Neuromodulation: Technology at the Neural Interface
This supplement was made possible by an unrestricted educational grant from St. Jude Medical NeuromodulationMedical Management of Chronic Low Back Pain: Efficacy and Outcomes
Section snippets
THE PREVALENCE OF LOW BACK PAIN (LBP)
LBP is a leading health and socioeconomic problem across industrialized nations with a lifetime prevalence rate in the United States approaching 80%. Approximately one-quarter of U.S. adults experience at least one day of acute LBP during a three-month period (1), and up to 10% of this group will develop chronic low back pain (CLBP) (2., 3., 4.). The trend of rising CLBP prevalence is associated with soaring rates of disability and healthcare costs (5).
ETIOLOGIES AND MECHANISMS
Correlating the painful symptoms of LBP with diverse etiologies and mechanisms is a major clinical and research challenge. Multiple natural history studies have classified LBP as chronic if the painful symptoms persist longer than three months (6). However, classifications based exclusively on duration fail to discriminate among key clinical factors, such as the presence of a pars fracture or neurocompressive lesions, that likely account for much of the variation in the duration of a patient’s
WHOSE PAIN BECOMES CHRONIC AND WHY?
A systematic review of literature that examined the course of acute LBP found that on measures of pain and disability, patients improved rapidly within the first month, sustained more modest improvements after three months, then began to demonstrate reduced improvement or none at all (13). A study of 96 patients with CLBP found that the most powerful predictor of chronicity was continued poor function at four weeks after pain onset (14). It may appear obvious that a quick recovery can indicate
EARLY INTERVENTIONS
Regardless of the pain’s original etiology or ongoing mechanism, early intervention is key to helping acute symptoms of back pain to resolve (18,19). Initial treatments for back pain include advice to remain active, patient educational materials, the application of superficial heat, acetaminophen (APAP), and nonsteroidal anti-inflammatory drugs (NSAIDs) (7). NSAID use is associated with gastrointestinal and renovascular risks (7), and the possibility of end-organ injury should be considered
LONGER TERM TREATMENT OPTIONS
Patients who do not respond to the previously recommended self-care measures and first-line medications at four weeks have additional nonpharmacologic and pharmacologic treatment options (Table 2) (7,21). This section presents management strategies for CLBP accompanied by brief summaries of the evidence for each treatment.
THE EVIDENCE REGARDING OPTIMAL THERAPIES
Physicians who treat LBP employ a wide variety of treatments and diagnostic procedures. The process of clearly delineating optimal therapies by observing their outcomes is complicated by conflicting results and varying methodologies from primary studies and literature reviews. In general, evidence examining common medical therapies confirms short-term benefits for many treatments, yet none emerges as clearly superior, and evidence demonstrating long-term benefits is lacking (2). Trials
CONCLUSION: PERSONALIZED SOLUTIONS YIELD BEST OUTCOMES
Evidence fails to clearly distinguish one medical treatment for CLBP as clearly superior to another. Certain interventions appear well supported, including professionally delivered CBT (51), NSAIDs (7), and opioids, at least short term (26). However, no strategy works well for every patient, and the long-term benefits and risks of many common therapies remain in question. A major limitation of evidence-based guidelines for the management of LBP is that these recommendations are drawn from the
Acknowledgement
The authors acknowledge the contribution of medical writer Beth Dove, of Lifetree Clinical Research in Salt Lake City, Utah, in the preparation of this manuscript.
Authorship Statements
Drs. Webster and Markman conducted the study and assisted with drafting and revising the manuscript. Both authors approved the final manuscript.
How to Cite this Article:
Webster, L.R., Markman J. 2014. Medical Management of Chronic Low Back Pain: Efficacy and Outcomes Neuromodulation 2014; 17: 18–23
REFERENCES (57)
- et al.
Contemporary low back pain research—and implications for practice
Best Pract Res Clin Rheumatol
(2010) On the definitions and physiology of back pain, referred pain, and radicular pain
Pain
(2009)- et al.
Symptoms of depression and stress mediate the effect of pain on disability
Pain
(2011) - et al.
Can we predict poor recovery from recent-onset nonspecific low back pain? A systematic review
Man Ther
(2008) - et al.
Current methods of the US Preventive Services Task Force: a review of the process
Am J Prev Med
(2001) - et al.
Efficacy and safety of oxymorphone extended release in chronic low back pain: results of a randomized, double-blind, placebo- and active-controlled phase III study
J Pain
(2005) - et al.
Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain
Pain
(2007) - et al.
Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial
J Pain
(2010) - et al.
The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy
Pain
(2010) - et al.
Topiramate in chronic lumbar radicular pain
J Pain
(2005)
Chronic low back pain analgesic studies—a methodological minefield
Pain
Abnormal brain chemistry in chronic back pain: an in vivo proton magnetic resonance spectroscopy study
Pain
Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients
Pain
The impact of selective publication on clinical research in pain
Pain
Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002
Spine
Chronic non-specific low back pain—sub-groups or a single mechanism?
BMC Musculoskelet Disord
The epidemiology of low back pain in primary care
Chiropr Osteopat
Chronic low back pain—a dreaded vicious circle! [Article in German]
Praxis (Bern 1994)
The rising prevalence of chronic low back pain
Arch Intern Med
Predicting poor outcomes for back pain seen in primary care using patients’ own criteria
Spine
Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society
Ann Intern Med
Chronic back pain is associated with decreased prefrontal and thalamic gray matter density
J Neurosci
Low back pain
N Engl J Med
Why does acute back pain become chronic?
BMJ
Acute low back pain: systematic review of its prognosis
BMJ
Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain
Spine
Pharmacogenetics of pain: the future of personalized medicine
Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study
J Occup Rehabil
Cited by (15)
The influence of nociceptive and neuropathic pain states on the processing of acute electrical nociceptive stimulation: A dynamic causal modeling study
2020, Brain ResearchCitation Excerpt :This high prevalence has led to the recognition of low back pain (LBP) as a significant public health problem (Amorim et al., 2016). Despite the functional disability, impairment of psychological status and low quality of life related to chronic LBP, a well-defined targeted and effective treatment strategy for these patients is still lacking (Hong et al., 2014; Webster and Markman, 2014). The fact that pain is a very complex and multidimensional experience, with different psychological processes (e.g., pain catastrophizing) that are mediating the net pain response (Edwards et al., 2016; Meints and Edwards, 2018), is not helpful to find suitable treatments for all patients.
Physical Activity and Yoga-Based Approaches for Pregnancy-Related Low Back and Pelvic Pain
2017, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal NursingCitation Excerpt :Given that less than a quarter of women in the United States engage in regular physical activity during pregnancy (Evenson & Wen, 2010) it is possible that PR-LBPP is the result of and/or is exacerbated by physical inactivity. Further, given the fact that psychosocial stress, mood disturbances, and passive coping strategies have been shown to affect pain reactivity in other clinical populations, such as those who develop chronic pain (Starkweather et al., 2016; Webster & Markman, 2014), it may be reasonable to postulate a causal mechanism in relation to PR-LBPP. These areas of research require further well-designed studies to precisely determine causative mechanisms versus factors of association.
Effectiveness of duloxetine on severity of pain and quality of life in chronic low back pain in patients who had posterior spinal fixation
2022, Journal of Orthopaedics, Trauma and RehabilitationA 15-Year Follow-up Retrospective Study on 959 Spine Surgeries: What Can We Learn from Real-world Data?
2021, Clinical Spine SurgeryContribution of COMT and BDNF Genotype and Expression to the Risk of Transition from Acute to Chronic Low Back Pain
2020, Clinical Journal of Pain
For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http://www.wiley.com/bw/submit.asp?ref=1094-7159&site=1