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Chronic low back pain in a working-age adult

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Low back pain is an extremely common patient complaint. Most cases resolve fairly quickly after the acute episode. However, a small but significant number of patients develop chronic low back pain; a persistent disabling condition. Patients suffer from unremitting pain and often become functionally impaired. Multiple patient characteristics have been identified that place patients at risk for developing chronic low back pain. Currently, it is difficult to find clinical guidelines on how best to manage chronic low back pain, and it remains a substantial treatment challenge for both physicians and patients. The causes, risk factors, prognosis and treatment strategies for chronic low back pain will be discussed in this chapter. The evidence regarding different pharmacological and non-pharmacological treatment modalities will be reviewed and a logical, focused treatment strategy will be outlined.

Section snippets

What causes chronic low back pain?

There are many differential diagnoses of low back pain (Table 1). This chapter will focus on mechanical disorders. Mechanical low back pain may be defined as pain secondary to trauma or deformity of an anatomic structure. These disorders are usually exacerbated by physical activity and are relieved by lying supine. Careful clinical evaluation with a thorough history and physical examination helps to differentiate the patients with mechanical back pain from those with non-mechanical back pain.

Risk factors for the development of chronic low back pain

Many different patient characteristics have been described that seem to predict who is at risk for developing chronic low back pain. However, only a few have been replicated consistently in multiple studies. These include increasing age, previous back pain, job dissatisfaction, pain below the knee, and depression.*4, 9, 10, 11, 12 Depression has long been noted to be associated with various chronic pain syndromes, and several studies have reported its relationship with chronic back pain in

Prognosis of chronic low back pain

The longer a patient suffers from back pain, the worse the prognosis.*4, 5, 14 The chance of low back pain resolving is highest during the first weeks.4 By the end of 1 year, that chance diminishes significantly.5, 14 In Van den Hoogen et al's5 study on the course of low back pain, 35% of patients had pain at 12 weeks and 10% of patients still had pain at 1 year. Thomas et al11 reported similar outcomes at 1 year, with 10% of patients complaining of the same back pain from the original episode.

Therapeutic strategies

In most cases of chronic low back pain, the exact mechanical disorder remains a mystery and the physician is left with the difficult task of treating the patient's symptoms. The pain may cause these patients to be disabled in their activities of daily living and, as mentioned above, psychosocial factors also commonly play a role.12 Therefore, a global treatment strategy is often required to manage these patients. Many different pharmacological and non-pharmacological therapeutic options exist

What to do for the individual chronic patient?

There is little consensus regarding how best to manage patients with chronic low back pain. The first step in deciding how to approach any individual patient is a thorough history and physical examination in an attempt to determine the source of the pain. As mentioned above, the exact aetiology of mechanical low back pain often remains unidentified. However, sometimes the physician can determine which structures are being affected. For example, if the pain is due to osteoarthritis of the lumbar

Could chronic back pain be prevented by better management of acute back pain?

Whether or not chronic back pain could have been prevented by better management of acute back pain depends on whether or not chronic back pain is a continuum of the same disease as acute back pain or a separate entity altogether. This is a difficult question to answer, and is made even more difficult by the fact that back pain is really a symptom rather than a disease. Therefore, different underlying pathologies for chronic low back pain may progress through different natural courses from the

Summary

Chronic low back pain is mainly due to mechanical disorders that often remain unidentified. It can cause significant functional disability, and commonly becomes frustrating for both patients and physicians to cope with and treat. Patients and physicians need to understand that complete resolution of symptoms is an unrealistic expectation, and the goals of therapy should be improvement in functional status and pain control. There is still no consensus on the best way to manage chronic low back

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