Chronic low back pain and psychosocial issues

Psychosocial factors are at least as important as biomedical factors in the onset, maintenance, and treatment of chronic low back pain. This article reviews some of the common psychosocial factors that influence the course of pain from acute to chronic status, cognitive behavioral interventions used to alter dysfunctional pain cognitions, and avoidance behaviors and the emotional distress that can accompany pain and pose barriers to recovery. The interplay of cognitive, emotional, behavioral, biomedical, and social factors is described using a fear avoidance model. Interdisciplinary pain rehabilitation is discussed as an effective option for more biopsychosocially complex patients.     

Chronic low back pain and cognitive function

Chronic low back pain can impact cognitive function. Patient can have decreased problem-solving abilities, decreased speed of information processing, and delayed memory in addition to the development of different psychological conditions. Treating chronic pain effectively can potentially reduce those negative effects and potentially improve patients' cognitive function.     

Chronic low back pain and vertebral manipulation]

OBJECTIVE: This study examined the short-term effectiveness of vertebral manipulation for treating chronic low back pain and disability. METHODS: Sixty-four patients were randomly assigned into two groups. One group received 4 true vertebral manipulations (VMG), and the other group received sham manipulations (sham-VMG) under the same conditions as for the first technique. Patients formulated assessments after the manipulations and 1 month later. RESULTS: Sixty-four patients participated in the study. Patients receiving the true manipulations showed significant improvement in pain (visual analogic scale score decrease from 71.8+/-18.11 to 49.37+/-16.78; P<0.001) and function (Oswestry scale score decrease from 15.59+/-6.03 to 12.25+/-5.69; P<0.001). Pain improvement persisted at the second month (P=0.01). The improvement was more evident in the VMG than the sham-VMG. No change in perceived disability was observed in the sham-VMG. CONCLUSION: Our study confirms the efficiency of short-term vertebral manipulation for treating chronic low back pain. The assessment of vertebral manipulation effectiveness is difficult. This manual therapy must be preceeded by a specific clinical exam performed by a trained physician.     

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.     

Chronic low back pain in traumatic lower limb amputees

OBJECTIVE: To ascertain the prevalence of back pain amongst traumatic lower limb amputees attending a regional rehabilitation centre and to determine the possible causes of back pain. DESIGN: All traumatic lower limb amputees given a semi-structured questionnaire to complete and a comparative subgroup of amputees with back pain and without back pain underwent physical examination, gait analysis, magnetic resonance scanning (MRI) and gait/standing stability analysis. SETTING: A subregional amputee rehabilitation centre. RESULTS: Transfemoral amputees were more likely to suffer from back pain (81 %) than transtibial amputees (62%) (p<0.05) and of those suffering from severe back pain, 89% and 81% also suffered from severe pain in the phantom limb and severe stump pain respectively. In two comparative subgroups of amputees there was no significant difference between back pain and pain-free groups except those with pain were more likely to have a body mass index (BMI) ratio above 50% of the recommended ratio. No difference in degeneration or disc disease between the groups on MR scans was found. Impact ground reaction forces during walking, irrespective of limb, were significantly greater (p < 0.05) in the pain-free group than in the pain group, as was walking speed. Gait asymmetry measures were similar in both groups. Centre of pressure displacement measures during standing were greater in the pain group than in the pain-free group. CONCLUSIONS: Low back pain in amputees is a significant problem equal to that of pain in the phantom limb and a biomechanical (myofascial) rather than a degenerative aetiology is suggested.     

Chronic low back pain and the reaction to repeated acute pain stimulation

Previous research has shown an interaction between chronic and acute pain behavior. Chronic low back pain (CLBP) patients seem to have a higher pain perception threshold and a lower pain tolerance than pain-free controls. The major focus is, however, on another aspect of pain behavior: habituation of the pain response after repeated stimulation. Habituation of the pain perception threshold was found for control subjects but not for CLBP patients. Inability to habituate to pain may be regarded as a risk factor in the development of CLBP.     

Chronic low back pain, depression, and attributional style

Twenty consecutive, chronic low back pain patients admitted to our pain treatment unit completed the Attributional Style Questionnaire (an instrument that detects a cognitive style that is correlated with, and that predicts, depression) and the Beck Depression Inventory. An age, sex, and education-matched group of normal subjects, a group of patients with asymptomatic essential hypertension, and a group of patients with end-stage renal disease receiving dialysis treatment served as controls. The majority of the chronic-pain and renal-dialysis patients had elevated depression scores, whereas none of the normal subjects or hypertensive patients were outside the nondepressed range. The Attributional Style scores of the pain and renal dialysis patients were significantly deviant from the normal control group, but no more so than those of the patients with hypertension. The results of this study suggest that individuals with a chronic medical condition, either symptomatic (chronic low back pain or renal disease) or asymptomatic (essential hypertension) in nature, develop an attributional style characteristic of depression. These data neither lend support nor refute the thesis that chronic pain syndromes are a variant of, or a masked, depression. Rather, this research implies that a more important question is what identifiable risk factors (for example, attributional style) predispose patients with chronic pain to develop a depressive illness.     

Work-related low back pain

Low back pain is a common problem among working adults in the United States. Occupational risk factors for low back pain include forceful lifting, bending and twisting of the trunk, whole body vibration and heavy manual labor. The initial assessment of the patient with low back pain requires obtaining an occupational history to identify risk factors in the workplace in addition to the usual inquiries and physical assessment. For those with uncomplicated low back pain, minimal use of medical tests and rapid return to limited activity are indicated. Long-term prevention of low back pain requires modification of occupational or other risk factors.     

Easing low back pain

Most of the time, low back pain does not have a serious cause. It may result from straining or “pulling” the muscles in your back or from the pressure of poor posture or overweight. Often, the pain is nearly gone in a week or so with only simple treatment methods.     

Neuropathic low back pain

In this discussion, we hope to advance a clinical approach to low back pain that is more in line with our modern understanding of neuropathic pain. We review the current understanding of normal and pathologic neuroanatomy of the lumbar spine and then outline how pathology in the different structures can lead to neuropathic pain and cause common pain patterns seen in clinical practice. We also detail the available treatments for neuropathic low back pain.