Chronic Low Back Pain
Joel M. Stevans, DC, and Robert B. Saper, MD, MPH
Overview: Chronic Low Back Pain
Low back pain (LBP), the most common type of pain in the United States, results in substantial morbidity, disability, and cost to society. Annual direct costs associated with this condition are more than $50 billion in the United States, and indirect costs (e.g., productivity) are estimated to be even greater.
The lifetime prevalence of LBP ranges between 60% and 85%; therefore, most adults will experience an episode of LBP at least once during their lifetime. LBP is the fifth most common reason for visits to primary care physicians, and it is the single most common reason that U.S. adults use complementary and alternative medicine.
Of these alternative therapies, manipulation, massage, acupuncture, and mind-body approaches such as yoga are frequently used. The prognosis for acute LBP (ALBP) is very good.
Most episodes resolve within 6 weeks, regardless of treatment given. Recurrence rates are high (20% to 35%), however, and approximately 5% to 20% of patients will go on to develop chronic LBP (CLBP),
Despite its high prevalence and substantial impact on patients, the medical system, and society, back pain remains poorly understood, with relatively little consensus on optimal treatment.
An integrative approach, in which the evidence for various conventional and complementary and alternative medicine therapies is considered in the context of the patient's clinical picture, preferences, and values, is therefore ideally suited to address this costly and complex condition.
Important points to consider
Identify and correct beliefs that physical activity will worsen back pain.
Patients with low back pain most likely to respond to manipulation:
Duration of current episode less than 16 days
Extremity symptoms not distal to the knee
Low fear avoidance
Palpation of one or more hypomobile lumbar segments.
One or both hips with internal rotation range of motion greater than 35 degrees
One year of conservative therapy is often recommended before surgery is considered.
Prevention Prescription
Educate: Nonspecific low back pain is not progressive and will not disable you unless you let it.
Maintain normal physical activity as much as possible.
Lift properly: Bend your knees and keep your back straight
Take regular 5-minute breaks to stand and stretch when sitting for long periods. Strengthen trunk muscles and walk regularly.
Have a regular stretching or yoga routine. Keep a healthy body weight.
Integrative therapeutics review
When deciding among the following therapeutic options for low back pain (LBP), augment the biomedical model of evaluation and management with a biopsychosocial approach.
Evaluation
Rule out potentially serious disease (red flags) and significant neurologic involvement. If present, refer for imaging and specialty care as appropriate.
Identify risk factors for chronicity (yellow flags).
Do not routinely use imaging in patients with nonspecific LBP and no red flags.
For nonspecific back pain, consider patients' preferences and clinical classifications in treatment planning.
Education and Self-Care
Reassure patients about the benign nature and favorable prognosis of nonspecific back pain.
Advise patients to stay active and carry on as normally as possible.
Dispel inappropriate beliefs.
Pharmaceuticals
Acetaminophen: 500 mg, one to two tablets three to four times daily Nonsteroidal antiinflammatory drugs (take with food)
Ibuprofen: 400 to 800 mg three times daily
Naproxen: 375 to 500 mg twice daily
Botanicals and Supplements
Willow bark containing 240 mg of salicin: taken once daily
Devil's claw: 400 mg, two capsules three times daily (standardized to 2% harpagosides and 3% total iridoid glycosides)
Mind-Body Therapy
Consider cognitive-behavioral, operant, and respondent therapies, such as progressive muscle relaxation, as treatment options for patients with chronic LBP
Recommend yoga as a treatment option for patients with chronic LBP.
Refer for multidisciplinary functional restoration in patients with chronic LBP in
whom conservative options have failed and who exhibit high levels of physical and psychological disability.
Biomechanical Therapies
Recommend 4 to 8 visits of spinal manipulation as a treatment option for patients with acute and chronic LBP.
Recommend 8 to 12 visits of therapeutic exercise in patients with chronic back pain.
Consider a short course of 4 to 8 visits of massage as a treatment option for patients with acute and chronic LBP
Bioenergetic Therapies
Acupuncture: Consider a short course of 4 to 8 visits of acupuncture as a treatment option for patients with chronic LBP.
Key Web Sources
http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/05_06/mar06/FABQ1.pdf
http://thepainsource.com/2010/12/revised-oswestry-disability-index/
http://www.spine-health.com/wellness/exercise/mckenzie-therapy-mechanical-low-back-pain
http://www.yogajournal.com/poses/finder/therapeutic_focus/t_back_pain
http://www.spine-health.com/treatment/chiropractic/how-select-best-chiropractor
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