Treatment for chronic low back pain (pain persisting for over 3 months) falls into three broad categories: monotherapies, mulitidisciplinary therapy, and reductionism.
Most monotherapies either do not work or have limited efficacy (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery).
Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on pain.
The reductionist approach (pursuit of a pathoanatomical diagnosis with the view to target-specific treatment) should be implemented when a specific diagnosis is needed.
While conventional investigations do not reveal the cause of pain, joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%).
Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.
- 1. Koes BW, can Tulder M, Ostelo R, et al. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001; 26: 2504-2513.
- 2. McGuirk B, King W, Govind J, et al. The safety, efficacy, and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 2001; 26: 2615-2622.
- 3. Bogduk N, McGuirk B. Medical management of acute and chronic low back pain: an evidence-based approach. Amsterdam: Elsevier, 2002.
- 4. Nachemson A, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott, Williams and Wilkins, 2000.
- 5. van Tulder MV, Goossens M, Waddell G, Nachemson A. Conservative treatment of chronic low back pain. In: Nachemson A, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott, Williams and Wilkins, 2000: 271-304.
- 6. van Tulder MW, Scholten RJPM, Koes BW, Deyo RA. Nonsteroidal anti-inflammatory drugs for low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25: 2501-2513.
- 7. Moulin DE, Iezzi A, Amireh R, et al. Randomised trial of oral morphine for chronic non-cancer pain. Lancet 1996; 347: 143-147.
- 8. Salerno S, Browning R, Jackson SL. The effect of antidepressant treatment of chronic back pain. A meta-analysis. Arch Intern Med 2002; 162: 19-24.
- 9. van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration. Spine 2003; 28: 1978-1992.
- 10. Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003; 138: 871-881.
- 11. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 21: 2784-2796.
- 12. Fritzell P, Hagg O, Wessberg P, Nordwall A, Swedish Lumbar Spine Study Group. 2001 Volvo award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain. A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001; 26: 2521-2534.
- 13. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic back pain: systematic review. BMJ 2001; 322: 1511-1516.
- 14. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low-back pain. Spine 1996; 21: 1889-1892.
- 15. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: 1132-1137.
- 16. Schwarzer AC, Wang S, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54: 100-106.
- 17. Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20: 1878-1883.
- 18. van Kleef M, Barendse GAM, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999; 24: 1937-1942.
- 19. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25: 1270-1277.
- 20. Cohen SP, Salahadin A. Lateral branch blocks as a treatment for sacroiliac joint pain: a pilot study. Reg Anesth Pain Med 2003; 28: 113-119.
- 21. Bogduk N, Karasek M. Two-year follow-up of a controlled trial of intradiscal electrothermal anuloplasty for chronic low back pain resulting from internal disc disruption. Spine J 2002; 2: 343-350.
- 22. Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy (IDET) for discogenic low back pain. Spine J 2004. In press.
- 23. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999: 56.
- 24. Chrubasik S, Eisenberg E, Balan E, et al. Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med 2000; 109: 9-14.
- 25. Chrubasik S, Kunzel O, Model A, et al. Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomised controlled study. Willow bark extract for low back pain. Rheumatology 2001; 40: 1388-1393.
- 26. Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic noncancer back pain. A randomized prospective study. Spine 1998; 23: 2591-2600.
- 27. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003; 138: 898-906.
- 28. McIlveen B, Robertson V. A randomized controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998; 84: 17-26.
- 29. Foster L, Clapp L, Erickson M, Jabbari B. Botulinum toxin A and chronic low back pain. A randomized, double-blind study. Neurology 2001; 56: 1290-1293.
- 30. Yelland M, Glasziou P, Bogduk N, et al. Randomised controlled trial of prolotherapy injections, saline injections and exercises in the treatment of chronic low back pain. Spine 2003. In press.
- 31. van Tulder MW, Ostelo R, Vlaeyen JWS, et al. Behavioral treatment for chronic back pain. A systematic review within the framework of the Cochrane Back Review Group. Spine 2000; 25: 2688-2699.
- 32. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997; 22: 2959-2967.
- 33. Waddell G, Gibson A, Grant I. Surgical treatment of lumbar disc prolapse and degenerative lumbar disc disease. In: Nachemson A, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott, Williams and Wilkins, 2000: 305-325.
- 34. Bennett G, Serafini M, Burchiel K, et al. Evidence-based review of the literature on intrathecal delivery of pain medication. J Pain Symptom Manage 2000; 20: S12-S36.
- 35. Heavner JE, Racz GB, Raj P. Percutaneous epidural neuroplasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anaesth Pain Med 1999; 24: 202-207.
- 36. Flor H, Fydich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992; 49: 221-230.
- 37. Moneta GB, Videman T, Kaivanto K, et al. Reported pain during lumbar discography as a function of anular ruptures and disc degeneration. A re-analysis of 833 discograms. Spine 1994; 17: 1968-1974.
- 38. Adams MA, McNally DS, Wagstaff J, Goodship AE. Abnormal stress concentrations in lumbar intervertebral discs following damage to the vertebral bodies: cause of disc failure? Eur Spine J 1993; 1: 214-221.
- 39. Waguespack A, Schofferman J, Slosar P, Reynolds J. Etiology of long-term failures of lumbar spine surgery. Pain Med 2002; 3: 18-22.
- 40. Graziotti PJ, Goucke CR. The use of oral opioids in patients with chronic non-cancer pain. Management strategies. Med J Aust 1997; 167: 30-31. <MJA full text>
- 41. Canadian Pain Society. Use of opioid analgesia for the treatment of chronic non-cancer pain – a consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage 1998; 3: 197-208.
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