Back Pain

instituteforchronicpain.org

What is chronic back pain?

Back pain affects most everyone at some point. At any given time, 25% of

the population will have had low back pain in the previous three months. It
is one of the most common reasons for medical visits. Fortunately, the vast
majority of cases of new back pain will resolve within a few weeks to
months.

Some people have back pain that does

not go away. Back pain is considered
chronic when it lasts longer than six

months. Chronic low back pain affects

about 10% of the population. It is one
of the most common reasons for

disability. Additionally, among all

health conditions, back pain is one of

system.

the highest costs to the healthcare

Despite these alarming statistics, it is important to recognize that most

people with chronic back pain live well and do not seek healthcare for it on

a regular basis. Roughly, three quarters of people with chronic back pain fit
this description. They are neither distressed nor impaired enough to seek
care for it. Or, they recognize that medical options for chronic back pain

are limited and not very effective. So, they self-manage their chronic back
pain. Either way, it is possible to self-manage chronic back pain and live
well enough to have no need to seek care for it. In fact, the majority of
people with chronic back pain are not seeking care for it.

Common causes of back pain are varied. Broadly speaking, the many

common causes of back pain can be divided into three categories: muscular,

orthopedic, and nervous. Muscle strain and tears can cause back pain.

Degenerative changes of the spine can cause pain. Changes in the nervous

system, commonly referred to as central sensitization, can also cause pain.

Less common causes of back pain are spinal fractures, infection and cancer.
It is often difficult to know the cause of back pain in an individual case.

There are no examinations or tests that can definitively prove a cause of

pain for any of the three most common categories of causes mentioned
above.

Take, for example, orthopedic causes of back pain. CT or MRI scans are

commonly used to identify degenerative changes of the spine as possible

causes of back pain. When found, it is easy to assume that these findings
provide a definitive diagnosis of the cause. However, most healthcare
providers know that the research does not support this assumption.

To understand this point, it is helpful to know something about how science

goes about finding a cause of pain in general. In order to find a cause of

pain, scientific inquiry tries to find something that is unique to those who

have pain and which subsequently differentiates those who have pain from
those who do not have pain. Findings of degenerative changes of the spine
on MRI or CT scans are not unique to patients with back pain in this way.
Numerous studies consistently show that people without back pain have
degenerative changes of the spine at just as high a rate or higher than
people with back pain. There currently is no way of knowing what

differentiates degenerative changes of the spine that are painful from those
that are not painful. Another possibility is that there is no difference and
the findings of degenerative changes of the spine on MRI or CT scans are
simply irrelevant. There is currently no test that can tell for certain.

As such, in the individual case, it is difficult to know what is causing pain,

even if an MRI or CT scan shows degenerative changes of the spine. Are
these changes relevant to the patients pain when we know that people
without back pain are likely to have the same findings? Healthcare
providers dont ultimately know.

Is there a cure for chronic back pain?

In the absence of a known cause, healthcare providers and their patients
often proceed through various therapies and procedures on a trial-anderror basis. There are many common treatments for chronic back pain:

Many of these therapies and procedures have been shown in research to be

effective in reducing pain and increasing functioning. However, in this
regard, effective does not mean curative. Unfortunately, there are no
known cures for chronic back pain.

Therapies & Procedures for chronic

back pain

In 2007, the American College of Physicians and the American Pain Society
developed clinical practice guidelines for chronic back pain. They

determined that providers should first recommend self-management for

patients with back pain. Moreover, they recommended that healthcare

providers educate patients on how to self-manage back pain. They do not

recommend the use of immediate CT or MRI scans for back pain unless
there is evidence of severe neurological problems or evidence of other
severe conditions like cancer or infection. If back pain continues and

becomes chronic, they recommend the use of medications and chronic pain
rehabilitation therapies.

In terms of medications, they note that even the most effective medications
only moderately reduce pain. They recommend the use of acetaminophen
and non-steroidal anti-inflammatory medications first. If these fail to

reduce pain, they recommend using tricyclic antidepressant medications.

They note that these three classes of medications have the most and highest
quality evidence supporting their effectiveness. They also note that the
poor quality of evidence for the use of opioid and anticonvulsant
medications.

In terms of chronic pain rehabilitation therapies, they recommend the use

of exercise, cognitive behavioral therapy, and chronic pain rehabilitation
programs (which put the two previous types of therapies together in a
coordinated fashion).

The clinical practice guidelines recommend MRI or CT scans and possible

referral for surgical evaluation only if patients meet two criteria: a) when

patients fail to progress from the above-mentioned treatments and b) they

show evidence of neurological problems, such as referred pain.

It is important to recognize that the order of these recommendations reflect

the likelihood of their being effective. That is to say, based on the available
research evidence, the first recommendation is the one that is most likely
to be helpful, the second recommendation is the second most likely to be
helpful, the third is the third most likely to be helpful, and so on.

It is also important to recognize how often these guidelines do not get

followed in actual practice. While many patients have acetaminophen and

non-steroidal anti-inflammatory medications recommended to them, most

patients do not get tricyclic antidepressant medications, exercise, cognitive

behavioral therapy, or chronic pain rehabilitation programs recommended
to them. When they do, it is only after they have undergone MRI or CT

scans and have tried multiple interventional and surgical procedures, all of
which have either poor quality research supporting their effectiveness or
are known to be less effective.

Author
Murray J. McAllister, PsyD, is the executive director of the Institute for

Chronic Pain. The Institute for Chronic Pain is an educational and public
policy think tank. Its purpose is to bring together thought leaders from

around the world in the field of chronic pain rehabilitation and provide
academic-quality information that is also approachable to all the

stakeholders in the field: patients, their families, generalist healthcare

providers, third party payers, and public policy analysts. Its aim is to

change the culture of how chronic pain is managed through education and
consultation efforts that advocate for the use of empirically supported

conceptualizations and treatments of chronic pain. Dr. McAllister is also on

staff of the chronic pain rehabilitation services for Courage Kenny

Rehabilitation Institute, Minneapolis, MN, USA. He also blogs at
the Institute for Chronic Pain Blog.

2012 Institute for Chronic Pain. All rights reserved.