The Origin of Lower Back Pain (Part II)

Despite the LBP issues mentioned previously, interventions have become commonplace based on the “pain generator.”

Dr. Gene Carragee of Stanford University evaluated discography and found positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness.⁸

Dr. Roger Chou, et al., discussed nonsurgical interventional therapies for LBP: and reviewed the evidence for the American Pain Society to develop clinical practice guidelines. The report in Spine (2009) reflected, “Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.”⁹

Varying perceptions of and treatment for LBP

Our experience tells us that our patients vary in their perception of pain.

Lloyd reported “successful adjustment to chronic LBP is associated with a patient’s ability to effectively engage a sensory modulation system. In patients in whom such activation does not occur, subjective lack of control may predispose to altered affective and behavioral responses with poor adjustment to pain. Pain experience may be further modified by reorganization of somatosensory cortex, contributing to maintenance of the chronic pain state.”¹⁰

The brain appears to be remapping circuitry based on chronic pain. The patient visit presented with a complaint of LBP that may alter the somatosensory cortex.

An Israeli study in 2009 showed symptom resolution for a new LBP complaint was significantly higher in patients who decided on the general practitioner, even when controlling for severity of illness and degree of disturbance to everyday functioning. Health status after one month showed that patients who chose the general practitioner were more likely to have their problem solved (36 vs. 17%, P < 0.05).¹¹

Lambeek, et.al. assessed the efficacy of an integrated care program for LBP against that of a more conventional care program, as a means of helping patients with this condition return to work. In the study, one group received integrated care from a team made up of a clinical occupational physician, a physical therapist, an occupational therapist, and a medical specialist. Another group received the usual type of care for chronic back pain, administered by a medical specialist, general practitioner, occupational physician, and/or allied health care professionals.

Members of the integrated care group achieved a full, sustainable return to work in a median period of 88 days, while the same was accomplished in the conventional care group after a median 208 days. By the 12-month follow-up, the integrated care group had experienced significantly greater improvement in functional status than had the conventional care patients. However, the investigators found no significant difference in pain reduction between the two groups at 12 months.¹²

Thus, though the pain reduction remained similar, the adaptation was more successful in the multidisciplinary group. “Though the patient may have the same pain, they don’t feel the same way about it. The pain doesn’t impact functioning the way it used to. It doesn’t make me feel disabled.”³

Finding the “pain generator” for the lumbar spine requires careful and broad assessment, using all the tools necessary to define the issue.

The issue remains complex. Interventions and surgery wisely used result in good outcomes.

The question remains: Have we identified the “pain generator?”

3 The Back Letter. Vol 26, No. 2, February 2011
8 A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography. Carragee, E., et al. Spine: 15 August 2006 - Volume 31 - Issue 18 - pp 2115-2123
9 Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline Chou, R., et al. Spine: 1 May 2009 - Volume 34 - Issue 10 - pp 1078-1093
10 Differences in Low Back Pain Behavior Are Reflected in the Cerebral Response to Tactile Stimulation of the Lower Back. Lloyd, D., et al., Spine: 20 May 2008 - Volume 33 - Issue 12 - pp 1372-1377
11 Neville, A., et al., Acute Low Back Pain: Is Gatekeeping Second Best. Isr Med Assoc J. Nov 2009; 11(11):647-51
12 Lambeek, L., et al., Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ. Mar 16 2010;340:c1035.