Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine

Original Editor - Stacy Schiurring based on the course by Ziya Altug
Top Contributors - Stacy Schiurring, Tarina van der Stockt, Kim Jackson, Rucha Gadgil, Lucinda hampton and Jess Bell

Introduction[edit | edit source]

Evidence-Based Practice

When practising physiotherapy, there are many correct ways to treat a condition. Clinical expertise in the field comes from knowing when to use one technique over another based on your assessment of the patient in front of you. It is important for each clinician to use evidence-based and supported judgement when selecting interventions for an individual. When doing a literature review, it is also important to use the highest quality of research available. [1]

The aim of this article is to provide an introduction to the treatment of chronic low back pain (LBP) using integrative lifestyle medicine.  

Chronic LBP[edit | edit source]

Chronic pain is defined as pain that occurs most days or every day over a continuous period of at least 3 months.[2] According to the American College of Sports Medicine, LBP “is considered a major public health problem with the lifetime prevalence reported as high as 84%.” [1][3] According to a 2019 article published in The Journal of Pain, 10.6 million people or approximately 4.8% of the adult population in the United States have experienced chronic pain.[2]

As healthcare providers, physiotherapists should learn more about managing LBP. A 2019 systematic review sites the following burdens and costs of chronic LBP:[4]

  1. On individuals: decreased quality of life and ability to participate in activities of daily living and leisure.
  2. On employers: increased absenteeism and decreased work productivity.
  3. On society: increased demands on an already burdened healthcare system.

The video below provides information on the prevalence of LBP in North America. It lends support to physiotherapy assessment and treatment of LBP, and illustrates the need for holistic management of chronic LBP which will be discussed in more detail in the next section of this article.

[5]

Lifestyle Medicine[edit | edit source]

A 2012 survey by the National Center of Complementary and Integrative Health found that 30% of adult Americans use health care approaches that have origins outside of western conventional medicine.[6] Given this information, it is important for a well-rounded therapist to have many different effective treatment options that take into account a patient’s values and beliefs.

Integrative health attempts to bring the benefits of both conventional and complementary medicine together in a way that provides whole-person care.  It often combines conventional western medicine with lifestyle changes, physical rehabilitation, psychotherapy, and complementary health.[6]

What is whole person health? “Whole person health refers to helping individuals improve and restore their health in multiple interconnected domains—biological, behavioral, social, environmental—rather than just treating disease. Research on whole person health includes expanding the understanding of the connections between these various aspects of health, including connections between organs and body systems.”[6]

Lifestyle Medicine

Lifestyle Medicine  combines the modern western practice of medicine with evidence-based lifestyle therapeutic approaches to prevent and reverse lifestyle-related chronic illness.  Examples of lifestyle practices include: [6][7]

  • Nutritional: Whole-food and plant-based diet, dietary supplements, probiotics
  • Physical: Regular physical activity, acupuncture, massage, adequate sleep
  • Psychological: meditation, hypnosis, music therapy, relaxation techniques
  • Combination of the above: yoga, tai chi, dance therapy, art therapy.


Lifestyle medicine encourages clinicians and patients to work together to uncover root causes of medical conditions, by treating the root cause of an impairment long-term improvements can be achieved.[1]

Multimodal Treatment Approach[edit | edit source]

The biopsychosocial model of pain acknowledges and takes into consideration that pain is influenced by multiple factors: biological/physiological, psychological, behavioural, and socio-economical/-environmental/-cultural.  This model is often used with chronic pain and can help guide physiotherapy evaluation and treatments to include multimodal approaches to treat the whole person.[1] 

OPTIONS TO CONSIDER FIRST FOR LBP
For back pain lasting less than 12 weeks,

consider the following options:

For back pain lasting greater than 12 weeks,

consider the following options:

  • Acupuncture
  • Massage
  • Superficial heat
  • Spinal manipulation
  • Acupuncture
  • Cognitive behavioural therapy
  • Electromyographic biofeedback
  • Exercise program
  • Low level laser therapy
  • Mindfulness-based stress reduction
  • Motor control exercises
  • Multidisciplinary rehabilitation
  • Progressive relaxation
  • Spinal manipulation
  • Tai chi
  • Yoga

This table, adapted from the Journal of the American Medical Association (JAMA) in July 2021 lists treatment options for acute versus chronic LBP and illustrates the multiple treatment options available for both complex types of pain.

LIfestyle Factors

The following lifestyle factors have been found to contribute to chronic LBP:

  1. Obesity [8][9]
  2. Post Traumatic Stress Disorder and depression [10]
  3. Smoking [11]
  4. Alcohol consumption (in persons with alcohol consumption dependence) [12]
  5. Sedentary lifestyle [13]
  6. Exposure to heavy lifting loads [14]

Clinician Strategies to Complement the Lifestyle Medicine Approach[edit | edit source]

  1. Build a therapeutic alliance with our patients: for example use of voice to provide comfort and choose words that are positive and encouraging. [15][16]
  2. Include patients in decision-making process for their treatments [17]
  3. Improve interprofessional collaborations with physicians, occupational therapists, dietitians, yoga professionals [18]
  4. Utilise motivational interviewing techniques [19]
    1. Open-ended questions
    2. Acknowledge and praise good intentions and efforts
    3. Use reflective listening
    4. Summarise the person’s situation
    5. Inform and advise the person
  5. Optimise clinic design: for example, bring nature into the building with views through windows which provide natural light, living plants, use of soothing colours like green calm background music, tranquil art, and comfortable furniture in waiting areas. [20][21]

This video provides an example of how simple verbal and visual cues can guide a person through a diaphragmatic deep breathing exercise. Please note how the speaker uses a calm even voice and the colours are gentle and muted, this helps to set the tone of this relaxation prompt. A video such as this would be an excellent part of a home exercise program.

[22]

Conclusion[edit | edit source]

It is important for physiotherapists to have well-rounded approaches to treating chronic LBP due to its high prevalence and effect on a patient’s quality of life.  Integrative lifestyle medicine attempts to treat the whole person and provide a more holistic quality of care than traditional western medicine alone. This style of medicine requires the clinician to involve the patient in their care and explore all aspects of their daily life to identify the root cause of their chronic pain and it encourages the physiotherapist to reach out to other disciplines to provide well-rounded treatment to the patient.

Resources[edit | edit source]

Please read a recently published journal article on this topic by Dr Ziya Altug.[23]

Please listen to this recording of Dr Andrew Weil and Dr Deepak Chopra as they discuss the art and science of the breath.[24]

Organisational Websites:

Related Physiopedia Pages:

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Altug Z, Introduction to Integrative Lifestyle Medicine.  Physioplus. November 2021.
  2. 2.0 2.1 Pitcher, M.H., Von Korff, M., Bushnell, M.C. and Porter, L., 2019. Prevalence and profile of high-impact chronic pain in the United States. The Journal of Pain, 20(2), pp.146-160.
  3. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription, 11th ed. Philadelphia, PA: Wolters Kluwer; 2022: 172.
  4. Buruck G, Tomaschek A, Wendsche J, Ochsmann E, Dörfel D. Psychosocial areas of worklife and chronic low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):480.
  5. TEDx Talks. Low Back Pain: Myths vs. Facts | Sid Anandkumar. Available from: https://www.youtube.com/watch?v=ErmOTERAnQo [last accessed 03/12/2021]
  6. 6.0 6.1 6.2 6.3 National Center for Complementary and Integrative Health. Integrative Health. Available from: https://nccih.nih.gov/health/integrative-health (accessed 30 Nov 2021).
  7. Rippe JM, ed. Lifestyle Medicine, 3rd ed. Boca Raton, FL: CRC Press; 2019: xiv.
  8. Heuch I, Heuch I, Hagen K, Zwart JA. Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trøndelag Health Study. Spine (Phila Pa 1976). 2013;38(2):133-139.
  9. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol. 2010;171(2):135-154.
  10. Suri P, Boyko EJ, Smith NL, et al. Modifiable risk factors for chronic back pain: insights using the co-twin control design. Spine J. 2017;17(1):4-14.
  11. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123(1):87.e7-35.
  12. Ferreira PH, Pinheiro MB, Machado GC, Ferreira ML. Is alcohol intake associated with low back pain? A systematic review of observational studies. Man Ther. 2013;18(3):183-190.
  13. Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation?. Pain. 2009;143(1-2):21-25.
  14. Coenen P, Gouttebarge V, van der Burght AS, et al. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med. 2014;71(12):871-877.
  15. Alodaibi F, Beneciuk J, Holmes R, Kareha S, Hayes D, Fritz J. The relationship of the therapeutic alliance to patient characteristics and functional outcome during an episode of physical therapy care for patients with low back pain: an observational study. Phys Ther. 2021;101(4):pzab026.
  16. Unsgaard-Tøndel M, Søderstrøm S. Therapeutic alliance: patients' expectations before and experiences after physical therapy for low back pain-a qualitative study with six months follow-up [published online ahead of print, 2021 Aug 2]. Phys Ther. 2021;pzab187.
  17. Coronado-Vázquez V, Canet-Fajas C, Delgado-Marroquín MT, Magallón-Botaya R, Romero-Martín M, Gómez-Salgado J. Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review. Medicine (Baltimore). 2020;99(32):e21389.
  18. Perreault K, Dionne CE, Rossignol M, Morin D. Interprofessional practices of physiotherapists working with adults with low back pain in Québec's private sector: results of a qualitative study. BMC Musculoskelet Disord. 2014;15:160.
  19. Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011;92(2):176-183.
  20. Rehn J, Schuster K. Clinic design as placebo-using design to promote healing and support treatments. Behav Sci (Basel). 2017 Nov 9;7(4):77.
  21. Wiercioch-Kuzianik K, Bąbel P. Color hurts. the effect of colour on pain perception. Pain Med. 2019;20(10):1955-1962.
  22. Hands on Mediation. 4-7-8 Calm Breathing Exercise - Relaxing Breath Technique. Available from: https://www.youtube.com/watch?v=1Dv-ldGLnIY [last accessed 02/12/20021]
  23. Altug, Z., 2021. Lifestyle Medicine for Chronic Lower Back Pain: An Evidence-Based Approach. American Journal of Lifestyle Medicine, 15(4), pp.425-433.
  24. Youtube. The Art and Science of Breath with Dr. Andrew Weil. Available from: https://www.youtube.com/watch?v=HniejvYdUh0 [last accessed 02/12/2021]