Managing chronic low back pain – targeting the relevant factors

Chronic low back pain (CLBP) has for many decades been treated as a disorder which primarily reflected damage to the tissues (discs, bones, joints, muscles, ligaments etc.) of the lower back. However, it is now clear that what was previously considered tissue “damage” on scans is actually common among people without pain, as described here recently. In addition, approaches which have tried to relieve pain by focussing treatment almost exclusively on the tissues of the back – including a range of medical, surgical, exercise and manipulative approaches – have failed to significantly reduce the suffering associated with CLBP. It has increasingly been recognised that cognitive and psychosocial factors such as a person’s beliefs about their problem, as well as fear, anxiety, stress, depression and social isolation are linked to greater risk of a back problem becoming chronic. Interventions aimed at addressing these cognitive and psychosocial factors appear to help alleviate CLBP a little, but not any more than traditional therapies. There is also emerging evidence that CLBP is associated with difficulty perceiving where the spine is in space, and how the body is positioned and controlled. Changes in sensation evident over the spine have also been linked to disrupted movement patterns. These changes in movement are often associated with high levels of muscle tension across the region of pain. These altered movement patterns are often fuelled by protective habits and attempts to avoid pain and movement. There is some evidence that these protective patterns may in themselves become provocative in the long term – abnormally stressing pain-sensitive spinal structures. Furthermore, lifestyle factors such as smoking, chronic daily stress, a sedentary daily life, obesity and sleep deficits are also risk factors for CLBP. The breadth of these contributing factors to CLBP can seem overwhelming to some – how can all these different factors be considered and addressed? The Pain-Ed team’s perspective on CLBP management is that it should (1) consider all these factors during patient assessment and (2) target management at those factors most closely linked to that individual’s pain, as discussed on this earlier postThis paper provides an overview of how this can be done, as articulated by Prof. Peter O’Sullivan at the IFOMPT conference in Quebec last year.

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