Back pain is a very common presentation for people to seek healthcare. Back pain is also very complex, there are structural, functional, neurochemical and psychosociological reasons why a person develop lingering back pain.
Most episodes of back pain are short-lasting with little or no consequence, but recurrent episodes are common and back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences.
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Prevalence Of Back Pain In Australia
- About 4 million people or 1 in 6 Australians (16%) had back problems in 2017–18
- In 2015, back pain was the 2nd leading cause of disease burden, accounting for 4% of Australia’s total disease burden
- In 2017–18, there were 181,000 hospitalisations for back problems
Pain Mechanism
Low back pain is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and pain-processing mechanisms.
Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes
For nearly all people presenting with low back pain, the specific nociceptive source cannot be identified and those affected are then classified as having so-called non-specific low back pain.
There are some serious causes of persistent low back pain (malignancy, vertebral fracture, infection, or inflammatory disorders such as axial spondyloarthritis) that require identification and specific management targeting the cause, but these account for a very small proportion of cases.
The combined effect on individuals of low back pain and comorbidity is often more than the effect of the low back pain or the comorbidity alone and results in more care, yet typically a poorer response to a range of treatments.
Hence, when we looking at the targeted pain mechanism to treat the back pain, we should consider the following:
- Nociceptive: Tissue Injury e.g. intervertebral disc, facet joint, vertebral endplates (Modic changes)
- Neuropathic: Nerve Injury e.g. nerve impingement, radicular pain (sciatica), post-surgical pain, central stenosis
- Nociplastic: Sensitised Nervous System e.g. nonspecific low back pain, fibromyalgia
Clinical Presentation
Morning stiffness, muscle spasm, reduced range of motion, crepitus (crackling sounds), muscle weakness, shooting pain down the legs, numbness, tingling, fatigue, and pain-related psychological distress are also seen frequently in patients with low back pain.
Scientific research has helped us to understand pain is a multidimensional dynamic experience with multiple brain sites activation. From localised muscle or nerve inflammation to neuroplasticity (ie. structural and chemistry changes of the nervous system) leading to emotional distress and behavioural changes.
Factors associated with Back Pain Function Loss
- Symptom-related factors: Previous episodes, Back pain intensity, Presence of leg pain, Lethargy, Being distracted during an activity
- Lifestyle factors: Body mass, Smoking, Physical activity, Awkward postures, Heavy manual tasks
- Psychological factors: Depression, Catastrophising, Fear avoidance beliefs
- Social factors: Physical work loads, Education, Compensation, Work satisfaction
Effects of Persistent Pain
- Biological: Heightened Pain, Cognitive Impairment, Sleep Disturbance, Physical De-Conditioning, Medication Over-Use, Suppression of immunity
- Psychological: Depression, Anxiety, Post-Traumatic Stress, Learned Helplessness, Suicide Risk
- Sociocultural: Social Withdrawal, Dysfunctional Relationships, Isolation, Carer Stress, Vocational Role Interference, Financial Ramifications
Pain treatment Options
It is no longer acceptable to apply single model fo care to everyone living with osteoarthritis related pain. It is best practice that treatment should be mechanism-based, symptom-based and disease-based. No two patients are alike, why should the treatment follow a strict algorithm? Treatment plans should be patient-centred with biopsychosocial strategy, with personalised approach in a stepped-care model.
The goal of the treatment is to promote resilience, healing, prevent and reduce pain chronification.
Most of the widely promoted interventions to prevent low back pain (eg, work-place education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices) do not have a firm evidence base.
Common Treatment Options include (but not limited to):
- Patient Education
- Pharmacotherapy
- Physical Activities
- Cognitive Modification
- Sociological Support
- Procedural Interventions
Pain Education
“Educational Interventions that aim to change one’s understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself” – Explaining Pain
Education is a powerful tool to help you to understand information about the different treatment approaches, information about the disease, about the pathophysiology, and about the diagnostic imaging.
Consistent recommendations for early management are that individuals should be provided with advice and education about the nature of low back pain and radicular pain; reassurance that they do not have a serious disease and that symptoms will improve over time; and encouragement to avoid bed rest, stay active, and continue with usual activities, including work.
Physical Activities
Exercise therapy is particularly helpful in decreasing pain and improving joint motion. Research shows that a comprehensive programme tailored to individual needs is recommended. No one exercise programme is more superior or beneficial.
Recommended physical treatments, particularly for persistent low back pain (>12 weeks duration), include a graded activity or exercise programme that targets improvements in function and prevention of worsening disability.
E.g. Low-Level Aerobic Exercise For Fibromyalgia, Strength-Training For Back Pain with Deconditioning, Flexibility Training For Arthritis, Balance Training For Weakness Or Risk of Falls
The benefits of exercises include Improve Sleep, Weight Loss, Endorphine Secretion, Reverse Deconditioning, Functional Gain.
Yoga, Tai Chi, Acupuncture, Pilates, Hydrotherapy have mixed evidence with short term pain and disability reduction.
Cognitive Modification
Cognitive Behavioural Therapy (CBT) is the most common psychological intervention. It consists of cognitive appraisal, restructuring beliefs, behavioural activation, problem solving and motivation. It helps people living with osteoarthritis pain to conquer fears of moving and emphasise on exacerbation management.
Pain Medications
The most often recommended in the guidelines include paracetamol and anti-inflammatories. Recent research from UNSW demonstrated paracetamol has no benefit in pain reduction. Topical or oral anti-inflammatories were shown to be effective for pain relief and for function.
There is no scientific evidence and role for Muscle Relaxants and Benzodiazepines use.
Nerve medications have established efficacy for back pain, which result in pain reduction and improve function. The mechanism is thought to be enhancing the descending modulatory systems (ie. the calming system from our brain).
Regarding opioids use, the small gain weighted against the side-effects, and the risk of addiction and overdosage, has led to an overall discouragement of prescribing these products to patients with osteoarthritis. If pain is severe and not responding to the conventional management, cautious selection of safer opioids with clear goals are essential.
Procedural Interventions
Depending on the symptoms, mechanism and underlying pathology, procedural interventions could be very beneficial to facilitate functional gain. These include:
Joint-block with steroid injection: better outcome to people who show signs of facet joint or sacroiliac joint inflammation.
Nerve-block with Radiofrequency Treatment: efficacy could last beyond 1 year especially those with higher pre-procedural pain scores and low opioids use.
Disc injection: for people with disc pathology
Neuromodulation: when there is refractory pain management from above procedures
Surgical Options
There are low-quality evidence supporting surgical decompression for lumbar disc herniation.
There are no significant differences in disability scores between spinal fusion or rehabilitation for non-radicular back pain with degenerative changes.
Discectomy, laminectomy and/or fusion are effective for symptomatic spinal stenosis or radiculopathy, which has shown improvement in pain intensity, functionality and quality of life for 2-4 years.
Action Points
Low back pain is a major problem throughout the world and it is getting worse—largely because of the ageing and increasing world population. Low back pain is a complex condition and contributed by physical, psychological and sociological factors. Your treatment plans should be tailored to your needs.
Dr Chow Chow provides remarkable collaborative system with Sydney top leading experts, this includes physical therapist trained in spinal rehabilitation programme, pain psychologist, dietitian for healthy eating habits, Orthopaedic Surgeons and Neurosurgeon specialising in back pain management.
Have any questions about how to manage your back pain? Contact email info@drchowchow.com
Resources
- Australian Institute of Health and Welfare AIHW
- Hartvigsen, Jan, et al. “What low back pain is and why we need to pay attention.” The Lancet 391.10137 (2018): 2356-2367.
- Foster, Nadine E., et al. “Prevention and treatment of low back pain: evidence, challenges, and promising directions.” The Lancet 391.10137 (2018): 2368-2383.
- Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082-2097.
- Moseley, G. Lorimer, and David S. Butler. “Fifteen years of explaining pain: the past, present, and future.” The Journal of Pain 16.9 (2015): 807-813.
- Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;1(1):CD011279. Published 2017 Jan 14.
- Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8(8):CD007407. Published 2020 Aug 12.
- Chen, Bing-Lin, et al. “Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis.” Clinical rehabilitation 32.2 (2018): 146-160.
- Bydon M, De la Garza-Ramos R, Macki M, Baker A, Gokaslan AK, Bydon A. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech. 2014;27(5):297-304.
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May;34(10):1066-1077.
