New findings for the treatment of chronic, nonspecific low back pain

Two forms of nonspecific low back pain are seen as major public health problems worldwide. These two conditions are low back pain (LBP), not attributable to a recognizable, specific pathology, and chronic LBP (C-LBP), indicating the presence of LBP for more than 3 months. Close to 12% of the population is disabled by LBP[1,2] and its lifetime prevalence is as high as 84%, whereas the lifetime prevalence of C-LBP is about 23%. 

The recent findings on these two conditions, based on high-quality,[3] sys­tematic reviews, are as follows:

The many classification systems of LBP can be divided into three categories: diagnostic, prognostic, and directing treatment.4 At present, none of the classification systems can be adopted for all purposes.[4

Some classifications, such as the Quebec Task Force, National Institute for Occupational Safety and Health, and McKenzie, have been validated and showed some degree of reliability. But each of these classification systems remains at the hypothesis-generating stage, which means they still need to be tested and replicated by future studies to determine their applicability.[5-7]

Outcome measures should be routinely assessed in C-LBP patients,[8] and should be chosen based on the pa­tient’s most important domains, such as pain, function, and quality of life. Based on the ease of administration and the patient’s responsiveness, the Visual Analog Scale or the Numeric Rating Pain Scale is recommended for measuring pain, the Oswestry Disability Index or the Roland Morris Disability Questionnaire for measuring function, and the SF-36 or SF-12 for measuring quality of life. 

Furthermore, the Fear Avoidance Belief Ques­­tion­naire, Tampa Scale for Kinesiophobia, or Beck Depression Inventory is most useful for measuring psychosocial domains. Objective outcomes can be measured based on the patient’s return to work, complications, or res­ponse to medication.

Surgery for C-LBP provides the most responsive pain (Visual Analog Scale) and functional outcome (Oswes­try Disability Index) measures; these are the only outcome measurement tools that demonstrate large effect size.[9] However, following spinal surgery for C-LBP, changes in pain have little correlation with changes in health-related, quality-of-life outcomes. 

MRI findings and C-LBP show a weak association. However, the link between degenerative MRI findings and C-LBP cannot be established, owing to the quality, cross-sectional nature, and heterogeneity of the un­derlying population in the primary studies.[10

Furthermore, there is no evidence to suggest a greater benefit from the use of surgical treatment over nonsurgical treatment to address degenerative MRI changes. Therefore, the use of MRI for the work-up of C-LBP and the surgical treatment of C-LBP are not recommended, should they be based solely on degenerative MRI changes.

Opioids and NSAIDs are said to be effective in treating C-LBP, but antidepressants have no meaningful clinical benefits. Furthermore, opioids are not recommended for treating C-LBP, because they are associated with significant side effects and dem­onstrate no greater effectiveness than NSAIDs.[11]

Structured exercise and spinal manipulative therapy appear to offer equal benefit in the management of pain and function in C-LBP.12 If no clinical benefit is observed following 8 weeks of structured exercise or spi­nal manipulative therapy, the treatment plan should be re-evaluated, and perhaps, modified. At present, insufficient evidence exists to assess the relative benefit of acupuncture against structured exercise or spinal manipulative therapy.

Spinal fusion surgery can be considered for patients with isthmic spon­dylolisthesis, and following failed nonsurgical treatment.[13] At 2 years, the standardized mean difference for pain and function in favor of fusion was modest among those without isthmic spondylolisthesis. However, for isthmic spondylolisthesis patients facing a lengthy rehabilitation, the results significantly favored fusion.

Fusion surgery demonstrates great­er benefits than conservative treatments among C-LBP patients who are nonsmokers or have no additional comorbidities.[14]

C-LBP patients with personality disorders may respond better to conservative treatments, while those with­out a personality disorder may respond more favorably to fusion. Patients with higher depression and neuroticism scores may also respond better to conservative management.[15]

Contrary to some beliefs, C-LBP patients with pending litigation, on sick leave, with lighter jobs, or those who are unmarried, may respond better to fusion than to nonoperative care.[16] However, these findings need to be replicated further by other studies.
—Kukuh Noertjojo, MD, MHSc, MSc
—Craig Martin, MD, MHSc
—Celina Dunn, MD, CCFP

This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.


References

1. Fourney DR, Andersson G, Arnold PM, et al. Summary Statement. Chronic Low Back Pain. A heterogenous condition with challenges for an evidence-based approach. Spine 2011;36(21S):S1-S9. www.ncbi.nlm.nih.gov/pubmed/21952181
2. Balaque F, Mannion AF, Pellise F, et al. Non-specific low back pain. Lancet. Published online 7 October 2011. DOI:10.1016/S0140-6736(11)60610-7. www.ncbi.nlm.nih.gov/pubmed/21982256
3. Norvell DC, Dettori JR, Fehlings MG, et al. Methodology for systematic reviews on an evidence-based approach for the management of chronic low back pain. Spine 2011;36(21S):S10-S18. www.ncbi.nlm.nih.gov/pubmed/21952182
4. Fairbank J, Gwilym SE, France JC, et al. The role of classification of chronic low back pain. Spine 2011;36(21S):S19-S42. www.ncbi.nlm.nih.gov/pubmed/21952188
5. Kamper SJ, Maher CG, Hancock MJ, et al. Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Practice and Research. Clinical Rheumatology 2010;24:181-191. www.ncbi.nlm.nih.gov/pubmed/20227640
6. Foster NE, Hill JC, Hay EM. Subgrouping patients with low back pain in primary care: Are we getting any better at it? Manual Therapy 2011;16:3-8. www.ncbi.nlm.nih.gov/pubmed/20580595
7. Waddell G. Subgroups within “nonspecific” low back pain. Editorial. Rheumatology 2005;32:395-396. www.ncbi.nlm.nih.gov/pubmed/15742427
8. Chapman JR, Norvell DC, Hermsmeyer JT, et al. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine 2011;36(21S):S54-S68. www.ncbi.nlm.nih.gov/pubmed/21952190
9. De Vine J, Norvell DC, Ecker E, et al. Evaluating correlation and responsiveness of patient-reported pain with function and quality of life outcomes after spine surgery. Spine 2011;36(21S):S69-S74. www.ncbi.nlm.nih.gov/pubmed/21897347
10. Chou D, Samartzis D, Bellabarba C, et al. Degenerative magnetic resonance imaging changes in patients with chronic low back pain. Spine 2011;36(21S):S43-S53. www.ncbi.nlm.nih.gov/pubmed/21952189
11. White AP, Arnold PM, Norvell DC, et al. Pharmacologic management of chronic low back pain. Spine 2011;36(21S):S131-S143. www.ncbi.nlm.nih.gov/pubmed/21952185
12. Standaert CJ, Friedly J, Erwin MW, et al. Comparative effectiveness of exercise, acupuncture and spinal manipulation for low back pain. Spine 2011;36(21S):S120-S130. www.ncbi.nlm.nih.gov/pubmed/21952184
13. Wood KB, Fritzell P, Dettori JR, et al. Effectiveness of spinal fusion versus structured rehabilitation in chronic low back pain patients with and without isthmic spondylolisthesis. Spine 2011;36(21S):S110-S119. www.ncbi.nlm.nih.gov/pubmed/21952183
14. Choma TJ, Schuster JM, Norvell DC, et al. Fusion versus nonoperative management for chronic low back pain. Do comorbid diseases or general health factors affect outcome? Spine 2011;36(21S):S87-S95. www.ncbi.nlm.nih.gov/pubmed/21897346
15. Daubs MD, Norvell DC, McGuire R, et al. Fusion versus nonoperative management for chronic low back pain. Do psychological factors affect outcomes? Spine 2011;36(21S):S96-S109. www.ncbi.nlm.nih.gov/pubmed/21952192
16. Mroz TE, Norvell DC, Ecker E, et al. Fusion versus nonoperative management for chronic low back pain. Do sociodemographic factors affect outcome? Spine 2011;36(21S):S75-S86. www.ncbi.nlm.nih.gov/pubmed/21952191

Kukuh Noertjojo, MD,, Craig Martin, MD,, Celina Dunn, MD,. New findings for the treatment of chronic, nonspecific low back pain. BCMJ, Vol. 54, No. 1, January, February, 2012, Page(s) 39 - WorkSafeBC.



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