Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:

1. Define the multidisciplinary treatment approach for chronic low back pain and differentiate between usual care and multidisciplinary treatment approaches.

2. Develop evidence-based treatment plans encompassing psychosocial, physical, pharmaceutical, and interventional therapies for patients with chronic low back pain.

3. Explain the benefits of a biopsychosocial approach to chronic pain.

Chronic low back pain (CLBP) is a global public health crisis with a mounting socioeconomic burden. CLBP, defined as pain lasting more than 12 weeks, has immense psychosocial and socioeconomic consequences.1 Low back pain has a lifetime prevalence of 84% and is the leading cause of years lived with disability and workdays lost.1 In the United States, low back pain and neck pain had the highest health care spending of 154 studied conditions resulting in $134.5 billion in expenditures with increasing prevalence.2 Indirect costs, including disability and work absenteeism, are estimated to be greater than $50 billion per year.3

CLBP is a multidimensional condition. Biopsychosocial components adversely impact mental health, employment status, and social and family functioning. Patient prognostic factors that contribute to the conversion from acute to chronic low back pain include pain severity and functional impairment, prior episodes of low back pain, and both psychosocial and workplace factors.1 The usual care directed for CLBP is often at the discretion of the treating health care provider, most often without consideration for a multidisciplinary approach. Patients with CLBP resistant to standard care have ongoing and recurrent symptoms and bear the most significant disease burden.4 Treatment of CLBP is challenging, as many treatment strategies are supported by low-level evidence resulting in mixed outcomes. Furthermore, the opioid epidemic is a health crisis with unprecedented rates of fatal overdoses, many of which are attributed to prescription medications.5

Multidisciplinary treatment approaches for CLBP are based on the biopsychosocial model identifying chronic pain as a complex interaction of physiological, psychological, and social factors.6 Screening for comorbid psychological and emotional disorders should be performed for all patients with chronic pain at the onset of treatment due to the frequency and negative influence of these factors on pain outcomes.6 Individualized treatment plans are developed targeting all facets of chronic pain, including physical, psychological, educational, social, and work-related components delivered by a team of health care providers.7 Multidisciplinary treatment teams, comprising a physician, nurse, psychologist, physical therapist, and occupational therapist, work synergistically to develop comprehensive patient treatment plans (Table 1).8 Multidisciplinary treatment goals include reducing pain and restoring physical functional capacity and psychosocial performance.7 An individualized approach, which underscores the patient's responsibility in healing, addresses symptomatology and response to treatment instead of being pain-free.

Table 1. Multidisciplinary Team Members' Roles and Responsibilities

Multidisciplinary treatment is an effective evidence-based approach for decreasing pain, disability, long-term work impairment, and opiate prescriptions.2 Conservative nonpharmacologic therapy is trialed before initiating pharmacologic or interventional treatments in a stepwise fashion (Figure 1). Multidisciplinary treatment has historically been focused on patients with CLBP that is resistant to standard therapies; however, early multidisciplinary treatments decrease work absenteeism and pain in patients with moderate pain, expanding program use beyond only those cases resistant to standard therapies.2 Described next are the specific components that comprise the multidisciplinary approach for the treatment of CLBP.

Figure 1. Multimodal treatment therapies used in a multidisciplinary program.

Physical Therapy

Physical therapy is a conservative treatment modality recommended for most patients with CLBP.6,7 Evidence-based treatments include general and specific exercise, manual therapy, education, relaxation training, functional modifications, and mobilization. Therapeutic exercises aim to strengthen muscles, increase soft tissue stability, restore range of motion, reduce kinesiophobia, and improve cardiovascular conditioning and proprioception.

In patients with CLBP without generalized pain, moderate- to high-intensity exercise is recommended. Patients with generalized pain should incorporate progressive, low-intensity, submaximal fitness, and endurance activities.9,10 Stabilization exercise programs may be substituted in patients who cannot tolerate general exercise with equivalent effectiveness.9

Thrust manipulation and nonthrust mobilization improve spine and hip mobility, reducing pain and disability.9 In patients with referred lower extremity pain, treatments using repeated movements in a specific direction promote centralization of symptoms, which in turn reduces pain.9,10

Patient education and reinforcement are integral to patient ownership; therapies incorporating both fear avoidance and traditional physical therapy are more effective than monotherapy.3 Compared with usual care, patient-focused education decreases disability, reduces pain catastrophizing, improves pain beliefs, and increases range of motion.9 Inclusion of evidence-based pain neuroscience education improves the overall prognosis for low back pain. Educational topics should include active pain-coping strategies; reducing fear and catastrophization; and early resumption of everyday activities focusing on improvement in activity levels.9

Treatments addressing fear avoidance combined with physical therapy are more effective than physical therapy alone, based on long-term follow-up.10

Occupational Therapy

Occupational therapists identify individual physical determinates of disability and effects on occupational and vocational activities, developing a cost-effective treatment plan. An estimated one-third of chronic pain patients cannot live independently, and two-thirds cannot perform routine daily activities without assistance. Interventions including graded activity, pacing, energy conservation strategies, and ergonomic modifications at work and home have reduced pain and increased return to work in patients with CLBP. Occupational therapists also give instruction on body posture and mechanics, which can further improve patient outcomes. However, few randomized controlled trials detail the benefits of occupational therapy with the need for further investigation.11 Improvement in physical function is directly correlated to changes in pain beliefs.12

Cognitive-Behavioral Therapy

Patients with chronic pain disorders often have comorbid psychological conditions and maladaptive cognition. This includes catastrophizing and fear-avoidance beliefs, which are predictive of low back chronicity.12 Furthermore, motivation for secondary gain and perceived financial incentives for remaining disabled is an independent risk factor for treatment failure. This results in increased disability days and reduced treatment adherence. The biopsychosocial approach addresses and manages this psychopathology.7 Patients who adopt a sick role and are preoccupied with pain and disability often relinquish social and occupational responsibilities.8

Cognitive-behavioral therapy (CBT) encourages a proactive role in the recovery process, developing motivation and accepting a multidisciplinary treatment approach with the goal of using positive reinforcement to replace maladaptive cognitions, emotions, and behaviors through the use of coping strategies. Focus is transferred from a passive recipient of curative treatment to an active participant in functional and vocational restoration, reducing health care use, despite the pain.13

Pharmacologic Therapy

Nonpharmacologic therapy is preferred over pharmacologic treatment for management of CLBP. A short-duration treatment may provide symptomatic relief of CLBP while allowing patients to participate in active therapies. The American College of Physicians Clinical Practice Guidelines recommend pharmacologic therapies when patients have had an inadequate response to conservative nonpharmacologic treatment and recommend against using chronic opiate therapy in the treatment of CLBP.14

Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line pharmacologic therapy for back pain.15 NSAIDs inhibit cyclooxygenase (COX) isoenzymes, which in turn block the conversion of arachidonic acid to prostaglandins. Prostaglandins mediate inflammation and sensitize peripheral nociceptors.16

NSAIDs should be used at the lowest effective dose for the shortest duration to limit renal, cardiovascular, and gastrointestinal systemic side effects.15 Acetaminophen may be substituted as first-line therapy when there are contraindications to NSAIDs. Acetaminophen weakly inhibits COX isoenzymes inhibiting prostaglandin synthesis.16 Acetaminophen is inferior to NSAIDs when used for CLBP but has a lower risk for adverse events and lower cost.17 Acetaminophen overdose is the most common cause of acute liver failure in the United States. Patients must exercise caution when using concomitant acetaminophen-containing drugs.15

Antispastic and antispasmodic muscle relaxants indirectly act on skeletal muscle. These medications do so by inhibiting central polysynaptic neuronal events.15 There are limited trials investigating muscle relaxant effectiveness in CLBP. Antispastic agents are not recommended for nonspecific CLBP. Instead, they may treat spasticity secondary to central nervous system injury. Antispasmodic agents are effective for acute symptomatic relief of CLBP flairs when used in a short duration (<2 weeks). Side effects include dizziness and drowsiness.18 Benzodiazepine muscle relaxants are not recommended for treatment of CLBP due to increased risk of addiction potential and side effects including drowsiness, fatigue, and respiratory depression.18

Tramadol and more potent opiates should only be considered in severe, disabling pain refractory to more conservative modalities and only for a limited duration.15 Tramadol is a prodrug metabolized by CYP3A4 and CYP2D6, inhibiting serotonin-norepinephrine reuptake and acting as a partial [mu]-opioid receptor agonist.13 Tramadol use in CLBP is associated with a moderate decrease in pain and a slight improvement in function. Still, it is associated with an increased risk of suicide, seizures, abuse, and serotonin syndrome.15,19

Opioids are not recommended in the routine management of chronic pain. Long-term use has been shown to precipitate hyperalgesia and central sensitization. Opioids act on G-protein-coupled opioid receptors inhibiting adenyl cyclase, decreasing voltage-gated calcium channels' conductance, and opening rectifying potassium channels.15 Complications of opioid use include nausea, dizziness, constipation, drowsiness, dry mouth, respiratory depression, and abuse disorders. If opioid medications are prescribed, patient screening is integral, as a history of mental health or substance use disorders increases the risk for developing opioid misuse.5 A discussion of risks and practical benefits is recommended before treatment, with frequent reevaluations of efficacy, adverse effects, and aberrant behavior.17,18 Interdisciplinary pain care decreases opioid use and misuse in chronic pain patients resulting in improved functioning, psychological symptoms, and emotional quality of life.15

It is estimated that 50% of patients with CLBP experience comorbid depression, with the treatment of both depression and pain resulting in improved outcomes.18 Serotonin-norepinephrine reuptake inhibitors (SNRIs) provide analgesic effects by inhibiting serotonin and norepinephrine reuptake and modulating descending pain inhibition. Duloxetine is the most effective SNRI, decreasing pain intensity and improving functionality when compared with placebo.17 The most common side effects of SNRIs are dry mouth, nausea, dizziness, headache, and insomnia.15 Tricyclic antidepressants and selective serotonin reuptake inhibitors result in no difference in pain or depression compared with a placebo.17

Antiepileptics are commonly prescribed for neuropathic pain; however, there is limited evidence supporting their use in the treatment of CLBP with and without sciatica. Gabapentinoids inhibit voltage-dependent presynaptic calcium channels. These medications act at the [alpha]-2-[delta]-1 subunit, inhibiting the release of excitatory neurotransmitters.20

In a 2017 meta-analysis, patients with chronic pain who took gabapentin and pregabalin showed no difference in pain scores when compared with those taking a placebo. Associated drowsiness and fogginess were limiting their use.20 Antiepileptic topiramate has multiple binding sites. The medication inhibits voltage-sensitive sodium and calcium channels, potentiates [gamma]-amino butyric acid (GABA), and inhibits glutamate receptors. Topiramate is effective in CLBP, decreasing pain, pain sensitivity, disability, and promoting weight loss, but has significant side effects.17

Interventional Procedures

Patients resistant to medical therapy are evaluated for interventional procedures, which decrease opioid use and increase functionality in properly selected patients.21

Predictors of treatment failure with interventional treatment include:

1. Poorly controlled psychiatric disorders;

2. Catastrophizing and fear-avoidance behavior;

3. High baseline levels of disability and pain scores;

4. Chronic opioid use;

5. Previous spine surgery; and

6. Poor patient selection.15

The most common cause of CLBP lumbar facet joint degeneration is exacerbated with lumbar extension and rotation.22 Facet joints are innervated by 2 medial branches of the dorsal ramus of a spinal nerve root, 1 from the same level and 1 from the level above. A diagnostic medial branch block with small amounts of local anesthetic is the most reliable diagnostic test. After a successful diagnostic block, a therapeutic radiofrequency (RF) ablation of the medial branches may be performed, providing pain relief and functional improvement lasting 6 to 12 months.22 Intra-articular facet joint corticosteroid injections have limited supporting evidence but may be substituted in patients with contraindications to RF ablation.22

Sacroiliac (SI) joint pain is located primarily in the gluteal region and is most common in patients with spondyloarthropathies, advanced age, or post-lumbar fusion.15 SI joints innervation is supplied by ventral rami of L4 and L5, dorsal rami of L5, S1, and S2, and the superior gluteal nerve. Intra-articular corticosteroid injections, although diagnostic, have limited evidence supporting short- or long-term pain relief.22 Cooled RF ablation is more effective than conventional RF, which spares dorsal branches. Cooled RF can improve pain, disability, physical function, and quality of life for more than 9 months.22

Epidural corticosteroid injection (ECI), performed via interlaminar, transforaminal, or caudal approaches, may provide pain relief for up to 3 months in selected patients.15 Level I evidence supports the use of ECI in radiculitis and herniated disc pain.23 Level II evidence exists for interlaminar or caudal ECI for spinal stenosis (lumbar extension causing neurogenic claudication). Level II evidence also exists for caudal ECI for the postlaminectomy syndrome.23 Fluoroscopic or CT guidance improves effectiveness and decreases complications.22 Serious complications, although rare, include intrathecal (IT) injection, epidural hematoma, spinal cord injury, and embolic infarction after intra-arterial injection of particulate corticosteroids.

CLBP causes changes in the neurophysiological processing of nociceptive information. These changes include hyperalgesia, reduced endogenous analgesia, and decreased mechanoreceptive and proprioceptive perception.24

Neuromodulation delivers targeted electrical impulses to nerves, modulating abnormal neural pathways to decrease pain. Spinal cord stimulation (SCS) effectively prevents mixed neuropathic pain and refractory CLBP with predominant limb pain-reducing pain scores, improving quality of life, and reducing cost.24 Traditional SCS delivers electrical impulses to myelinated sensory fibers in the dorsal column, interrupting pain transmission.25

Stimulation is provided through percutaneously or surgically placed electrodes in the epidural space. The electrodes are connected to an external power source with 40- to 60-Hz pulse frequencies.24 The trial period for the temporary leads usually lasts between 3 and 10 days. The trial results are used to determine whether the placement of a subcutaneously implantable pulse generator is indicated.22 High-frequency (10,000 Hz) SCS provides a subthreshold stimulation without producing paresthesia. This form of stimulation is more effective for back, leg, and radicular pain than traditional SCS. SCS is regarded as a safe, minimally invasive procedure with reversible minor complications occurring up to 40% of the time. Serious complications such as infection, allergic reaction, epidural hematoma, dural puncture, and neurologic injury are rare.24 Tolerance to SCS may occur in as many as 29% of patients, where increased pulse amplitude is needed to achieve analgesic benefit.22

Dorsal root ganglion (DRG) SCS is useful to treat localized areas of pain, which are difficult to treat with traditional SCS. The DRG contains the cell bodies of peripheral sensory neurons at each spinal level. DRG SCS delivers electrical impulses to these afferent fiber types.25 Peripheral nerve field stimulation (PNFS) stimulates primary afferent neurons.26 Multiple stimulator leads are placed subcutaneously at the sites of maximal lumbosacral pain. There have been few serious complications.22 PNFS in combination with SCS is more effective in reducing pain scores in chronic axial back pain when compared with SCS alone.

IT infusion devices are used in refractory noncancer pain to control pain and reduce opiate medication usage and systemic side effects. A catheter is placed within the dural sac, delivering medication directly to the spinal fluid, bypassing the blood-brain barrier. IT therapy is more resistant to tolerance than is SCS, with effectiveness for up to 6 years. However, IT use in noncancer pain has mixed evidential support. IT infusion is indicated only after the failure of more conservative treatments. Candidates must complete a detailed physical and psychosocial examination due to high costs and severe side effects.27 Specifically, IT granuloma formation at the catheter tip can result in spinal cord compression.22 Ziconotide, a first-line therapy for neuropathic and nociceptive pain, blocks presynaptic N-type calcium channels in the dorsal horn of the spinal cord. This medication has been shown to raise creatine kinase values, and levels should be checked at baseline and intermittently during use.

Integrative Therapies

Movement-based treatments can also play a significant role in multidisciplinary treatment strategies. Yoga is a total mind-body workout that combines strengthening and stretching poses with deep breathing and meditation. In patients with mild CLBP, yoga offers improvements in pain and function. Aerobic exercise alone improves pain, disability, and mental health in patients with nonspecific CLBP.28 Spinal mobilization techniques such as thrust manipulation and nonthrust mobilization can improve spine and hip mobility, reducing pain and disability.28 The improvements may not be clinically meaningful due to low baseline pain or disability.29

Acupuncture and acupuncture-related therapies such as dry needling and electroacupuncture are based on the amalgamation of health systems worldwide, including China, Japan, Russia, Canada, Korea, France, and the United States. The proposed mechanism of action for acupuncture is that it stimulates high-threshold small-diameter nerves located in the spinal cord, brainstem periaqueductal gray matter, and hypothalamic neurons. This, in turn, triggers endogenous opioid mechanisms.13 The evidence supports the use of this therapy to treat pain and prevention and treatment of nausea and vomiting.28 In CLBP, acupuncture is a cost-effective therapy resulting in short-term improvement in pain and function, when compared with usual care.10 However, many of the clinical studies performed on acupuncture lack sufficient sample size, follow-up, and outcome measures, decreasing statistical power and significance. Side effects are uncommon but include bleeding, infection, dermatitis, and retained needle fragments.13

Limitations of Multidisciplinary Treatment for CLBP

Establishing a multidisciplinary team requires substantial upfront costs and creates reimbursement challenges from third-party insurance payers.8 Comprehensive pain care decreases overall health care costs by reducing additional surgical procedures and overall health care use. Furthermore, patients are more likely to return to work and have improved quality of life when compared with conventional treatment. Early use of a multidisciplinary approach is imperative, as the first year of chronic pain treatment is the most expensive and labor-intensive.8 Further studies are needed comparing the direct and indirect costs of a multidisciplinary approach compared with usual care. Such data could lead to increased program use and reimbursement.8

Intensive and integrated rehabilitation may span 6 to 8 hours per day over 6 weeks, resulting in noncompliance in patients who continue to work.8 A less time-intensive program of 4 days per month can improve disability, pain, work outcomes, and psychological status in patients with moderate pain, allowing broader implementation.

Communication is paramount so that all clinical team members develop integrative treatment plans.8 Coordinating treatment team meetings may be complicated; however, the implementation of virtual platforms has made communication easier. The Reboot Online randomized controlled study compared evidence-based, multidisciplinary online treatment programs to usual care in chronic pain patients. Participants in the Reboot Online group reported more significant improvements in pain self-efficacy, pain severity, movement-based fear-avoidance, pain-related disability scores, and psychological distress versus those in the usual care treatment group.29 The use of telemedicine has expanded access to multidisciplinary care and improves patient coordination and treatment team communication for patients with CLBP, but limits physical examinations and raises concerns over reimbursement.29

Conclusion

CLBP is a global pandemic with increasing prevalence and health care expenditures. Multidisciplinary treatment programs provide evidence-based care for patients with CLBP, decreasing pain and work absenteeism while improving functionality. An individualized, evidence-based treatment program comprising CBT, physical therapy, occupational therapy, and pharmacologic, interventional, and integrative therapies can reduce health care use and expenditures. Traditionally, access to care from multidisciplinary teams has been limited; however, with increasing use of telemedicine, the multidisciplinary approach could become more accessible, resulting in increased use and improved outcomes.

References