Managed Physical Medicine

What Is Pain? New Considerations in the Treatment of Low Back Pain

Recent studies on biological and psychological processes are informing how we understand low back pain. How does this new research translate to the clinic?

This blog is part 2 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”

In the last decade, mainstream treatment of low back pain (LBP) has broadened from a sole biomechanical focus to a more holistic approach informed by how pain is processed in the brain.

New evidence-based frameworks have emerged to help guide conversations about pain between providers and patients. We interviewed MedRisk Advisory Board member and a leader in low back pain treatment, Dr. Philip W. McClure, PT, PhD, FAPTA, about this developing shift in the field.

How has our understanding of LBP evolved over the years?

Twenty years ago, patients who presented complaining of pain with no physical evidence were often labeled as looking for secondary gain. It was believed that low back pain was solely caused by excessive mechanical load injuring the tissues – and so the treatment was focused primarily on mechanical methods as well. We have learned a lot over the last decade, and now we understand that pain can be experienced without ongoing tissue damage or harm. We call this phenomenon central sensitization. The nervous system is recognized as an active part of the pain process that can change over time and, therefore, contribute to persistent pain conditions. Rather than a simple mechanical model of tissue overload, we now recognize that pain can also be the result of complex interaction between inflammatory and biochemical processes as well as the psychosocial environment.

How has this informed LBP treatment?

Up until recently, only providers who were really in tune with their patients may have dug deeper than the physical exam to understand contributors to their pain. Now, that process is far closer to mainstream. This is due in part to simple classification schemes that are being embraced by practitioners to help assess patients’ pain early on. The STarT Back Screening Tool is a nice example; it’s been shown to decrease disability from back pain, reduce time off work and reduce costs by making better use of health resources. STarT Back is a simple survey you can run through with patients that helps put them into categories of low, medium or high risk of poor outcome by asking questions about how their low back pain has affected their daily habits as well as how they perceive the severity of their injury. Being able to do this helps a general practitioner say, “This is a high-risk patient; they need more than the usual” versus “This is a low-risk patient, and they are likely to do well.”

How do providers go about discussing this new understanding of pain with patients?

The science of how to most effectively communicate about pain with patients is growing dramatically, but there is still a lot of work to be done to ensure best practice becomes common practice. Essentially, we need to teach LBP patients that, based on what we know about how the brain processes pain, pain does not always equal harm. We need to avoid fear-invoking words and images that are common medical terminology and instead use words that promote the ability to engage in activity and encourage confidence. For some patients, practitioners need to explain that it is safe to keep moving despite the pain and that actual physical activity can make you feel better. But there is an art to saying, “We believe you hurt, and we are going to give you our best care” while also saying “You need to stay active.” The reality is the best care includes staying engaged and staying active. Unfortunately, patients aren’t always getting this message.

What implications does this have for workers’ comp patients?

How an employee’s injury is managed early on may have significant effects on their recovery downstream. A common example is a patient who has injured their back at work. If the company says we only want you back when you’re 100%, then the patient is out of work, gets used to being out work and gains an identity as an injured worker. For some patients, this may lead them to think, “It’s not safe for me to work, so it must not be safe for me to be active” when, as we’ve discussed, this is usually not the case. Companies and patients benefit when employers are able to find modified duty to help keep workers engaged even if they are not at full duty yet. Those involved in work-related social activities have a far better prognosis for durable return to work.