Chronic low back pain remains a source of frustration to the private health care practitioner. Despite burgeoning research and improved treatment modalities, approximately 28% of these patients continue to report pain more than a year after onset of back symptoms. A part of the frustration is not just in how we define chronic pain (greater than 6 months duration), but a failure to appreciate the natural history of longstanding low back pain.
A substantive portion of the literature on chronic back pain highlights the presence of biobehavioral issues such as catastrophizing about pain, elevated fear avoidance, and maladaptive pain beliefs to name a few. Not so well appreciated is the presence of morphological changes in the lumbar musculature (atrophy and fatty infiltration) as well as neuroplastic changes in the brain that may limit the performance of physical activities and pose difficulties with motor control. Symptomatically chronic back pain presents more as a persistent episodic disorder, some refer to as a “moving target”, rather than a single entity.
Most patients feel temporarily better after short periods of therapy for specific bouts of pain. However, flare-ups are inevitable, leading to the feeling that the treatment has failed and fear for the worst, thus necessitating further diagnostic probing at great expense. Utilizing knowledge of the natural history including flare-ups and biobehavioral issues, a complete reconceptualization of the approach to chronic back therapy is warranted.
This may already be the case in large pain institutions. However small private practices are left treating the flare-ups as if they are part of a new episode of a failed back syndrome. Beattie et al. (2016) are investigating the utilization of a decidedly active approach referred to a “demedicalization”. The approach focuses on pain education, long term exercise training using patient preferred activities to heighten spinal tolerances and manage symptom triggers.
Results appear promising thus far and will need the buy-in of more practitioners and funding agencies. This is so especially because the approach relies on a solid therapeutic alliance between therapist and client as well as utilizing a longer treatment window beyond the typical 6 – 8 weeks of intense therapy.
raz J Phys Ther.2016 Nov-Dec; 20(6):580-591
Feedback appreciated to Dr Hercules Gant PhD
Email: hercules.grant@ rejuvenationhealth.ca