Chronic low back pain: Progress in therapy

Low back pain is a common complaint in the primary care setting. Although most patients with acute low back pain will improve with conservative treatment, back pain often recurs, and a subset of patients will progress to chronic and sometimes disabling symptoms. A variety of treatments have been used for chronic low back pain; the best evidence supports intensive rehabilitation programs that include tailored exercise therapy in conjunction with cognitive behavioral interventions and education. The benefit of medications, including nonsteroidal anti-inflammatory drugs, analgesics, and possibly antidepressants or muscle relaxants, must be weighed against potential adverse effects. There is insufficient evidence regarding the effectiveness of many of the available therapies for chronic low back pain, and well-designed, randomized controlled trials are needed to clarify the role of these treatments.     

Experts' opinions on complementary/alternative therapies for low back pain

BACKGROUND: Complementary/alternative therapies are used for low back pain more frequently than for any other indication, yet evidence for or against their efficacy is fragmentary. Notwithstanding this void, the high prevalence of such therapies drives their integration into our health care systems. Expert opinions on the use of complementary/alternative therapies for low back pain could therefore be helpful until more data from randomized, controlled trials become available. OBJECTIVE: A postal questionnaire survey was designed to generate opinion from a systematically identified expert panel on the clinical effectiveness of complementary/alternative therapies for low back pain. METHODS: Computerized searches were conducted to systematically identify by objective criteria 50 clinical experts on low back pain. Each panel member received a questionnaire to assess the perceived clinical effectiveness of complementary/alternative therapies for 4 defined categories of low back pain. RESULTS: For acute uncomplicated low back pain, osteopathy and chiropractic were rated as effective by most experts. For chronic uncomplicated low back pain, most experts considered acupuncture as effective. Experts perceived homeopathy generally as ineffective for any type of low back pain. Clinical experience with herbalism as a treatment for low back pain was insufficient to form an opinion. CONCLUSION: Experts' opinion is in favor of the effectiveness of osteopathy and chiropractic for acute uncomplicated low back pain. Acupuncture is judged to be of some value for chronic, uncomplicated low back pain. Homeopathy is perceived as ineffective for any type of low back pain. Insufficient experience with herbalism as a treatment for low back pain prevents firm conclusions.     

Patient Willingness to Pay for Reductions in Chronic Low Back Pain and Chronic Neck Pain

Many recommended nonpharmacologic therapies for patients with chronic spinal pain require visits to providers such as acupuncturists and chiropractors. Little information is available to inform third-party payers’ coverage policies regarding ongoing use of these therapies. This study offers contingent valuation-based estimates of patient willingness to pay (WTP) for pain reductions from a large (n = 1,583) sample of patients using ongoing chiropractic care to manage their chronic low back and neck pain. Average WTP estimates were $45.98 (45.8) per month per 1-point reduction in current pain for chronic low back pain and $37.32 (38.0) for chronic neck pain. These estimates met a variety of validity checks including that individuals’ values define a downward-sloping demand curve for these services. Comparing these WTP estimates with patients’ actual use of chiropractic care over the next 3 months indicates that these patients are likely “buying” perceived pain reductions from what they believe their pain would have been if they didn't see their chiropractor—that is, they value maintenance of their current mild pain levels. These results provide some evidence for copay levels and their relationship to patient demand, but call into question ongoing coverage policies that require the documentation of continued improvement or of experienced clinical deterioration with treatment withdrawal.PerspectiveThis study provides estimates of reported WTP for pain reduction from a large sample of patients using chiropractic care to manage their chronic spinal pain and compares these estimates to what these patients do for care over the next 3 months, to inform coverage policies for ongoing care.     

Spinal cord stimulation in pain management: a review

Spinal cord stimulation has become a widely used and efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. This technique is likely to possess a savings in costs compared with alternative therapy strategies despite its high initial cost. Spinal cord stimulation continues to be a valuable tool in the treatment of chronic disabling pain.     

“The failed back surgery syndrome”: Definition and therapeutic algorithms – An update

Approximately 30% of patients experience persistent or recurrent low back and/or pain projecting into the legs following technically adequate lumbosacral surgery. Such pain conditions are often alluded to as the failed back surgery syndrome (FBSS). FBSS represents a significant clinical and economic concern. The treatment of FBSS presents a challenge to physicians, as conservative therapies and spinal reoperations are often unsuccessful – if not a significant cause (besides fibrosis) of the persistent pain syndrome is found at the post-operative examinations. Neuropathic pain radiating into the leg(s) is often the main component of this persistent and disabling syndrome. In this case, spinal cord stimulation (SCS) has been shown to be a successful therapeutic option. Studies have demonstrated that up to 60% of implanted patients experience 50% or more pain relief following SCS. Moreover, SCS has been shown to improve both quality of life and functional status in a significant number of patients. In order to address the challenge of managing both chronic back and leg pain, a multidisciplinary group of physicians experienced in pain management and spinal surgery assembled to discuss and formulate a treatment strategy for FBSS, based on a systematic review of the literature that focused on the role of SCS. The outcome of these discussions however remained unpublished why an update, taking into account also the moderns technologies has been performed.The development of new treatment algorithms should allow, easier, more rational and effective management of this common and clinically – as well as economically – important problem.     

Structure quality in outpatient care of chronic pain patients

BACKGROUND: Outcome quality of medical treatment depends on structure quality of the treatment facility. In the present study we tried evaluate structural parameters of outpatient treatment facilities relating to management of headache, low back pain and cancer pain. METHODS: 109 outpatient treatment facilities (104 offices, 3 outpatient departments of hospitals, 2 pain ambulances of hospitals) in middle franconia, one of the larger Bavarian administrative division (population: 1,6 Mio.), have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung"). RESULTS: Only one treatment facility worked within an interdisciplinary setting. Less than 25% (median) of total patients of an outpatient treatment facility suffered from acute or chronic headache, low back pain or cancer pain. 38% of physicians participated regularly on pain conferences. Established methods for diagnosis and documentation of patients suffering from chronic headache, chronic back pain and cancer pain were regularly used by 16%, 12% and 10% of physicians, respectively. Regular interdisciplinary cooperation in the management of patients with chronic headache, chronic back pain and cancer pain was indicated by 28%, 24% and 41% of physicians, respectively. However, personal discussion of patient related problems took place in less than 5% of physicians. Although a considerable number of different therapies (included as standard therapy for outpatient management of chronic pain in the "Schmerztherapievereinbarung") can be applied in each outpatient treatment facility (median:5), psychological therapy for management of chronic headache, chronic back pain and cancer pain was used regularly by 5%, 2% and 7% of physicians, respectively. Scoring of all examined structural parameters provides a measure for the quality of the parameters of a certain outpatient treatment facility as compared to that of an optimal outpatient facility for pain treatment (quality score=100%). However, 75% of examined outpatient treatment facilities reached quality scores only up to 43%. CONCLUSIONS: There are considerable structural deficits in outpatient treatment facilities involved in management of patients suffering from chronic headache, chronic back pain and cancer pain. Realisation of standards according to the "Schmerztherapievereinbarung" needs organisation of an interdisciplinary network between the different specialties necessary for pain management. Interdisciplinary cooperation should be supported by the official organization of the medical self-government in Germany--the Kassen?rztliche Vereinigung--which has to assure optimal conditions for outpatient treatments.     

Multimodale Therapie bei chronischem HWS- und LWS-Schmerz

BACKGROUND: Multimodal therapy has been established for patients with chronic low back pain, but studies reporting results in patients with chronic neck pain are rare. METHODS: This prospective clinical study compared the results in 97 patients with chronic cervical pain and 231 patients with chronic lumbar pain after three weeks of multimodal therapy. The following factors were analyzed in both groups at the beginning and after 6 months: ability to work, pain intensity and functional back capacity. RESULTS: Both groups had improved significantly after 6 months in all outcome parameters. Functional back capacity and ability to work at 6 months were not different between the two groups, but pain intensity was significantly lower in patients with low back pain compared to patients with neck pain. CONCLUSION: Multimodal therapy is also an efficient treatment strategy for patients with chronic cervical pain as has already been shown for patients with chronic lumbar pain.     

Komorbidität bei Patienten mit chronischen Rückenschmerzen

BACKGROUND: Studies concerning comorbidity in patients with chronic low back pain and its correlation to the stage of chronification are rare. METHODS: This case-control study (matched-pair analysis) examines the number and specificity of comorbidity as well as the extent of disability due to comorbidity in 51 patients with chronic low back pain compared to age- and sex-matched control persons. Moreover, the correlation of comorbidity and the stage of chronification was analysed in these patients. RESULTS: Patients with chronic low back pain had significantly more comorbidities and a higher disability due to comorbidity compared to the control persons. The higher the stage of chronification according to the Mainz Pain Staging System (MPSS) the higher was the number of comorbidities. CONCLUSION: Comorbidity should be given due consideration when evaluating diagnosis, therapy, prognosis and therapy outcome in patients with chronic low back pain.     

Conservative management of low back pain. An evaluation of current methods

The overwhelming majority of patients with low back pain recover, most of them within 6 to 12 weeks. Those who do not, however, represent a major challenge to physicians, who need to choose from among the many therapies for low back pain that have been advocated but in many cases not proven. For those with chronic low back pain, a functional restoration program and a multidisciplinary pain management program may prove effective.     

Multimodale Verfahren – auf die Mischung kommt es an!

In the last 50 years conventional treatments have not been able to slow down the expanding chronic low back pain problem. However, nowadays health care has changed according to a broad biopsychosocial model of health, the positive effect of activity on health and healing, emphasis on function rather than pain or impairment, and reliance upon clinical evidence. In search for new solutions "functional restoration" (FR) programs have been developed. They include multidisciplinary treatment of patients in groups, consisting of 6-8 h of treatment a day, lasting 3 to 6 weeks and usually integrating intense physical and ergonomic training, psychological (behavioral) therapy, patient education, and instruction in social- and work-related issues. FR programs have yet to demonstrate their effectiveness in several countries. Controlled studies in the USA were very positive regarding the return-to-work rate, whereas studies in Scandinavian countries did not demonstrate similar results. Possible reasons for the different results concerning back-to-work ratios might be that study design, patient population, content of the program, and other external factors are different and studies as well as effects are therefore not directly comparable. According to several well-controlled studies, the most probable reason for this different effect may be that social and security (health care) systems and cultures differ among countries and that patients with chronic low back pain respond differently to this combination. Sick absenteeism and inability to work may be influenced by many factors besides pain that cannot be addressed by intervention or prevention programs, e.g., job satisfaction, education level, and the compensation systems. It may be that the lower economic benefit during sick leave in the United States leads to favorable results from functional restoration programs. Concerning the prediction of success, several studies have shown that medical background, diagnosis and physical impairment as well as physical variables (mobility, strength) have limited predictive value. Return to work and pain reduction are much better predicted by length of absence from work, application for pension, and the patients' disability in daily-life activities. In the last five years another important variable of success has been identified: avoidance behavior has been suspected to be a major contributor to the initiation and maintenance of chronic low back pain. The perpetuation of avoidance behavior beyond normal healing time subsequently leads to negative consequences such as "disuse syndrome", which is associated with physical deconditioning, sick role behavior, psychosocial withdrawal and negative affect. Accordingly, fear-avoidance beliefs were strongly related to absenteeism from work due to back pain and were the best predictors of therapy outcome in 300 acute low back pain patients. In a prospective study on 87 patients with chronic low back pain (CLBP) we demonstrated that fear-avoidance beliefs were the strongest predictors of return to work after a functional restoration treatment program. Although nonspecific mechanisms such as emotional disturbance, helplessness, pain anticipation, disability, and job circumstances could be identified as influencing the chronic pain process, we have to remember that long-lasting experience of pain is usually a very individual process in which several conditions may work together in a unique combination. Treatment procedures must consider this variability by focusing on general mechanisms, as well as on individual conditions and deficits. FR treatment strongly depends on behavioral principles that rule the whole therapeutic process: Adequate information is necessary to overcome unhelpful beliefs; information has to be related to the patients' daily experiences and their mental capability to understand them. Pacing, goal-setting, graded exposure with exercise quotas and permanent feedback as well as contingent motivation characterize the training procedures. Training procedures must incorporate the patients' daily activities early on. The patients' efficacy expectations are the most potent determinants of change in the training process. Exacerbation of pain is not taken as a failure of the therapeutic concept, but as a challenge to self-management. However, the important principle in managing chronic low back pain is "treating patients rather than spines."     

Clinical reasoning for manual therapy management of tension type and cervicogenic headache

In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.     

Psychosocial risks for disability in children with chronic back pain.

Psychosocial factors related to disability in adults with chronic back pain have been well studied, but little is known about factors associated with functional impairment in pediatric patients with chronic back pain. The purpose of this study was to examine whether 2 potential risk factors-use of catastrophizing as a coping technique and presence of a familial pain history-were associated with disability in pediatric back pain patients. Participants were 65 patients (ages 8-18) with chronic back pain seen at a multidisciplinary pain clinic. Patients completed measures of pain (visual analog scales), disability (Functional Disability Inventory), and catastrophizing (Internalizing/Catastrophizing subscale of the Pain Coping Questionnaire). Parents provided demographic information and familial pain history. Patients reported that chronic back pain caused disruptions in their daily functioning and they missed, on average, 2.5 days of school every month. Catastrophizing and familial chronic pain history both were significantly associated with greater disability, with use of catastrophizing being the stronger predictor of disability. This study presents important findings on potential psychosocial risk factors of functional disability in children and adolescents with chronic back pain. Future research might clarify mechanisms by which such coping styles are developed and explore how familial communication about pain might influence a child's coping ability. PERSPECTIVE: Pediatric patients seeking treatment for chronic back pain often present with substantial functional impairment that is not well explained by disease variables or pain intensity. Two important psychosocial variables (catastrophizing and familial pain history) may provide a context for a better understanding of pain-related disability in children.     

Multimodal, polypragmatisch und kostenintensiv

There are many therapies for low back pain, from simple interventions up to complex surgical procedures and multimodal therapy programs. But what does the medical evidence say? Are expensive therapies worth the money they cost? This review gives an overview of frequently used interventions and complex therapy programs and as far as possible the medical evidence and costs. Reviewing the scientific evidence the need for early interdisciplinary multimodal diagnostics in patients with chronic low back pain becomes evident. Single interventions are often not indicated. Further research is needed to define subgroups for special treatment programs. Radiography, interventional pain therapies, and operations should be used with great care.     

Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms.

For years enhancement of a patient's level of physical fitness has been an important goal in rehabilitation treatment in chronic low back pain (CLBP), based on the hypothesis that physical deconditioning contributes to the chronicity of low back pain. However, whether this hypothesis in CLBP holds is not clear. In this paper, possible mechanisms that contribute to the development of physical deconditioning in CLBP, such as avoidance behaviour and suppressive behaviour, are discussed. The presence of both deconditioning-related physiological changes, such as muscle atrophy, changes in metabolism, osteoporosis and obesity as well as deconditioning related functional changes, such as a decrease in cardiovascular capacity, a decrease in muscle strength and impaired motor control in patients with CLBP are discussed. Results of studies on the level of physical activities in daily life (PAL) and the level of physical fitness in patients with CLBP compared to healthy controls were reviewed. In studies on PAL results that were either lower or comparable to healthy subjects were found. The presence of disuse (i.e., a decrease in the level of physical activities in daily life) in patients with CLBP was not confirmed. The inconclusive findings in the papers reviewed may partly be explained by different measurement methods used in research on PAL in chronic pain. The level of physical fitness of CLBP patients also appeared to be lower or comparable to the fitness level of healthy persons. A discriminating factor between fit and unfit patients with back pain may be the fact that fit persons more frequently are still employed, and as such may be involved more in physical activity. Lastly some suggestions are made for further research in the field of disuse and deconditioning in CLBP.     

Symptoms of impairment, disability and handicap in low back pain: a taxonomy.

The functional consequences on everyday living which result from chronic low back pain commonly require services which are difficult to access. This deficiency in meeting the needs of these patients is partially explained by inadequacies in clinical assessment. Medical evaluation may be exhaustive, but frequently the assessment of physical and psycho-social dysfunction at the personal and family level is inadequate. In low back pain, as with most chronic ailments, there is no agreed-upon taxonomy of the functional consequences of the disorder upon which to establish a comprehensive clinical appraisal. In this paper a taxonomy is presented for the impairments, disabilities and handicaps which result from chronic low back pain. The taxonomy has been based on data from a survey of 74 individuals with low back pain and is structured generally according to the International Classification of Impairments, Disabilities and Handicaps (WHO 1980). The taxonomy is proposed as a conceptual framework and vocabulary for both clinical practice and research. The taxonomy is not a measurement instrument nor does it indicate the frequency of occurrence of disabilities. A classification is basic to the advancement of scientific understanding, and usage of a standard vocabulary such as this plays an important role in establishing a responsive health service capable of meeting the needs of the population with chronic low back pain.     

Trunk muscle recruitment patterns in specific chronic low back pain populations

BACKGROUND: It is hypothesized that injury or degeneration of osteoligamentous spinal structures would require compensation by trunk musculature and alterations in motor control to maintain spine stability. While, biomechanical modeling has supported this hypothesis, studies of muscle recruitment patterns in chronic low back pain patients both with and without significant osteoligamentous damage have been limited. This study utilized a non-randomized case-control design to investigate trunk muscle recruitment patterns around the neutral spine position between subgroups of patients with chronic mechanical low back pain and asymptomatic controls. METHODS: Twenty subjects with chronic low back pain attributed to clinical lumbar instability were matched to 20 asymptomatic controls. In addition 12 patients with non-specific chronic low back pain were studied. Surface EMG from five trunk muscles was analyzed to determine activation levels and patterns of recruitment during a standing reach under two different loading conditions. FINDINGS: The chronic low back pain group with symptoms attributed to clinical instability demonstrated significantly higher activation levels of the external oblique and rectus abdominus muscles and lower abdominal synergist ratios than the control group. No significant differences were found between patient subgroups. INTERPRETATION: While these data demonstrate altered muscle recruitment patterns in patients with chronic low back pain, the changes are not consistent with Panjabi's theory suggesting that these alterations are driven by passive subsystem damage. However, the higher activation of global abdominal musculature and altered synergist patterns may represent a motor control pattern that has consequences for continued dysfunction and chronic pain.     

Modafinil for the treatment of pain-associated fatigue: review and case report

Fatigue is a symptom that is frequently found in chronic pain patients with low back pain and/or neck pain. At the present time, no specific psychopharmacological treatment for this problem has been identified. Modafinil is a wakefulness-promoting agent that the FDA has approved for the treatment of excessive daytime sleepiness associated with narcolepsy. There have been reports on the use of modafinil for the treatment of fatigue in various neurological syndromes. This literature is reviewed. As such, modafinil treatment was initiated for a patient with severe fatigue associated with chronic low back pain and neck pain. There was dramatic improvement in fatigue and associated function. This case is described. It is the first such case report in the literature. The significance of this finding to the treatment of pain-associated fatigue is discussed.     

Perceived Short- and Long-Term Effects of Bereavement Support Group Participation at the Hospice of Petaluma

Fatigue is a symptom that is frequently found in chronic pain patients with low back pain and/or neck pain. At the present time, no specific psychopharmacological treatment for this problem has been identified. Modafinil is a wakefulness-promoting agent that the FDA has approved for the treatment of excessive daytime sleepiness associated with narcolepsy. There have been reports on the use of modafinil for the treatment of fatigue in various neurological syndromes. This literature is reviewed. As such, modafinil treatment was initiated for a patient with severe fatigue associated with chronic low back pain and neck pain. There was dramatic improvement in fatigue and associated function. This case is described. It is the first such case report in the literature. The significance of this finding to the treatment of pain-associated fatigue is discussed.