Chronic Low Back Pain Gregory E. Hicks, PT, PhD University of Delaware

Chronic LBP 80% will experience LBP at some point in their life (van Tulder, 2001) 80-90% recover within 6 weeks (van Tulder, 1997) 5-15% will develop chronic LBP

Is There An Alternative Model? Biopsychosocial model

Vicious Cycle of Pain Pain Catastrophizing Kinesiophobia Fear Avoidance Behaviors Disability, Disuse, Depressions and Sick Leave Pain Experience Kori et al, 1990 Vlaeyen et al, 1995 Elfving et al, 2007

Outcomes for Assessment of Therapeutic Effectiveness 5 Core Measures –Back Specific Function Oswestry, Quebec –General Health Status SF-36, EuroQOL –Pain Visual Analog Scale, McGill Pain Questionnaire –Work disability Days off work –Patient satisfaction Patient Satisfaction Scale

Nonpharmacologic Therapies for Acute and Chronic LBP: A review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guidelines Chou and Huffman, Ann Intern Med, 2007

Quality of Evidence Good –Evidence from at least 2 high quality trials Fair –Evidence from at least 1 high quality trial or from 2 or more higher quality trials with limitations Poor –Evidence is limited due to insufficient power or poor study design

Back Schools Educate LBP sufferers in exercises, ergonomic techniques and the psychological aspects of low back pain –Main criticism-education is not put in the context of the persons specific job duties Fair quality of evidence –Inconsistent results from trials Small net benefit Results were best when done in occupational setting or more intense programs based upon original Swedish model.

Psychological Therapies Cognitive-Behavioral Therapy Biofeedback –Use of auditory and visual signals reflecting muscle tension or activity to inhibit or reduce muscle activity Progressive Relaxation –Deliberate tensing and relaxing of muscles to facilitate the recognition and release of muscle tension

Psychological Therapies Standard Cognitive-Behavioral Therapy –Good quality of evidence –Moderate net benefit Biofeedback –Poor quality of evidence –Unable to estimate effect Progressive Relaxation – Poor quality of evidence –Large impact on short term pain

Cognitive-behavioral Interventions The intervention encompasses a 6-session structured program where participants meet in groups of 6 to 10 people, 6 times, once a week for 2 hours. First session deals mainly with helping participants feel comfortable and getting to know one another and providing information about the course

Multidisciplinary Therapy Combines and coordinates physical, vocational, and behavioral components and is provided by multiple health care professionals with different clinical backgrounds. Intensity and content varies widely

Multidisciplinary Therapy Good quality of evidence Moderate net benefits gained More intense multidisciplinary rehabilitation was more effective than less intense programs

Functional Restoration AKA- work hardening or work conditioning Involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility and cardiovascular fitness in injured workers

Functional Restoration Fair quality of evidence –9 higher quality trials with conflicting reports Moderate net benefit gained

Modalities Includes all typical passive modalities –Ultrasound –TENS –Interferential –Moist heat –Short wave diathermy –Laser

Modalities Poor quality of evidence –5 higher quality trials No benefit gained

Lumbar Supports Poor quality of evidence –1 higher quality trial No benefit in this population

Massage Fair quality of evidence –3 higher quality trial Moderate benefit gained

Traction Fair quality of evidence –3 higher quality trial Not effective (for continuous traction)

Spinal Manipulation Includes manipulation and mobilization Good quality of evidence –15 higher quality trials Moderate benefit gained

Exercise Includes supervised exercise programs or formal home exercise programs, ranging in focus from general aerobic fitness to muscle strengthening and flexibility

Exercise Good quality of evidence Small to moderate benefits –Varies due to variation in types and combinations of exercise used

Systematic Review on Exercise Liddle, Pain, 2004 Strengthening for the lumbar extensors and abdominals is key! Unclear about the benefit of flexibility training due to study designs –Flexibility is often included with other forms of exercise Supervision contributes to maintenance of exercise benefits and appears to increase compliance Higher doses of exercise (>/=20 hours) are more effective in improving outcomes

Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial Ferreira et al., Pain, patients with CLBP randomized for 8wk intervention General exercise included strengthening, stretching and aerobic exercises. Motor control exercise involved retraining specific trunk muscles using ultrasound feedback. Spinal manipulative therapy included joint mobilization and manipulation.