Personalized medicine (and chiropractic) is the way of the future. This week, some advice on a personalized approach to low back for your patients…
Non-specific low back pain (NSLBP) is defined as pain that cannot be attributed to a clear pathoanatomical source or cause. The diagnosis of NSLBP is distinct from specific causes of low back pain (LBP), such as pain arising from a tumour, infection, fracture, inflammatory disorder, radicular pain, cauda equina syndrome, or referral from a visceral organ. NSLBP is a prevalent condition, characterized by a high rate of recurrence and chronicity, with a variable clinical trajectory. NSLBP accounts for approximately 90% of LBP cases and remains the leading cause of years lived with disability globally.
The distinction between specific and non-specific low back pain is considered useful in research settings, as it helps exclude subjects with serious pathology from study groups. However, classifying most low back pain cases as non-specific can be seen as a clinical oversimplification, as it fails to account for the individual experience of pain, including frequency, intensity, and underlying neurophysiological pain mechanisms. These variables may influence how healthcare providers individualize treatment of low back pain. Therefore, the authors of this review present a logical treatment algorithm on how to create a personalized treatment program for a patient with NSLBP.
Excerpt from the Review (written by Dr. Demetry Assimakopoulos):
Personalized Management of NSLBP:
Personalized assessment and management should be tailored to the person considering a range of biopsychosocial factors, using a multimodal treatment approach.
The assessment of a person with NSLBP should aim to identify the differential contributions to their pain. Frequent re-evaluation is essential to address changes in contributions or goals. Baseline assessment begins with screening for red flags requiring urgent or semi-urgent referral. Pain mechanisms (nociceptive, neuropathic, or nociplastic) can then be identified through patient history, clinical musculoskeletal evaluation, and thorough neurological assessment of the painful area and extremities. Additional drivers, including psychosocial factors, contextual elements (ex. work), medical comorbidities, and medications, should also be considered as they influence pain presentation and prognosis. Finally, the clinicians should identify the person’s beliefs about their condition, treatment expectations, goals, and preferences, alongside selecting patient-relevant outcome measures. This process informs the creation of an individualized, tailored treatment program to address the patient’s unique needs and circumstances.
Treatment of NSLBP should be rooted in a strong therapeutic alliance, shared decision-making, and cognitive behavioural principles. The primary goals of therapy are to reduce or prevent further pain, enhance function, and reduce sensitivity. Exercise therapy should be initiated and tailored to the person’s preferences. Pharmacotherapy can also be used to decrease pain sufficiently to allow engagement in rehabilitation and therapy.
Understanding pain mechanisms can help guide treatment strategies. If the pain is nociceptive, addressing the nociceptive driver with manual therapy and targeted exercise may be indicated. For neuropathic pain, a similar approach to treating nociceptive pain can be used, but referral to a specialist should be considered if conservative treatment fails or neurological deficits are identified. If nociplastic pain is suspected, neurophysiological pain education focused on modifying beliefs about pain and disability is essential. Throughout this process, reassurance and education are critical to fostering a positive therapeutic environment by minimizing anxiety and catastrophizing. (Reviewer’s note: It is worth emphasizing that a person in pain for whatever reason needs to know the difference between hurt and harm. A general rule of thumb is that a new or worsening injury [AKA harm] is unlikely if pain [AKA hurt] induced by exercise is minor, < 24-hours in duration and does not affect the person much functionally. From here, a decision about whether to regress the activity to a more tolerable dose can be made. In the context of neuropathic pain secondary to a nerve root irritation, neuromobilizations to reduce mechanosensitivity of the irritated nerve can be trialed and individualized based on tolerance).
Reassessment after 1 and 3-months should be considered. Clinicians should endeavor to determine if there have been changes in primary pain drivers through repeating their assessment and assess treatment success and barriers. Treatment should be adjusted if necessary. Referral to a multidisciplinary pain management program should be considered if no meaningful recovery has been reached after 3-months.
This week’s Research Review: “Personalized Assessment & Management of Non-Specific Low Back Pain”
This paper was published in the European Journal of Pain (2024)
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