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10 Articles in Volume 13, Issue #10
Poor Adherence to Opioid Pain Management Regimens
A Practical Approach to Discontinuing NSAID Therapy Prior to a Procedure
Opioid-induced Osteoporosis: Assessing Causes and Treatments
Persistent Acute Lower Back Pain: The Importance of Psychosocial Evaluation
Research Advance Of The Year
A Day of Consulting in Rural America
Ask the Expert: Should You Test For and Treat Opioid-induced Hypogonadism?
Ask the Expert: Do NSAIDs Cause More Deaths Than Opioids?
News Briefs
Letters to the Editor

Persistent Acute Lower Back Pain: The Importance of Psychosocial Evaluation

Physicians need to recognize the ‘yellow flags’ that help identify patients at risk of developing chronic pain. Early intervention is key to prevention of disease progression.


Case Example

JB is a 56-year-old male who reports low back pain at his annual health examination. However, he is not seeking treatment for it. He indicates that he “doesn’t have time to worry about it,” with all the duties that maintaining his Midwestern farm requires, and he feels that “nothing can probably be done, anyhow.”

Low back pain is one of the most common pain conditions, affecting most people at some point in their lives.1-3 Data collected over three decades (1980-2009, inclusive) indicate that the 1-year incidence of any episode of low back pain (first ever or recurrent) ranges from 1.5% to 36%.1 Most episodes are short-lived; however, many patients experience multiple episodes of low back pain, and some patients develop chronic low back pain.2,4,5

Approximately half of these patients have recurrence of their low back pain within 1 year, and 70% have recurrence within 5 years.1 The annual prevalence of chronic low back pain has been estimated to be as high as 45%.2 Because chronic low back pain is a major cause of disability and associated healthcare costs,6,7 preventing the transition from acute to chronic pain is desirable.

Individuals with chronic low back pain have more comorbidities and use more pain-related medications and healthcare services than individuals without chronic low back pain.6 In a retrospective insurance claims analysis of data from 2008, mean (standard deviation [SD]) direct medical costs were $8385.97 ($17,507.11) and $3606.63 ($10,844.50) for patients with and without chronic low back pain, respectively.6 Practitioners must therefore remain aware of the many treatment options available for managing persistent acute pain (pain that lasts longer than required for usual healing but for less time than would be considered ‘chronic pain’) to be able to provide individualized therapy for patients, with the goal of preventing conversion to chronic low back pain.8-10

Although this idea is still somewhat controversial, the conversion of acute low back pain to chronic low back pain appears to be able to be prevented in some cases with appropriate intervention during the period in which acute pain persists.11 Identifying and managing patients at risk for conversion to chronic pain is, therefore, vital to preventing chronic low back pain and associated disability. The current case-directed review discusses how to identify and manage treatment of patients with persistent, acute low back pain; that is, acute, low back pain that has persisted beyond 4 to 6 weeks, as a possible means of preventing the transition to chronic pain.

Identifying Patients at Risk

Case Example

ML is a 48-year-old man who reports that he has been experiencing low back pain for 6 weeks. Since he began experiencing low back pain, he has tried to reduce his physical activity “as much as possible,” because he is concerned that physical activity will make the pain worse. He reports that he lives alone, does not have many friends, and that the pain has caused him to miss work and stay at home more because he “has been feeling down and just doesn’t want to go out.”

This patient is not alone. Results of a 2010 systematic review of the literature suggest that multiple factors may predict the development of persistent, disabling low back pain, including high levels of maladaptive pain coping behaviors, the presence of nonorganic signs, high levels of functional impairment at baseline, low general health status, and the presence of psychiatric comorbidities.12

Psychosocial factors may be particularly useful for predicting chronicity in low back pain.13 These include “yellow flags,” which are characteristics indicative of psychosocial barriers to recovery (Table 1).14 Depression and “maladaptive cognitions” (eg, somatization, rumination, and negative attitudes toward work and activity) may also signal a risk for low back pain persistence.15

Pain catastrophizing, or the tendency to dwell on the most negative consequences conceivable, also has been associated with disability.16 Furthermore, patients who avoid activity and social interaction due to fear of pain, as well as those who experience low mood and/or seek passive rather than active treatments, also are at increased risk for poor outcomes.13 The fear-avoidance model of chronic pain (Figure 1) summarizes the relationship between anxiety; escape and activity avoidance; disuse, disability, and depression; and pain perpetuation.16,17

Employment and workplace factors with physical and psychological impact, such as heavy manual labor, prolonged walking or standing, monotonous work, and job dissatisfaction, also may contribute to low back pain development and persistence.1,2,18 Additional contributing factors include lifestyle and social-demographic risks such as obesity, smoking, low socioeconomic class, low education level, and increasing age.1,2 However, despite observed relationships between smoking and obesity and low back pain, smoking cessation and weight loss interventions have not been shown to reduce long-term disability.19

Clinicians have a variety of tools to help identify patients like the sample patient above, who are at risk for developing chronic low back pain. The presence of recovery-limiting yellow flags can be detected through casual questioning during the patient interview (Table 2).13

Structured questionnaires, such as the Pain Catastrophizing Scale,20 the Fear of Pain Questionnaire,21 the Fear-Avoidance Beliefs Questionnaire,22 and the Coping Strategies Questionnaire,23 also can be used to determine the risk for catastrophizing. Additionally, identification of the patient’s avoidance-
endurance model response subtype may prove useful, because 3 of the 4 response subtypes (fear-avoidance, distress endurance, and eustress [ie, “healthful stress”] endurance) have been associated with increased risk of future pain problems.24 Conversely, patients who demonstrate adaptive responses to their pain have a greater likelihood of recovery. Examples include pacing one’s activities with rest periods during the day and using cognitive strategies, including cognitive restructuring.

Developing Management Strategies

Staying active is recommended for almost all acute back pain patients. Patients who are very acute and can barely turn over in bed should ambulate as soon as possible without great increases in pain and receive counseling regarding the expected course of their condition and effective self-care options.25,26 Bed rest should be discouraged.26

The short-term administration of pharmacologic therapies (eg, acetaminophen or non-steroidal anti-inflammatory drugs [NSAIDs]) should be considered,25,26 with the goal of facilitating continued activity by relieving associated discomfort. Whereas no optimal pharmacologic treatment approach has been identified for patients with persistent acute pain, providing around-the-clock pain management during this crucial period may help encourage increased activity by reducing the pain as a barrier.

Reducing Catastrophizing

Casual questioning of ML reveals that he exhibits multiple “yellow flags” suggestive of psychosocial barriers to recovery (eg, believes that activity is harmful, spends most of his time in bed, and lacks family support). Although ML has been prescribed physical therapy, he has attended only 1 session. He complained to his doctor that the physical therapy hurt too much and required too much effort. On subsequent doctor visits, he has requested prescriptions for massage therapy instead of physical therapy.

Cognitive and behavioral therapies,27-30 physiotherapy and other activity-based interventions,31 intensive patient education (eg, about the neurophysiology of pain), and exposure interventions32,33 can reduce catastrophizing. The presence of yellow flags14 may signal the need for such therapies,34,35 and selection of targeted interventions based on the presence of specific yellow flags may help improve outcomes in patients.35

Treatment programs typically comprise multiple components, such as education, relaxation, modifying thoughts and feelings, and scheduling pleasant activity.27 Appropriate counseling may help prevent disability by providing patients with assurance that their condition has a favorable prognosis and reasonable recovery expectations, and that effective strategies are available for dealing with their fears.36

Psychological interventions can help reduce pain intensity, pain interference, fear-avoidance beliefs, work-related disability, time for sick leave, and depression; increase the number of pain-free days that a patient experiences; and improve health-related quality of life.28,29 In one randomized, controlled trial conducted in 253 individuals with neck or back pain symptoms, cognitive-behavioral intervention reduced the risk of disability three-fold (odds ratio [OR] and 90% confidence interval [CI] for being on long-term sick leave, 3.33 [1.19 to 10.2] for usual therapy compared with cognitive-behavioral therapy).29

A smaller, randomized study, conducted in 67 patients with first-onset, persistent, acute low back pain (6 to 10 weeks’ duration) and impairment of work function, evaluated early intervention using a behavioral medicine rehabilitation approach. This approach included education about back function and pain, systematic graduated increases in physical exercise to quota with feedback, planning and contracting for activities of daily living, self-management and problem-solving training to cope with pain, contingent reinforcement of active functioning and non-reinforcement of pain behaviors, and vocational counseling. Use of this behavioral approach enhanced recovery and reduced occurrence of chronic pain and disability by approximately 15%, with even greater improvement observed among patients who completed the full course of therapy or attended booster sessions and received maximum therapy.11

Interventional Therapies

Case Example

TR is a 67-year-old woman with arthritis and spinal stenosis who does not want to be a bother to her children. She tends to stay at home because standing and walking activities increase her pain. She has noted that some types of pain medications (eg, ibuprofen, hydrocodone) decrease her pain level and allow her to be more active around the house and more social with her family, but she is worried about becoming addicted.

Interventional therapies benefit many patients but do not always prevent chronicity. Interventions that have demonstrated good or fair evidence of at least short-term, moderate benefit in certain clinical circumstances are summarized in Table 3.4 The benefits of several additional procedures (eg, caudal epidural injections, lumbar facet joint nerve blocks, lumbar radiofrequency neurotomy, and percutaneous adhesiolysis) remain controversial.37

Of course, clinicians also must consider the risks associated with interventional therapies when choosing strategies for individual patients. These may include potential for infection, allergic reactions, systemic side effects (eg, with corticosteroids), bleeding, cardiovascular response (eg, with sympathetic block), postdural puncture headache, and urological complications (eg, urinary retention).38 Although these events are not common, the potential for occurrence must be weighed against the anticipated benefits for the individual patient.

Interdisciplinary Rehabilitation

Case Example

NL is an active 38-year-old carpenter who complains that low back pain stemming from a recent injury is interfering with his work and his ability to coach his son’s soccer team. He was seen by the worker’s compensation doctor associated with his workplace, but he lost his job, was told the back pain was a pre-existing condition, and was denied for his worker’s compensation claim.

For patients at high risk for transitioning from persistent acute pain to chronic pain, early interdisciplinary intervention may prevent the development of chronic low back pain disability and provide cost savings.39,40 In one early intervention study conducted in 70 high-risk acute low-back pain patients, early interdisciplinary intervention with psychological, physical, and occupational therapies along with case management reduced healthcare resource utilization, pain medication use, and disability days, and also facilitated return to work. Associated reductions in costs per patient per year were considerable ($12,721 vs $21,843 for intervention vs non-intervention, respectively).39 In a more recent cost utility analysis, early interdisciplinary intervention was associated with a cost-utility ratio of $49,593/quality-adjusted life-year (QALY), which was lower than that observed with standard treatment ($71,001/QALY).40

Interdisciplinary rehabilitation is intense and time consuming, and is likely most useful in patients who are more engaged and able to participate.4 High cost, limited availability, and limited insurance coverage may render this approach impractical for some patients.


Early intervention may prevent the progression of persistent acute pain to chronic low back pain. Therefore, clinicians should attempt to identify underlying factors for progression in individual patients and direct therapy to address those factors.

All patients with low back pain should be advised to remain active and should be provided with information regarding the expected course of their condition and self-care options. Pharmacologic therapies may be useful for providing patients with relief from pain, with the goal of enabling them to continue normal physical activity and aid in rehabilitation while they are being treated for their pain.

Dr. McCarberg received technical editorial and medical writing assistance from Mary Tom, PharmD, Synchrony Medical Communications, LLC, West Chester, PA. Research support was provided by Mallinckrodt Inc, Hazelwood, MO.

Last updated on: July 27, 2015
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