Chronic Low Back Pain: Physiotherapy

O Physio Development physiodevelopment.com CHRONIC LOW BACK PAIN A Biopsychosocial Approach Up to 80% of people will experience low back pain at some point in their lives. Non-Specific 85% In 85% of cases, no specific cause can be defined, despite careful investigation.? Specific 15% Most people recover and return to normal activities. However, a small group of people experience persistent pain. Pain is a complex, multi-factorial experience. Why does pain persist in some people? This experience of pain is unique to each individual. It's important to determine which type of pain is present." ?? Nociceptive Pain Inflammatory Pain Neuropathic Pain Central Sensitisation Dysfunctional Pain Pain characteristics can change over time, and can also present as a combination of types. Chronic low back pain can be influenced by the following: Psychological Factors Increased pain tends to correlate with increased depression, anxiety and stress.4 Fear-avoidance of activities such as bending can increase pain-related disability.5 Lifestyle Factors Sedentary lifestyles tend to correlate with higher levels of pain and disability. Poor general health is associated with poorer outcomes in lower back pain." In people with chronic low back pain, poor sleep patterns can correlate with greater disability." Social Factors Job dissatisfaction and unwholesome work relationships may be associated with poorer outcomes. Hypervigilence and over-concern from family members is associated with increased pain and disability. 0 What are your patients' thoughts and perceptions about their back pain? When patients are given the opportunity to describe their experience, they often mention things such as: "I'm scared to bend forwards because l've had a bulging disc for years and I don't want to damage it any further." "I had an x-ray, and it's bone-on-bone in my lower back." "I need to get my core muscles stronger because my spine feels unstable." Unfortunately, these misperceptions have the ability to exacerbate fear-avoidance and pain sensitivity. So, how can we better help our patients with non-specific chronic low back pain? Listen: - Give the patient an opportunity to tell their story. - Explore the patient's beliefs, thoughts and perceptions of their pain, and why they feel it has not yet resolved. - What are their goals and expectations? Measure: - Utilise valid and reliable outcome measures to gather objective information. e.g., Orebro Musculoskeletal Pain Questionnaire (Short/Long Form) to screen for psychosocial variables, potential risk of pain-related disability and long-term work absence.11 - Measure the patient's functional capacity and exercise tolerance. e.g., Specific tolerances for sitting, standing, walking and any other relevant functional tasks. - What is their chosen movement pattern during sit-to-stand, rolling in bed, or picking up a small object from the floor? What other specific tasks are provocative? Can modifying their technique change their symptoms? Educate: - Compassionately address any inappropriate beliefs or perceptions around their presentation. - Reinforce that the spine is strong, resilient and reliable. - Pain does not equal tissue damage." Flare-ups are common, and strategies to manage these are important. - Reinforce that chronic pain is multi-factorial, and completely unique to each individual. Outline how each relevant variable may be influencing their pain presentation. - Acknowledge the importance of lifestyle factors, such as sleep hygiene, as part of a multi- dimensional management plan. Move: - Teach and facilitate a gentle return to normal, relaxed and unguarded movement. - Develop an appropriate exercise program for their current presentation, with the aim of improving functional capacity, cardiovascular endurance and exercise tolerance. Refer? - If you determine dominant psychosocial variables, or any variables outside of your clinical skill set, communicate with allied health practitioners. e.g., Discuss referral for further psychological assessment and management in cases of concurrent mental health conditions. - Communicate the relevance of a team-based approach, involving their general practitioner, as well as other allied health practitioners, if clinically relevant. References: 1. Dillingham T 1995. Evaluation and management of low back pain: and overview. State of the Art Reviews, vol. 9, no. 3, pp. 559-574. 2. Deyo R and Weinstein J 2001, 'Low Back Pain'. New England Journal of Medicine, vol. 344, no. 5, pp. 363-370. 3. Woolf C 2010, What is this thing called pain?", The Journal of Clinical Investigation, vol. 120, no. 11, pp. 3742-3744. 4. HaythornthwaiteJ and Benrud-Larson L 2000, 'Psychological aspects of neuropathic pain', Clinical Journal of Pain, vol. 16, s101, s5. 5. Crombez G, Vlaeyen J, Heuts P and Lysens R 1999, 'Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability', Pain, vol. 80, pp. 329-339. 6. Auvinen J, Tammelin T, Zitting P and Karppinen J 2008, 'Associations of physical activity and inactivity with low back pain in adolescents', Scandinavian Journal of Medicine and Science in Sports, vol. 18, no. 2, pp. 188-194. 7. Chou R 2010, Will this patient develop persistent disabling low back pain?', The Journal of the American Medical Association, vol. 203, no. 13, pp. 1295-1302. 8. Lautenbacher S 2012, 'Pain, sleeping problems and their many relatives', Pain, vol. 153, no.6, pp. 1138. 9. Hayden J et al 2009, 'Systematic review of low back pain prognosis had variable methods and results - guidance for future prognosis reviews', Journal of Clinical Epidemiology, vol. 62, no. 8, pp. 781-796, e1. 10. Flor H et at 1987, The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients', Journal of Psychosomatic Research, vol. 31, no. 2, pp. 251-259. 11. Linton, S. J., Nicholas, M., & MacDonald, S. (2011). Development of a short form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine, 36(22), 1891-1895. 12. Butler D and Moseley L 2010, Explain Pain, Noigroup Publications, Adelaide. Special thanks: Professor Peter O'Sullivan, Martin Rabey and the research team at Curtin University for their efforts and information. For more information regarding Cognitive Functional Therapy, please visit: www.pain-ed.com Feel free to share, discuss and comment to help improve our understanding of chronic low back pain. in n 8+