Managing lower back pain: You may be doing too much
New guidelines call for a measured approach to imaging and medication, while emphasizing psychosocial evaluation.
Again, psychosocial evaluation is important. When initially assessing a patient with chronic LBP, it is imperative to evaluate psychosocial factors. As noted earlier, psychosocial factors are better predictors of treatment outcomes than physical findings. Identifying factors related to poor outcomes (eg, anxiety, poor work history, passive attitude toward rehabilitation) can direct therapy and avoid polypharmacy.
Cognitive-behavioral and educational interventions will be more effective when targeting specific psychological and social factors (SOR: C).13,14 Fear-avoidance beliefs, distress, somatization, and pain catastrophizing place patients at the highest risk for poor outcomes. Primary objectives in psychosocial intervention are providing encouragement for overcoming demoralization; helping the patient make the connection between thoughts, feelings, and behaviors; and teaching the patient coping strategies and techniques to adapt to pain and resultant problems.
The ultimate goal for a patient like the one in this second case is to change his perception of chronic pain from overwhelming to manageable and to get him to see himself as resourceful and competent.15 Physician counseling has produced small positive effects in undifferentiated primary care patients with LBP, and it may therefore be more powerful when targeted to patients with specific psychosocial issues such as fear avoidance.16
Provide patients with a realistic outlook. Another key element is to direct patients’ expectations. Most people with chronic LBP will not become pain free, and patients need to know this fact. Aim treatment at improving function as well as reducing pain. You can assess functional status and improvement using patient questionnaires such as the Roland-Morris Disability Questionnaire (https://www.rmdq.org/) or the Oswestry Disability Index 2.0 (ODI, https://www.cpta.ab.ca/resources/Measurement%20Tools/Evaluative_Oswestry%20Disability%20Index.doc).17,18 Although these measures have not demonstrated utility in primary care practice, they have sufficient scale width to reliably detect change in most patients, and serial use can measure change clinically. These measures are used in research examining LBP functional outcomes in primary care; they are easy to use and score (SOR: C).19
What role for medications? Because of complex trade-offs between benefits and harms, evidence is insufficient to say one medication offers a clear net advantage over others in the treatment of patients with LBP. ACP/APS has identified good evidence for tricyclic antidepressants in chronic LBP (ACP/APS recommendation; SOR: B).2 Chronic LBP may exhibit periods of relative quiescence alternating with episodes of exacerbation.20 You can assist your patients in preparing for these occurrences. As with exacerbations in other conditions (eg, chronic obstructive pulmonary disease), you may want to prescribe short-term use of nonpharmacologic or pharmacologic therapies that can be tapered and discontinued after the exacerbation subsides. Patients are likely to differ in how they weigh potential benefits, harms, and cost of various medications. Such a strategy should limit financial burden and potential negative side effects of chronic therapy.
CASE 2
The patient’s course
The physician offers to partner with the patient in working toward a goal of improved functioning. The patient’s spouse accompanies him on 1 visit to discuss steps the family can take to improve fitness. With the ODI, the physician establishes the patient’s baseline function and tracks improvement over the period of care. The patient receives clinical massage therapy once a week, and his hydrocodone is tapered over the course of 6 visits. At the end of the period of care, the patient reports decreased pain and improved hopefulness.
Acknowledgements
The authors thank Honey Elder for organizing our work on this article and for her editorial assistance. Our efforts were supported in part by Grant Number R25 AT00682 from the National Institutes of Health (NIH). Contents are solely the responsibility of the authors and do not necessarily represent the official views of NIH.
Correspondence
William G. Elder Jr, PhD, University of Kentucky, K309 Kentucky Clinic, Lexington, KY 40536; welder@pop.uky.edu
