Management of chronic low back pain
With Dr Andreas Kopf | 9 Mar 2015 | Print
Dr Andreas Kopf is professor of clinical physiology, University of Nairobi, Kenya, and Director of the Pain Clinic, Charité University Medicine Berlin, Campus Benjamin Franklin, Germany.
A European survey found that between 12 and 30% of the population have chronic pain of six months’ or greater duration. Low back pain is the most common chronic pain syndrome and accounts for high direct and indirect costs including sick leave and early retirement. Furthermore, the impact on quality of life is high, even compared with advanced cancer patients.
To be able to identify patients as chronic pain patients, it is essential to understand the characteristics of this particular patient group. The International Association for the Study of Pain (IASP) provides a widely used definition for chronic pain as pain without apparent biological value that has persisted beyond the normal tissue healing time, usually taken to be three months. The literature has traditionally distinguished between chronic pain associated with cancer, or ‘malignant pain’, and ‘non-malignant pain’; although there is little evidence relating to the somatic or psychological mechanisms involved to suggest that such a distinction is warranted. Nevertheless, in common with one another, all chronic pain patients undergo a complex experience of biological, psychological and social changes.
Whilst there is no universal ‘pain personality’ that applies to all patients, certain characteristic features of the chronic non-malignant pain patient tend to be apparent. These include:
- Tight musculature
- Limited mobility
- Lack of energy
- Changes in appetite
- Fear of re-injury/fear-avoidance beliefs.
In addition, pain may disrupt sleep and cause irritability and social withdrawal. The patient’s beliefs about their pain (such as perceived ability to control the pain) and their coping strategies are correlated with high pain intensity ratings. In addition, certain psychiatric conditions may coexist, for example hypochondriasis, depression and anxiety disorders. Treating only one aspect of this complex syndrome is therefore insufficient.
It is well understood that several risk factors predict chronicity of low back pain, such as neuroplasticity, psychiatric comorbidity and low work satisfaction. However, iatrogenic factors may also contribute, such as inappropriate recommendations for resting and misinterpretations of radiological findings. Therefore, certain red and yellow flags have been recommended to enable clinicians to determine at an early stage whether ‘malignant’ etiology and/or chronification processes may be present, although the flag classification approach has limited sensitivity and specificity. Since the GP is often the first point of contact, specific assessment schedules have also been developed for differential diagnosis in primary care.[6,7] In general, fewer than one in seven patients with back pain have a specific pain etiology.
A great variety of management options for chronic low back pain have been developed. However, only a few therapies are evidence based. In particular, the sharp increase in the use of surgical interventions, opioids and nerve blocks over recent years has been pointed out. The evidence supporting the use of surgical interventions and various types of injection therapies has to be considered as low. There is limited evidence that epidural corticosteroid injections are not significantly different from placebo for general improvement in the short term or for reduction in work disability. In addition there is moderate evidence that facet joint injections with corticosteroids are not significantly different from placebo injections for short-term pain relief and improvement of disability.
There is low evidence regarding the efficacy of pharmacological options either as single modality treatment for chronic pain, or for long-term use.[13-15] On the other hand, the positive effect of a multimodal, complex pain management program for chronic back pain combining, for example, intensive, daily biopsychosocial rehabilitation with a functional restoration approach was well documented as early as more than a decade ago.
In conclusion, opioids and interventional therapies are far from being a ‘magic bullet’ for chronic low back pain and physicians are advised to integrate such therapeutic attempts, if indicated, in a multimodal approach to avoid further chronification and disability, with emphasis on functional restoration and behavioral therapy. Since outcomes can be rather disappointing, even from multimodal treatment, prevention of pain chronification through early assessment and allocation to adequate diagnostic and treatment pathways is today’s challenge.
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