Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain, Bill Garcia, Evidence in Motion, OMPT Fellowship, 2009

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 .

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1BcJI_Rc2aEi3U-Hu0edSrEmVRf8N867FGIQ782WaBlnpeUUDA|charset=UTF-8|short|max=10: Error parsing XML for RSS

Presentations

Management of the Chronic Low Back Pain This presentation, created by Joseph Eissler, Charles Ferran, Tanner Fields, and David Davis; Texas State DPT Class. Management of the Chronic Low Back Pain / View the presentation

Multidisciplinary Management of the Chronic Low Back Pain Patient This presentation, created by Lysette Burato, Jessica Charlton, Zach McClung, Kirk Michalec as part of the Texas State University Evidence-based Practice projects for PT7539 Ortho Spine course, discusses the current best evidence for multidisciplinary management of patients with chronic low back pain. Multidisciplinary Management of the Chronic Low Back Pain Patient / View the presentation

Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain This presentation, created by Bill Garcia, as part of the 2009 Regis University OMPT Fellowship, discusses current evidence for Cognitive Behavioural Therapy in the management of chronic low back pain. Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain/ View the presentation

Exercise for Low Back Pain: Where Do We Stand? This presentation, created by Jason Steere, as part of the 2011 Evidence in Motion Fellowship, discusses the current best evidence for exercise in the management of low back pain. Exercise for Low Back Pain: Where Do We Stand?/ View the presentation

Low Back Pain and Pelvic Floor Disorders This presentation, created by Ashley Aikman, Delesa Monroe, Ashley Trotter, Michael Landin, as part of the Texas State University Evidence-based Practice projects for PT7539 Ortho Spine course, discusses the the relationship between pelvic floor disorders and low back pain. Low Back Pain and Pelvic Floor Disorders / View the presentation