In my opinion this summarizes the current status of pain management, up quite well. The question is do you believe there is a magic technique? Low back pain (LBP) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies, opiod medications, spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach, and evidence that only 8–15% of patients with LBP have an identified patho-anatomical diagnosis, resulting in the majority being diagnosed as having non-specific LBP.3 The physiotherapy, manual therapy and medical professions have long focused on trying to find the magic ‘technique’, ‘muscle’, ‘injection’ or ‘surgical technique’ required to solve the problem of NSCLBP and PGP disorders. This reductionist approach to dealing with complex disorders in a simplistic manner clearly hasn’t delivered for our patients50 and contradicts current knowledge that NSCLBP should be considered within a multidimensional bio-psycho-social framework. In fact, it has been proposed that single-dimensional approaches may in fact exacerbate chronic disorders reinforcing a cumulative feedback loop.29 In response to the calls to manage NSCLBP from a bio-psycho-social perspective, a number of RCTs have tested cognitive behavioural approaches to more effectively manage the disorder. Yet systematic reviews of these approaches have failed to demonstrate greater efficacy than other active conservative approaches in managing NSCLBP.51 Possible reasons for this failure may relate to the lack of patient-centred and targeted management52 as well as a failure to address other dimensions such as neuro-physiological factors and maladaptive lifestyle and movement behaviours known to be associated with NSCLBP disorders.18 20 30 There is strong evidence that NSCLBP disorders are associated with a complex combination of physical behavioural, lifestyle, neuro-physiological (peripheral and central nervous system changes), sychological/cognitive and social fac- tors.12 20 30 These factors together have the potential to promote maladaptive cognitive behaviours (negative beliefs, fear, avoidance, catastrophising, hypervigilance),53 pain behaviours (pain communicative and avoidant behaviours)54 and movement behaviours,30 setting up a vicious cycle of pain sensitisation and reinforcing dis- ability. Changes in immune and neuro- endocrine function linked to altered stress responsiveness coupled with activation of the pain neuro-matrix in the brain may result in tissue hyperalgesia and altered neuro-muscular responses.1 Ref.: OSullivan P. Its time for change with the management of non-specific chronic low back pain. Br J Sports Med. 2012 Mar;46(4):224-7. Epub 2011 Aug 4. Via Lars Avemarie
Posted on: Mon, 24 Mar 2014 13:48:19 +0000
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