Chronic Lower Back Pain (CLBP)

The low back, or lumbar area, serves a number of important functions for the human body. These functions include structural support, movement, and protection of certain body tissues.

 

Chronic low back pain (CLBP) is the most expensive benign condition in industrialized countries and the most common cause of activity limitation in persons younger than 45 years.

 

Chronic LBP is not simply the same as acute LBP that persists for a greater duration. Usually 6-7 weeks is sufficient for healing to occur in most soft-tissue or joint injuries; however, 10% of LBP injuries do not resolve in this period. The evolution of CLBP is complex, with physiologic, psychological, and psychosocial influences. Although acute LBP has a favorable prognosis, the effect of CLBP and its related disability on society is tremendous. Unlike acute LBP, CLBP serves no biologic purpose.

 

Epidemiologic data suggest that risk factors for CLBP include cigarette smoking; morbid obesity; occupations that require repetitive lifting, especially in forward bending and twisting positions, particularly when lifting requirements exceed the worker's physical capacity; and exposure to vibration caused by motor vehicles or industrial machinery. Although extreme height and morbid obesity may predispose an individual to back pain, research studies have not clearly demonstrated that height, weight, or body build are directly related to the risk of back injury.

 

Chronic LBP is investigated with appropriate physician/physiotherapist evaluation and perhaps imaging studies.

If diagnostic studies are unrevealing of a structural cause, the question of whether the pain has a psychologic, rather than physical, cause must be adressed. Physical and nonphysical factors, interwoven in a complex fashion, influence the transition from acute to chronic LBP

 

Characterization of the pain as mechanical is a primary goal when investigating CLBP. Mechanical or activity-related spinal pain is most often aggravated by static loading of the spine (eg, prolonged sitting or standing), long-lever activities (eg, vacuuming or working with the arms elevated and away from the body), and levered postures (eg, forward bending of the lumbar spine). Pain is reduced when multidirectional forces balance the spine (eg, walking or constantly changing positions) and when the spine is unloaded (eg, reclining). Patients with mechanical LBP often prefer to lie still in bed, whereas those with a vascular or visceral cause are often found writhing in pain, unable to find a comfortable position.

 

Unrelenting pain at rest should suggest a serious cause, such as cancer or infection. Imaging studies and blood tests are usually mandatory in these cases and in cases of progressive neurologic deficit.

 

Physiotherapy for the spine can be divided into passive and active therapies. Passive therapies are those that physiotherapists apply, including modalities such as ultrasound, electric muscle stimulation, traction, heat and ice, and manual therapy. Passive modalities are most appropriate when used for short-term treatment of an acute back injury or an exacerbation of CLBP. When possible, self-administration of appropriate modalities by the patient is frequently advocated, especially for those with CLBP.

 

Active therapies (exercise) is widely used to treat CLBP. Specifically dynamic stabilization exercises are widely accepted as being effective. Teaching motor control exercises to ‘switch back on’ deep slow twitch postural muscles and inhibit the development of abnormal postural and movement patterns. Real-time ultrasound scanning of abdominal muscles can play an important part in giving feedback to patients so they can more effectively learn to engage the deeper postural muscles. Learning how to support the spine utilizing these muscles and developing effective painfree movement patterns through Pilates type exercises can also be of benefit to improve functional capacity.

 

Couple this physical training with cognitive-behavioral support (education sessions regarding the nature of the pain, spinal care, pain management, and disability avoidance, guidelines for postures, activities to avoid, and weight limits on material handling) and you have the best chance of ‘curing’ CLBP.

 

Failure of a ‘conservative’ therapy approach over a 3-6 month period may necessitate more aggressive interventions such as injection therapy, medication, pain management and in a small number of cases surgery may be appropriate.

However there is good news for people with chronic low back pain: Dr. Luciola Menezes Costa of the University of Sydney has revealed in a recent Australian study that about four in 10 will recover within a year. His findings show that the rate of recovery from chronic low back pain is higher than previously reported and that the prognosis for these patients isn't uniformly poor. These findings should prove reassuring for patients because it shows that it's possible to recover from a new episode of low chronic back pain, the researchers added.

The study appears in the Oct. 7 online edition of the BMJ.