Chronic low back pain

Summary

Limited evidence from four randomized controlled trials suggests that the addition of cognitive behavioral therapy (CBT) to usual care, which includes physical activity, may not improve outcomes in adults with chronic low back pain compared with usual care. Patients with CBT tended to take fewer days off work due to back or spinal complaints and experience fewer healthcare visits, but statistical significance was not achieved. Improvement in functional ability and disability was seen in both groups, but no significant differences were found between the two treatment groups, and there was no difference in relief of back or leg pain. The components of CBT delivered to patients, qualifications of those delivering the components, and the measurement of outcomes varied between the studies, making comparisons and conclusions difficult. Additional randomized controlled trials with a standardized CBT protocol delivered by trained professionals and use of standardized outcomes measurements would facilitate further assessment of the efficacy of CBT in addition to usual care for chronic low back pain patients.

Appendix references:

• 1 Chapman J R, Hanson B P, Dettori J R. et al .Spine Outcomes Measures and Instruments. 1st ed. Stuttgart New York: Thieme 2007: 81-89, 98, 245
• 2 Klasen B W, Hallner D, Schaub C. et al .Validation and reliability of the German version of the Chronic Pain Grade questionnaire in primary care back pain patients. Psycho-Social-Medicine [serial online] 2004 Available at: http://www.egms.de//pdf/journals/psm/2004-1/psm000007.pdf. Accessed November 20, 2008. 2004
• 3 Calin A M. Low Back Pain Rating Scale (Mannische). Centre for Evidence Based Physiotherapy web site. Available at: http://www.cebp.nl/vault_public/filesystem/?ID=1387. Accessed November 20, 2008. 2008

Clinical notes

Asdrubal Silveri, Uruguay

Chronic back pain continues to be a serious problem for all those involved with this pathology. When we refer to chronic lower back pain (LBP), we, in the first place, exclude pathologies which are clearly identified as tumors, infections, fractures, herniated discs, rheumatoid arthritis, fibromyalgia, osteoporosis, etc.

We refer to unspecific clinical pictures, the aetiopathogenesis of which is not clearly known and which are multifactorial, where multiple structures and multiple factors exist which may be involved in the cause, and the persistence of the pain. It is to be hoped that the more we get to know about the mechanisms responsible for the pain and how it is influenced by organic, psychosocial, and work factors, etc, we may be able to adopt more effective therapeutic measures which reduce the number of patients in whom the condition becomes chronic and consequently reduce the economic cost of this pathology to society. The attempts to improve the therapeutic measures, in order to obtain better functional capacity, have led different research centers to suggest various methods of treatment aimed at all the factors that may lead to the chronicity of the back pain. It is in this way that the results of different therapeutic measures have been analyzed and, in the case with which we are concerned today, the results of individual physiatric therapies, multidisciplinary group work, in small groups with different methodologies, stabilization of the spine, pain management, psychological support, relaxation therapy, and ergonomic work, with the physical therapist visiting the workplace, etc. All this has the aim of lowering costs during rehabilitation, enabling the patient to return to his workplace as soon as possible, and preventing the recurrence or early relapse of the condition responsible for the pain.

In the analysis carried out by the authors of the review, whose aim was to compare the results obtained with treatments which include only physical activity with those which also include the cognitive behavioral therapy component, no statistically valid evidence emerges regarding results according to the evaluation carried out by the patients themselves concerning their quality of life and the reduction of the pain (both back pain and irradiating pain), but not with regard to the days when work was lost or the number of consultations. The main aim of the cognitive behavioral therapy is to replace the coping skills, the emotions, and the behavior in better adapted situations. It aims to reduce the discomfort, by changing environmental contingencies and cognitive processes. Its method is based on a model of multidimensional pain which includes affective, cognitive, and behavioral elements, as well as physical elements.

Finally, it is important to give an opinion here regarding our experience: we consider that studies of this type are very important and require careful methodology, and that in order to be able to draw conclusions the studies should be serious, prospective and randomized, like those that have been analyzed. What experience has shown us is that psychological consultation has been very important in order to be able to define the characteristics of the patient’s personality, and in some cases it has enabled us to define patients with behavior that is altered because of their illness and has led us to consider certain appropriate therapeutic measures.

Clinical notes

Mario Solano, Costa Rica

What are we talking about? – When I read this kind of articles, and perhaps most about low back pain (LBP), this is the first question that pops up in my head.

I always tell my residents that we have to keep in mind that LBP is a symptom of something, and that something is what we have to discover in order to give proper treatment. So, how can we tell the difference between this two modalities of treatment if we don't know if we're treating the same disease? Of course, it's always possible to make intragroup comparisons but not intergroup ones.

We all know that most of the time in LBP we just discard certain pathologies and end up naming it as „mechanical”, but who are „we”? I think that applies to everyone who is involved in spine care, but what kind of message are we sending to the people who are not? And most of all: to our patients? When I see that in three of the four high-quality comparative studies (CoE I or II) LBP and sciatica and / or neurological signs are included in the same population, I wonder: are we implying they are the same pathology? Are we encouraging the general belief that there's always a herniated disc in every case of LBP? And, when in one of these studies they stated: „No attempts were made (eg, discography or other diagnostic injections) to find more specific diagnosis for these patients.” [1] –are we concealing all the efforts and studies in disc pathology which has led us to the nonfusion technology?

I think that in this era of communication, when every day we receive patients who prior to the visit have looked for information (and if you search LBP on Google, you find 60,200,000 results) the need for precision in terms is no small talk.

In my everyday practice, I prefer to educate my LBP patients, which most of the times means to get rid of all the fantasies and misconceptions that are „common knowledge”; as I've said, I strongly believe that in this era the problem is not the lack of information but the excess of it, and you have to sort it out, many times with an anxious patient who has made his / her own research, has spoken with familiars or friends, and brings a huge amount of concepts. And my concern is: if the treating physicians cannot agree on the meaning of all these terms and concepts, how can we as doctors clarify the situation for our patients?

I think it is time that we stop using LBP as a definite entity, instead, we should use it appropriately, as a symptom of other disease processes to better focus our treatment and to better explain to our patients what their actual problem exactly is and why we decide on any given treatment. For this purpose, I believe it is imperative that we start using the concepts surrounding LBP correctly, and that we reach a consensus as a community regarding said concepts.

When you compare the following two statements: „More than 650,000 surgical procedures are performed annually for back pain in the United States, with costs exceeding $20 billion. Whether this investment provides a good value is largely unknown.” [2] and „Modern medical care has not prevented a steady rise in back related disability in most developed countries, and some fear that medicine may have contributed to the rise.” [3], you can see that pure knowledge and more importantly our results regarding LBP have not improved over the years.

1. Bendix T, Bendix A, Labriola M, et al (2000)
   Functional restoration versus outpatient physical training in chronic low back pain: a randomized comparative study.
   Spine; 25(19):2494–2500.

2. Tosteson AN, Lurie JD, Tosteson TD, et al (2008)
   Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years.
   Ann intern Med; 149(12):901–903

3. Waddell G (1987). Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine; 12(7):632–644.