Multidisciplinary Treatment of Back Pain

“Viewing chronic nonmalignant pain in strictly disease model terms is the moral equivalent of kicking the refrigerator when the TV does not work.”
—Wilbert Fordyce, Ph.D., 1994

Back pain is universal and is the leading cause of disability and absenteeism from the workplace, yet specific causes of back pain, such as infections, tumors, osteoporosis, spondyloarthopathies and trauma, represent a minority of pain syndromes.(1) Conversion of acute back pain to chronic may be in part iatrogenic and is often strongly driven by psychological and psychosocial factors including fear of pain and re-injury, catastrophizing, depression, anxiety and fear of “decompensation” (loss of income or secondary gain).(2, 3, 4) Failure to address and treat these issues in chronic back pain often leads to continued disability.

Chronic pain is a complex social problem with medical aspects and should be assessed and treated as such. Towards such ends, a multidisciplinary assessment of the patient can identify important psychological and psychosocial variables and help drive appropriate treatment. A multidisciplinary evaluation of back pain should include a thorough medical evaluation of the spine, surgical and interventional consultation as appropriate, evaluation by a PT specializing in back pain to help address fear of movement and pain as well as biomechanical issues, and, at a minimum, a screening for perceived level of disabilityand mood disturbance, including depression and anxiety – both are found in the literature to contribute significantly to the perception of pain. Once these issues have been identified, treatment can focus on reducing pain and improving mood and function.

The natural history of low back pain is variable; however, it is clear that the vast majority of patients recover quickly. The task of early identification of those who may progress to a Chronic Pain Syndrome has largely been elusive. Although recognizing a Chronic Pain Syndrome is relatively easy once it has occurred, predicting its development has been harder. A number of personality characteristics have been thought to predict chronicity (age, sex, specific diagnosis, marital status, education, income, history of anxiety and depression, and current depression), but, in fact, the findings in the literature are not consistent. When variables are identified, they account for little of the variance when examined statistically. Once it has developed, however, a Chronic Pain Syndrome is characterized by intractable pain along with marked changes in behavior, affect, restrictions of daily activities and an overutilization of health care recourses.

Simply identifying the physical factors involved in the manifestation of the chronic pain and prescribing somatic treatments have been shown not to eliminate eliminate these symptoms for a significant subgroup of patients. A number of factors may contribute to the development of Chronic Pain Syndrome, and some may include pending litigation, an avoidance of responsibility, assumption of the sick role, avoiding an unpleasant work environment and taking on the role of a patient.Many of these characteristics and the emotional symptomatology found in the Chronic Pain Syndrome are amenable to behavior modification and are treated well with cognitive behavioral therapy and psychophysiological pain and stress management techniques, such as biofeedback, relaxation training and self-hypnosis. Successful rehabilitation relies on the appropriate treatment for mood disturbance, including antidepressant medication and psychotherapy, as well as the reinforcement of wellness behaviors, such as activity and removal of reinforcements for pain behaviors.

General References
1. Ehrlich GE. J Rheumatology 2003.

2. c.f. Vowles and Gross Pain 2003.

3. Hadjistavropoulos et al Behavior Research and Therapy 2000.

4. Systematic Review of Psychosocial Factors at Work and Private Life as Risk Factors for Back Pain. Spine. 25(16):2114-2125, August 15, 2000. Hoogendoorn, Wilhelmina E. MSc

Spinal Column, Spring 2005. Cleveland Clinic Spine Institute (CCSI).
Copyright @2005. Cleveland Clinic Foundation. All Rights Reserved.
http://cms.clevelandclinic.org/spine/documents/Spinal%20Column%20Sp05.pdf