Rehabilitation of Lumbar Spine Disorders: An Evidence-Based Clinical Practice Approach

Stefano Negrini

Fabio Zaina

Michele Romano

Salvatore Atanasio

Claudia Fusco

Carlo Trevisan

INTRODUCTION

The approach to low back pain (LBP) has changed dramatically in the past decades, while medicine has changed also (1, 2, 3, 4). Formerly, according to a classical disease model, all LBP classifications considered a pathoanatomic basis and consequently proposed treatments; but the increasing burden on society in terms of costs and disability (5), presumably due to inappropriate treatment and medical approach, lead to a revolution in the understanding of the problem (4, 6). Accordingly, LBP is now classified as secondary (<10% of cases) and primary, or idiopathic, or simply LBP; the latter is then divided according to the localization of symptoms (LBP and sciatica) and the duration of pain (acute, subacute, and chronic) (3, 7, 8, 9, 10, 11). Generally speaking, in this model LBP is recognized as a biopsychosocial syndrome (4, 12). Consequently, the importance of the discipline of Physical and Rehabilitation Medicine (PRM), as one with particular focus on biopsychosocial approaches according to the International Classification of Functioning (ICF) (13, 14, 15, 16, 17, 18, 19, 20), has greatly increased in this field (21, 22). As is always the case in medicine, these advancements require time to reach the clinical everyday world (10, 23, 24, 25, 26, 27). Today the clinical reality is a mix of different approaches, usually driven by what each single specialty, doctor, and/or allied professional knows and offers in terms of treatments, more than by a coherent and systematic evidence-based approach (28, 29). Considering the world of PRM and its inevitably multi-professional reality (14, 30), combined with the almost complete outpatient reality of LBP treatment, the confusion seems even higher than in other specialties (31, 32, 33, 34, 35). Moreover, considering the widespread recognition of LBP as a biopsychosocial syndrome, and consequently the crucial role PRM should have in its treatment, this confusion must be cleared away. That is the main aim of this chapter.

This chapter is fully evidence-based, but it is also totally focused on what to do in the clinical everyday world once the evidence is known: in reality it is an evidence-based clinical practice tool. Therefore, we will start from some clinical-scientific premises, including assessment and outcome criteria, the actual scientific evidence on treatments of PRM interest, and also the diagnostic-therapeutic pathways (flowcharts) (9) to be followed. In fact, another unavoidable premise is that in LBP rehabilitation, as well as in all other PRM approaches to patients who are diagnosed with a specific disease, a correct disease diagnosis is the first step and must be achieved. We cannot rehabilitate the patient if we do not start with diagnosis, and only after that can we look for a mandatory biopsychosocial picture of the patient, possibly inside the mainframe of ICF (17, 18, 36, 37, 38). Finally, we will have an evidence-based description of the single clinical LBP pictures of PRM interest, concluding with the rehabilitation approach to each of them.

The last important premise is one of terminology: rehabilitation is neither a pain-orientated (PO) nor a conservative treatment. From our perspective, the term “conservative treatment” should be abandoned because it is based on the past, when the only need was to define whether a LBP was surgical or not (21, 22). The term “conservative” is not the positive affirmation of what we have to be in regard to our patients. Instead it is only the negation of surgery, as if this were the gold standard. In the so-called field of conservative treatment there are abundant treatments that focus on pain (“PO treatments”); these have been traditionally used for years, and continue to be used, sometimes according to some evidence. However, with the increased scientific understanding of the limits of this PO approach (4, 5, 39), more complex rehabilitation approaches focusing on increasing function, on recovering activities and participation, and on rising quality of life have emerged and developed: we will call them functioningorientated (FO) approaches (40, 41, 42). These FO approaches are based on WHO’s understanding of functioning (13), representing the comprehensive view taken by PRM (14, 15, 16, 17, 18, 19, 20, 30). In most patients this is far more appropriate, and it should be the main concern of PRM specialists, who have the best conceptual tools with which to appropriately rehabilitate LBP patients (13, 14, 22, 30, 37, 38). This does not lead us to ignore PO treatments, which in some or many cases must be applied, but the differentiation is crucial to achieving a better understanding of our everyday behaviors, including their advantages and limitations.

ASSESSMENT, DECISION-MAKING PROCESS, AND REHABILITATON TREATMENT TOOLS

Assessment and Outcome Criteria

An appropriate diagnostic workup is the cornerstone of an effective treatment. It is founded on taking the most accurate medical history and conducting a thorough physical examination (8, 9, 10), both of which are useful in forging a good doctor-patient relationship. The first objective of assessing the patient who is experiencing back pain is to identify the patient who presents serious spinal pathology. It is possible to establish a well-defined pathology in only about 15% of patients who present LBP (43). Among patients suffering from LBP and sciatica for a period of approximately 4 weeks, Deyo et al., as well as Udén, were able to identify the following: herniated disc (4% to 5%); lumbar spinal stenosis (LSS) (4% to 5%); spinal fractures (4%), metastatic tumor or osteomyelitis (1%); and visceral pathologies such as aortic aneurysms, kidney, or gynecological disorders (<1%).

According to Waddell (44), when dealing with a patient suffering from LBP, the first step is to identify any possible serious spinal pathologies (primitive or metastatic neoplasia, infections or inflammatory diseases such as ankylosing spondylitis, osteoporotic fractures, cauda equina syndrome, or any of various neurologic diseases). An assessment of the pain is then conducted in order to determine whether it originates in the nerve root (sciatica from a prolapsed disc, spinal stenosis, or surgical scarring):

On one side of one of the lower limbs, generally radiating below the knee, down to the ankle and the foot
Very often more intense than LBP
Hypoesthesia or paraesthesia with the same distribution
Positive signs of radicular irritation
Motor, sensory, or reflex changes related to a single nerve root

Assessing LBP means evaluating pain symptoms, with all the ensuing uncertainties that this entails. It is especially difficult to objectively assess the severity of the pain due to the complex neurophysiologic sensory mechanisms and the psychoemotional assimilation that occurs in the experience of pain, and which cannot be differentiated by the person experiencing it (45). Regarding duration of the pain, the updated universally accepted classification is (3, 5, 8, 11, 46):

Acute LBP (ALBP): up to 4 weeks
Chronic LBP (CLBP): over 6 months
Subacute LBP (SALBP): from 2 to 6 months

A recent study has shown the presumable transition between ALBP and SALBP in 14 days (47), while others propose 90 days as the starting point of CLBP (9). As the symptoms of pain persist, there is a shift from a pathology of a physiological nature with biological ramifications to one characterized by psychosocial implications. The assessment at this stage no longer simply concerns a disorder but also disability and diminished quality of life.

Scientific Evidence on Assessment

Generally in the medical field, the basic requirements for any diagnostic test are its accuracy, safety, and reproducibility (48, 49, 50). Accuracy comprises the twin parameters of specificity and sensitivity: specificity refers to the ability of the test to be positive only when a pathology is present, while sensitivity is the characteristic of being positive whenever the pathology is present. Moreover, in order to ascertain the accuracy of a diagnostic test it is necessary to have a gold standard against which to measure the sensitivity and specificity. For spinal pathologies, in some cases the gold standard is the presence or absence of defined tissue pathology confirmed through a surgical procedure, while in other instances it is the confirmation or relief of pain. In all these cases, given the difficulty in obtaining an objective assessment of pain, the true accuracy of any test that provokes or alleviates pain carries an intrinsic uncertainty (51).

Various clinical guidelines (CGs) (8, 9, 52) stress the importance of taking a detailed medical history and a comprehensive physical examination of the patient, and they emphasize that during the first visit in particular, the physicians should dedicate their full attention to the patient and spend the appropriate amount of time needed to earn the individual’s trust. Indeed, evidence shows that an appropriate clinical approach can only have a beneficial impact on the pain and on allaying the patient’s fears (53).

Due to its biopsychosocial characteristics, an important future advancement in LBP assessment could be represented in the near future by the application of the ICF (15, 16, 17, 18, 19, 20) and mainly its core set (36, 37, 38, 54, 55, 56).

Red and Yellow Flags

To improve the accuracy of excluding serious spinal pathologies, as well as to reassure the patient, almost all existing CGs (8, 9, 52) have recommended that a series of risk factors called “red flags” (Table 33-1) be assessed as the patient’s medical history is taken down. The presence of one or more of these flags would determine whether there is a need for a targeted diagnostic confirmation and subsequent consultation with a specialist. Deyo has shown that red flags have a high degree of sensitivity for excluding a cancerous pathology among 2,000 patients with LBP (57).

Other CGs (58) have identified other risk factors, being indicators of the possible evolution in chronicity of pain, that have been called “yellow flags” (58, 59), whose presence, if found in ALBP or SALBP, indicate the need to take into account psychosocial factors and apply early therapeutic strategies in a cognitive behavioral approach (see Table 33-1).

Medical History and Physical Examination

The meta-analysis of van den Hoogen et al. (60) does not allow the drawing of definitive conclusions on the accuracy of medical history-taking, the physical examination, and the assessment of a Visual Analogue Scale (VAS), notably due to inadequacies in the methodologies of the primary studies, particularly regarding referral bias. However, there is agreement on the validity of medical history and physical examination to gather the red flags to detect conditions such as cancer, cauda equina syndrome, spinal stenosis, ankylosing spondylitis, or spinal deterioration due to osteoporosis.

TABLE 33.1 In the Diagnostic Process of LBP Patients It Is Important Since the Beginning to Search for Red Flags (Risk Factors for Secondary LBP Due to Important Pathologies): In Subacute Cases It Is Crucial to Search for Yellow Flags (Risk Factors for Chronicization of LBP) (9)

Red flags (Risk Factors for Secondary LBP Due to Important Pathologies)
Back pain in children <18 y with considerable pain or onset >55 y
History of violent trauma
Mild trauma in an aged patient
Constant progressive pain at night
History of cancer
Systemic steroids
Drug abuse, human immunodeficiency virus infection
Weight loss
Systemic illness
Persisting severe restriction of motion
Intense pain or minimal motion
Structural deformity
Difficulty with micturition
Loss of anal sphincter tone or fecal incontinence; saddle anesthesia
Widespread progressive motor weakness or gait disturbance
Inflammatory disorders (ankylosing spondylitis) suspected
	Gradual onset <40 y
	Marked morning stiffness
	Persisting limitation of motion
	Peripheral joint involvement
	Iritis, skin rushes, colitis, urethral discharge
	Family history
Yellow Flags (Risk Factors for Chronicization of Acute and SALBP)
Personal		Age (U form correlation)
		Female gender
		Minor ethnicity
		Low income
		Low education
Medical		High BMI
		Previous surgery
		Impairment
		Neurological deficit
		Radicular impingement (SLR, Wassermann tests)
Pain related		Duration
		Intensity
		Leg pain
		Pain in lateral flexion and/or in flexion-extension
		Difficulties in sitting
Impairment disability related		High referred impairment
Impairment disability related		High functional limitation at 4 wk
		High disability (Roland-Morris, Oswestry, Sickness Impact Profile)
		Perceived risk of not recovering
Psychosocial		Not appropriate signs and symptoms
		Avoidance behavior
		Psychological burden
		Vital energy reduction
		Reduced emotional confronting capacity
		Social isolation
		Depression (SCL-90, Zung, Back Depression Inventory)
		Somatization (SCL-90)
		Reduced coping strategies (CPCT)
Work related		High requests
		Reduced control on own work
		Monotony
		Low satisfaction
Treatments		Treatment before retiring from work
		Disability compensation
		Heat and cold therapies
		Physiotherapy
		Back school

Several studies have focused on how a physical examination is performed in regard to the range of motion of the lumbar spine, muscle strength, and provoking or relieving pain symptoms with specific movements. The McKenzie technique for determining which movements can cause the centralization of pain and what courses to take has not found unanimity in the literature for indicating prognosis. While positive findings have been reported in Long and Donelson (61, 62), other authors have yet to establish a clear clinical benefit (63).

A study by Simmonds et al. (64) has established the reliability, validity, and good clinical use of nine physical evaluations comparing asymptomatic subjects and LBP patients. Also, a modest correlation with the degree of disability was detected through a questionnaire. No evidence of clinical benefit has been obtained in the analysis of muscle strength carried out by various machines (65). In fact, a good correlation of testing and retesting has shown that the Biering-Sörensen test is simpler to conduct and is of greater benefit in clinical practice (66). Regarding muscle fatigue, Taimela et al. (67) have shown that LBP sufferers first get tired, whereupon the fatigue reduces the quality of movement, and consequently the muscle fatigue lessens the kinesthesia. Muscle fatigue, therefore, is a risk factor.

Clinical trials, as well as various national CGs, have taught us that a fundamental point of the evaluation is physical contact with the patient: palpation of the vertebral structure provoking pain and the direct assessment of regional and segment motion are an integral part of a complete physical examination. The analysis of literature in this area by Seffinger et al. (68) shows that the most reliable tests are those that provoke pain, while less reliable diagnostic testing is that which is done by palpating the soft tissues. Regional motion testing is also more reliable than segmental motion testing, and intra-examiner reliability is greater than inter-examiner reliability.

If, on the one hand, there is a lack of definition of the specific structural causes in a great number of LBP sufferers, on the other hand the practice tends to identify specific subgroups of subjects affected by LBP. Many consider lumbar instability to be one such subgroup. In this regard, a recent study (69) has examined predictive clinical indicators of instability, the gold standard being x-rays in the flexed and extended positions. A positive correlation was observed in the concurrent presence of hypermobility in the intervertebral motion test and the range of the lumbar flexion greater than 53 degrees (LR 12.8).

LBP and Leg Pain

Regarding the pain that radiates to a lower limb below the knee and the probable correlation with the presence of a herniated disc, scientific evidence (70, 71) generally refers to secondary or tertiary health care settings, the gold standard being the presence of a herniated disc confirmed by surgery. Therefore, it is most likely that only the more serious cases are being reported instead of cases of patients seeking primary care. Based on these studies, the distribution of pain seems to be the only sensitive symptom, while paresis and sensory deficits seem neither sensitive nor specific. Among the indicators, the depression of reflexes is not sensitive and straight-leg raising (SLR) seems to be an indicator of sensitivity (but of low specificity), while the crossed SLR has less sensitivity but a higher specificity. The positive presence of both suggests a better clinical indication of a herniated disc.

Concerning a prospective study of 105 patients (72), the strongest indicators of a herniated disc among the 25 clinical variables (the gold standard being the computer tomography [CT] and/or magnetic resonance imaging [MRI] scan) were the range of lumbar motion in forward flexion and the distribution of pain in the lumbar extension while in the standing position. Patients with herniated discs had significantly less mobility during forward flexion but a higher distribution of pain to the leg during a lumbar extension (Table 33-2).

Diagnostic Imaging

The choice of an imaging examination for diagnostic purposes should only be based on an evaluation of the symptoms, medical history-taking, and physical examination. The purpose of diagnostic imaging is to verify the suspicion of a serious
pathology due to red flags, or a herniated disc due to symptoms ascribed to nerve-root pain. In the case of LBP or simple sciatica, and in the absence of red flags, diagnostic imaging is not required within 30 days of the onset of symptoms (3, 8, 9).

TABLE 33.2 Findings in Patients with History of Well Described Lumbar Nerve Root Pain of Sufficient Predictive Value for Finding a Disc Hernia at Neuroradiographic Examination (9)

Finding	Prediction Strength
Crossed SLR reproducing pain in the symptomatic leg	+++
SLR <60 degrees (SLR reproduces leg pain)	++
Ankle dorsiflexion weakness	+
Great toe weakness	+
Impaired ankle reflex	+
Sensory loss, pins and needles, paresthesia	+
Patellar reflex weakness	+
Ankle reflex weakness	+
Severe radicular pain	++
Pain causing awakening at night	++
Severe lumbar motion restriction	++
Loss of lordosis and/or sciatic scoliosis	++
Unilateral leg pain worse than back pain	++
Radiation into foot	+
Pain drawing (exact dermatome depicted)	(+)

Regarding x-ray examinations, all the current CGs agree on refuting their diagnostic or therapeutic value in the absence of red flags and discourage any routine use. van Tulder et al. (73) have noted that the only x-ray anomaly that could be linked to LBP is disc deterioration (odds ratio 1.2:3.39). However, due to inadequate methodologies in primary studies this conclusion cannot be considered definitive. Consequently, the authors claim that “no firm evidence exists for the presence or the absence of an association between x-ray findings and nonspecific LBP” (Table 33-3).

TABLE 33.3 Studies on the Association Between Radiographic Findings and Nonspecific LBP Judged to be Valid (9)

Radiographic Finding	No. of Studies	Odds Ratio	Results
Disc degeneration	12	1.2-3.3	Moderately positive
Spondylosis	3	1.2-2.0	Negative
Spondilolysis and spondilolisthesis	6	0.82-1	Negative
Spina bifida	2	0.5-0.6	Negative
Transitional vertebrae	3	0.5-0.8	Negative
Scheuermann disease	2	0.8-3.6	Unclear

The noninvasiveness and characteristics unique to MRI in satisfactorily evaluating both soft and bone tissues allow it to be a more comprehensive tool for the diagnostic imaging of an LBP patient. That being said, there is no evidence that its use provides any real advantage in the treatment of simple LBP (74, 75). Many studies have shown that the presence of disc anomalies (bulges, swelling, hernia) in the vertebral canal, the foramen, and the vertebral structures are found in asymptomatic subjects. Consequently, Roland and van Tulder (76) recommended, somewhat provocatively, that radiologists add the following to the reports along with their referrals: “This finding may be unrelated to patient symptoms because it is often seen in asymptomatic subjects.” The MRI is a highly sensitive exam, and hence there is a risk of obtaining many false positives. We must bear this in mind in clinical practice so that costs can be kept down and unnecessary surgical procedures avoided.

Psychosocial Factors, Disability, and Quality of Life

The assessment of a patient with LBP must not be limited to a physical examination but should also include an analysis of psychosocial factors that play a crucial role in the chronicity of pain, delays in returning to work, and the success of the treatment. Evidence shows that some conditions—such as low level of job satisfaction, poor work motivation, disability compensation, dissatisfaction with previous treatment—are risk factors for chronicity and/or the relapse of LBP. Regarding psychological factors as chronicity/disability predictors, a recent review (77) has examined the role of psychological discomfort and depression (Zung scale), and somatization, while less evidence was attributed to cognitive factors such as catastrophism. However, although the symptoms of mental stress in asymptomatic subjects can be predictors (78), the main indicator for LBP is a positive medical history (79).

Persistent pain always entails a certain degree of disability. The measurement for disability in LBP can be gauged through means of dedicated and scientifically validated questionnaires such as the Oswestry LBP Disability Questionnaire and the Roland-Morris Questionnaire (80, 81, 82, 83). A recent study (84) has correlated pain (VAS), disability (Oswestry Questionnaire), and the quality of life (EuroQoL) in LBP patients. The data have shown a weak but significant correlation among the three elements. Thus, it appears that the persistence of pain and disability worsen the quality of life to an appreciable extent. Clearly, the impact of pain and disability on decreasing the quality of life depends more on their duration than their intensity. Moreover, even a clinically significant variation in the degree of pain can bring about nearly imperceptible changes in disability and quality of life. We must, therefore, adopt the concept of the minimal clinically important difference (85, 86), that is, the slightest change in an evaluation scale that will be perceived by the patient as an improvement in his or her condition. It is important to stress the benefit of such a concept as a better outcome criterion because it is aimed at the patient from a functional and psychosocial perspective. However, its a well-known fact that today there is also the need
to evaluate a treatment’s efficiency in terms of managing the costs of health care.

This section concludes with a word about younger patients: The findings of more recent studies show there is an increased incidence of LBP among children and adolescents. Among the defined risk factors in a school population of 10,000 subjects are the excessive weight of backpacks, the sitting level of students compared to that of the teacher, and the heights of chairs and desks (87). Starting with the premise that a better predictor of LBP is precisely a positive medical history and the awareness that children and adolescents exhibit significant differences regarding medical history, physical examination, and diagnosis compared to the adult population (88), it would appear altogether appropriate that new studies be conducted so as to bring this subgroup to the fore and thereby formulate better treatment and avoid the relapse of LBP in adulthood.

Diagnostic Therapeutic Flowcharts

Subsequent to the pioneering experience, not only for LBP but also for medicine in general, of the Quebec Task Force down in 1987 (89), which represented the first systematic effort to produce a CG in terms of a summary of the existing evidence on LBP treatment, this field has been one of the most prolific for CGs production (10, 90). In this context, with the objective of painting in a simple way the everyday clinical behaviors, those published in 2006 in Europa Medicophysica (9) (now the European Journal of Physical and Rehabilitation Medicine) (91) appear very interesting. The “Diagnostic Therapeutic Flowcharts for LBP Patients” (DTP) have been developed as real flowcharts (Figs. 33-1, 33-2, 33-5, 33-7, 33-9, 33-11, 33-13), in order to provide a complete idea of what should be done, and to cover, through expert multidisciplinary consensus, the multiple gray areas in which the actual evidence does not offer answers. Moreover, these DTP have other unique characteristics in terms of PRM (21) that are reported below. In Figures 33-2, 33-5, 33-7, 33-9, 33-11, 33-13, the most interesting flowcharts of the DTP are given to the reader, while in the open access version of the European Journal of Physical and Rehabilitation Medicine (EJPRM) (www.ejprm.org) they can be viewed for further details.

FIGURE 33-1. Overview of the flowcharts reported in the “Diagnostic Therapeutic Flowcharts for LBP Patients” published in 2006 in Europa Medicophysica, now the European Journal of Physical and Rehabilitation Medicine. The classification of LBP used can be easily gathered (9).

The DTP have been developed through a systematic search of the literature and a multidisciplinary consensus of all Italian scientific societies engaged in this field. The classical distinction between ALBP, SALBP, and CLBP is at the base of the DTP. Even though a recurrent form of LBP was hypothesized at the start of the DTP project, the absence of literature and the lack of any evidence on the possibility of differentiating a recurrent episode from a single first episode of LBP made it necessary to eliminate this classification item (9).

One of the most interesting points is represented in the flowchart in Figure 33-2. In fact, while preparing the DTP it was discussed how to grade the importance of the different rehabilitation approaches possible for SALBP and CLBP patients. It was agreed that, from the viewpoint of rehabilitation and also prevention, the most important patients were the SALBP ones, where it was still possible to try avoiding chronicization, which is the most awful end of the story, because it is extremely rare that a patient will exit from CLBP. In the meantime, which CLBP patient would deserve the highest attention so to reduce the burden of the biopsychosocial situation for them and for society? According to the literature, such a choice has been defined using the level of disability as a way to discriminate among patients (9, 21). This is a totally new conceptual development, but it is consistent with the actual knowledge of CLBP (22). Moreover, the actual disease-specific disability questionnaires have already defined cut-off levels in order to distinguish high-disability and low-disability patients (48, 81). This conceptual step forward provides a means by which to classify the various possible treatments (see Fig. 33-2).

Another important point of the DTP has been to recognize the importance not only of the therapy proposed but also the other elements constituting a complete approach to LBP patients. This starts with the biopsychosocial theory, which is the basis of a modern approach to LBP patients (3, 4). It clearly contradicts the usual disease-oriented approach, where only therapy could be considered enough. This is correct and typical of CGs for specific diseases, but it is incorrectly maintained for analogy in the field of LBP. Consequently, in the DTP all therapeutic schemes (Tables 33-4, 33-5, 33-6, 33-7 and 33-8), including those on secondary LBP, consider counseling, work and activities of daily living (ADL) interventions, physical activity counseling, PO therapy, and specific FO rehabilitation. Again it emphasizes the importance of all these elements in approaching what is not a “simple” disease but is instead a biopsychosocial syndrome.

FIGURE 33-2. Subacute and CLBP diagnostic flowchart (9).

Secondary LBP is usually not included in CGs (10), eventually with the exception of disk herniation (DH): In the DTP there are also specific flowcharts for spinal stenosis, spondilolisthesis and spinal instability, adult scoliosis (AS), spondiloarthritis. Excluding the last one, where a specific rheumatologic approach is proposed, in the others the main ideas were as follows:

Identify specific cut-offs for the eventual proposal of surgery;
A part from rare medical urgencies, postpone in any case surgery after an appropriate complete rehabilitation process;
Verify the absence of contraindications to surgery;
Fully inform the patient regarding the advantages and disadvantages so as to allow an individual, informed choice.

For each secondary LBP clinical picture, specific rehabilitation is listed according to the actual literature. For example, the best types of exercises are proposed even if there is no definitive proof in the literature today, but this is obviously discussed according to the strength of evidence.

The different flowcharts (modified) will be reported throughout this text when appropriate (see Figs. 33-2, 33-5, 33-7, 33-9, 33-11, 33-13).

Rehabilitation Approach: Treatment Tools

Actual Evidence in the Literature

Many therapies are proposed in LBP management in everyday clinical practice. For some therapies there are no data at all or limited evidence at best Occasionally, the only rationale of prescription is traditional, while for others we can rely on more consistent findings. We distinguish the treatment options as PO treatments (oral drugs and injections, physical therapies, manipulations), FO approaches, and educational interventions (9). This distinction could now appear to some readers less than totally justified: in fact, most of the PO approaches propose themselves as “normalizers” of physiology and/or “aetiological” (34, 61, 92, 93, 94, 95, 96), but to date there are no scientific proofs of these hypotheses. Moreover, according to the actual literature we will consider together ALBP and SALBP because there are not enough papers to make a real distinction between the two.

Acute and Subacute LBP

Pain Management

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be more effective than placebo concerning a general effect on ALBP. However, no single NSAID molecule overcame the others in terms of effectiveness. There is moderate evidence that NSAIDs are not more effective than paracetamol for ALBP, and paracetamol had fewer side effects. Traditional NSAIDs seem to have more gastric side-effects compared to COX-2, but there are no differences in terms of efficacy. In any case, the effect ranges are small. Benzodiazepines, as well as central muscle relaxants other than benzodiazepines, were shown to be more effective than placebo on ALBP (97).

Manipulations were shown to be more effective than placebo on pain in the short-term (within 6 weeks) but were not more effective on function (98). There is moderate evidence that lumbar supports are not more effective than no intervention or training in preventing LBP, and there is conflicting evidence about whether they are effective as supplements to other preventive interventions. It remains unclear whether lumbar supports are more effective than no or other interventions for the treatment of LBP (99).

No relevant data are available concerning steroid injections, oral colchicine, acupuncture, electromiographic biofeedback, lumbar supports, massage, transcutaneous electrical nerve stimulation (TENS), traction, thermic-effect based therapies (ultrasound, ice, heat), insoles (there is strong evidence that insoles are not effective for the prevention of LBP) as LBP treatments (98, 100, 101, 102, 103). Some herbal medicines (harpagophytum procumbens, salix alba, and capsicum frutescens) seem to reduce pain more than placebo (104).

Educational Interventions

Advice to stay active is effective and sufficient for the long-term improvement of function in ALBP (105, 106). The indication to rest in bed is less effective than the indication to stay active (107). There is strong evidence that an individual 2.5-hour session of oral education is more effective on short- and long-term return-to-work than no intervention. Educational interventions that were less intensive were not more effective than no intervention (108). There are no randomized controlled trials (RCTs) on ALBP using back schools (109).

Function-Oriented Rehabilitation Approaches

There are no RCTs on ALBP considering the multidisciplinary rehabilitation treatments. Exercises showed no effect in the first 2 weeks of LBP, but they were shown to be effective in SALBP in the occupational setting (110). There is some evidence that the McKenzie method is more effective than passive therapy for ALBP. However, the magnitude of the difference suggests the absence of clinically significant effects (63).

Chronic LBP

Function-Oriented Rehabilitation Approaches

Strong evidence exists to the effect that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach improves function as compared to inpatient or outpatient non-multidisciplinary treatments. There is reasonable evidence that this approach improves pain as compared to outpatient non-multidisciplinary rehabilitation or usual care. There is contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention (42).

Combined respondent-cognitive therapy and progressive relaxation therapy are more effective than waiting-list controls on short-term pain relief. However, it is unknown whether these results can be sustained in the long term. No significant difference has been detected between behavioral treatment and exercise therapy (111). A short-period of cognitive behavioral treatment and exercise therapy has a modest effect on pain and disability at one year. This effect can be influenced by preference toward treatment (112).

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with CLBP, particularly in health care populations (110). There is limited evidence regarding the use of McKenzie method in CLBP. The effectiveness of classification-based McKenzie is yet to be established (63).

Educational Interventions

The effectiveness of individual education is still unclear (108). However, there is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status in the short term and intermediate term as compared to exercises, manipulation, myofascial therapy, advice, placebo, or waiting-list controls for patients with chronic and recurrent LBP (109).

Regarding CLBP, there is strong evidence to support the use of advice to remain active, in addition to specific advice relating to the most appropriate exercise and/or functional activities by which to promote active self-management (106).

Pain Management

No clear evidence exists to the effect that antidepressants are more effective than placebo in the management of patients with CLBP. These findings do not imply that severely depressed patients with LBP should not be treated with antidepressants (113). The benefits of opioids in clinical practice for the long-term management of CLBP remain questionable (114).

Both TENS and traction, as a single treatment for LBP, are probably not effective (101, 115). Low-level laser therapy (LLLT), in contrast to a sham treatment, may be beneficial for pain relief and improved disability in patients with SALBP or CLBP, although the treatment effects are small. However, when LLLT is added to exercise and compared to exercise therapy, either with or without sham treatments, there appears to be little or no difference between the groups in terms of pain and disability (116).

The evidence is conflictive in regard to the efficacy of prolotherapy injections for patients with CLBP. When used alone, prolotherapy is not an effective treatment for CLBP, but combined with spinal manipulation, exercise, and other cointerventions it may improve CLBP and decrease disability (117).

Rehabilitation Tools

The rehabilitation treatment tools used in the field of LBP have three different backgrounds: mainly physical (exercises); mainly psychological (cognitive-behavioral approaches); finally social (education approaches). These are only tools that can be combined in a thorough rehabilitation of the individual patient so as to achieve the best results. They should not be considered separately, but only as ingredients in the correct mix designed to achieve the best individual rehabilitation. In fact, there is strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach is useful for CLBP (41, 42): in this case, the complete rehab package includes exercises (functional restoration) (118, 119) together with psychological (cognitive-behavioral) (111) and social approaches to the patient (40, 42) that allows to achieve the best results.

Exercises

The use of exercises as a therapeutic tool for LBP is quite common in most countries of the West (120), despite scientific evidence that shows its efficacy to be quite inconsistent. In a 2000 Cochrane review, the authors highlight the modest effectiveness of exercises in treatment for patients with CLBP while noting its effectiveness in reducing work absenteeism in patients with SALBP. In ALBP, the benefits of exercises are considered to be as effective as conservative treatment or nontreatment (110).

The low effectiveness of exercises, as reported in a great number of studies published in scientific journals, is in contrast to the benefits perceived by patients and experts in the treatment of LBP. This discrepancy may be due to the fact that in a great number of these studies with high scientific impact the subjects are randomly chosen and placed in various treatment groups without being first classified into subgroups based on the criteria of pain characteristics (121, 122, 123, 124). Such a method, being conceptually flawed from the outset, can skew the outcome of clinical trial results. Because classification based on a proposed relevant pathology is possible in at least 10% of cases (125), one of the objectives of a diagnostic procedure would be to allow the collection of data useful in placing subjects in homogeneous groups in order to prescribe the most appropriate treatment (121). If it is not possible to classify according to etiology, presumably it will be possible for functional characteristics, or others that are now under scientific exploration. Until then, we have to wait before being able to state clearly what the evidence on exercises can be.

Moreover, this may explain why various types of exercise— albeit with very different physiological origins—have all shown benefits in treating LBP, particularly CLBP (110, 120, 126).
A few years ago, an open question in the treatment of patients with LBP was to explore whether trunk-flexion exercises would be more efficient than trunk-extension exercises. Studies did not completely resolve this question because the choice of prescribing a preferred course of exercises could not be entrusted to randomness but instead through a careful examination of subjects based on the characteristics of the symptom and its modification (62). Recently, an in-depth meta-analytical study examined precisely the types of exercises that were potentially the most effective in the treatment of CLBP (110, 120, 126). While promising results emerged from the study, both in the area of muscle stretching and strengthening, its main conclusion was that much more research would be needed before a better definition of protocols could be reached, and that the best course is most likely that of subclassifying patients.

The objectives of exercise (Fig. 33-3) could include:

Reducing symptoms;
Regaining function, reducing disability and fears related to movement, and encouraging regular physical activity in SALBP and/or CLBP;
Preventing relapse.

Reducing the sensation of pain could be linked to biological changes in tissues, thanks to increased blood circulation, improved mechanics of the joints in question due to the stimulation of joint capsules and their ligaments, better function of stabilizer muscles, and a neurological de-sensitization of tissues, thanks to the repetition of movement (127).

In SALBP and CLBP, along with pain the patient must also face various other problems. Many studies have shown that “pain-related fear” has a negative impact on some basic spinal functions, such as elasticity and strength (128). This condition increases the risk of a progressive worsening of disability and the development of a deconditioning syndrome, which could be an additional obstacle to improving conditions. Another typical behavior is that a CLBP patient may exhibit “avoidance behavior”: The patient fears incurring back damage and adopts motor behavior marked by excessive caution (129), which further worsens motor neurological quality. An intensive, targeted exercise program could reduce the risk of kinesiophobia and have a positive impact on the related disability (130, 131). In this respect, there are proofs that a graded increased functional training has good results in SALBP (132, 133, 134), but this methodology can quite easily be extended to CLBP patients (110, 120) allowing to achieve cognitive-behaviorals goals as well (111).

There are many studies that have shown how the characteristics of the muscles that maintain the stability of the spine change after an episode of LBP. The lumbar multifidus muscle exhibits a delayed activation (135) and a decrease in the transversal size on the side of the pain (136). It has been observed notably that in the absence of specific treatment these deficits remain, even when the LBP disappears. The high incidence of recurrence in LBP the year after the first episode could be due to precisely this functional weakness in the stabilizer muscles. Some studies have supported this hypothesis by showing how a program of functional reactivation of these muscles could work as a safeguard against future episodes. A year after an episode, a group of subjects who had participated in a specific program for strengthening the lumbar multifidus muscle had a 30% rate of relapse compared to 84% in the group of patients who had not participated. Even a follow-up three years later revealed a significant difference in the results, with a 35% rate of relapse in the group tested compared to 75% in the control group (137).

FIGURE 33-3. Examples of exercises that can be performed by patients with LBP with different aims. A: Development of kinesiophoby is one of the main elements to avoid in CLBP management: for this reason patient must experiment kind of movement as far as complex. B: Trunk and pelvis imbalancing exercise to improve coordination and motor control of the spine.

The same results were observed for adolescent LBP (138, 139). The choice of favoring a program of stabilizing exercises to prevent the relapse of LBP is not clearly supported by scientific literature. In the case of recurrent nonspecific LBP, a program of general exercise reduces disability more effectively than a program centered on stabilizing the spine, which should only be an option for cases having obvious signs of instability.

Finally, the so-called functional rehabilitation approach is discussed (41, 118, 140, 141). This gained popularity in the recent past and has been proposed as an inpatient intensive training of 3 to 5 weeks (142, 143) or as a long-term training program, mainly machine-guided outpatient training (67, 119, 144). The main theory at the basis of this approach is derived from sports medicine (141) and considers function more than pain: in fact results are best in the functionaldisability domains than on the pain itself that is in any case decreased (41). Even without considering that any kind of rehabilitation by definition must be “functional” (22), this approach has shown good results (41) and must be adopted as a concept, even if other settings (i.e., outpatient without specific machines) can be considered apart from the ones presented in the literature.

Cognitive Behavioral Approach

Cognitive-behavioral intervention is commonly used in the treatment of disabling CLBP, and it originates from a new viewpoint in regard to chronic pain. The traditional medical approach considers pain as a cause of illness and consequent disability according to an established illness model (4, 12). This provides a circle in which physical damage causes pain that will eventually cause impairment, and the impairment will ultimately induce a disability. Nevertheless, while acute pain has a biologic means of alarm to signal tissue damage, chronic pain lacks this characteristic; it is not only influenced by somatic pathology but also by psychological and social factors (44). Moving from this consideration, Waddel (Fig. 33-4) theorized a new model of illness for LBP, known as biopsychosocial model, in which various aspects can determine and explain chronic pain. They are:

Physical dysfunction: It depends on an imbalance between the demands of physical ability and real body capacities that are not ready to provide the required performances.
Belief and coping: Human thought and the way of perceiving pain play a crucial role in determining how the patient manages his health problem. Frequently, patients with CLBP are persuaded that they suffer from a serious pathology and are therefore hardly considered curable. They have incorrect assumptions about the possibility of recovery, often due to previous failed treatment. This leads them to adopt a discouraged approach to the problem and to new proposed treatments. The different strategy for coping with pain can explain why certain patients overcome the acute phase, while others come to suffer from CLBP. There are two means of response to pain: actively face it (copers), or undergo it (noncopers). Pain-related fear, catastrophizing beliefs, and lack of psychological and cognitive instruments with which to oppose painful symptoms lead the patient to assume an avoidance behavior from the same pain. This means the reduction of physical activity, work, and social relationships until one arrives at a physical and psychological deconditioning.
Distress: Increased pain perception, emotional stimulus, psychological factors are deeply linked, and they can give rise to a vicious circle. Feelings of fear, anxiety, anger, and depression are common in patients of this kind.
Illness behavior: It is heavily conditioned from prejudices about the pathology, future treatments, and the ability of medical care to resolve the pain.
Social relationship: Social networks such as family, friends, and colleagues can influence the emotional status, development of illness beliefs, and coping strategy. A favorable family activity can help to face and overcome pain, while an accommodating ground to illness will increase it. This model provides a multidisciplinary approach to the problem that requires, above all, a multidisciplinary treatment through the use of different techniques appropriate for the individual subject, such as his or her psychological state.

FIGURE 33-4. The biopsychosocial model of illness for LBP as proposed by Waddell (4): various aspects can determine and explain chronic pain.

Two systematic Cochrane reviews (42, 111) and additional trials (132, 133, 145), all of which are considered high quality studies, showed there is strong evidence that behavioral treatment is more effective for pain, functional status, and behavioral outcomes than placebo, no treatment, and waiting-list control, most of all when it is intensive, and that a graded activity program using a behavioral approach is more effective
than traditional care for returning to work. One low-quality trial (146) found there is no difference between the effects of behavioral therapy and exercise therapy in terms of pain, functional status, or depression for as long as a year after treatment.

The goal of the cognitive-behavioral approach to nonspecific CLBP is the ability to modify wrong beliefs about health status and changing the perception of health. Weisenberg (147) and Meichenbaum (148), who in 1977 first introduced this model, support the importance of change in the health pattern by a cognitive incentive, seeking to modify the patient’s relationship with the chronic pain by offering him/her the possibility of reacting to pain through an awareness of the real problem. This approach must be presented to the patient like a process of correct learning (14, 30), in the passage from an illness behavior to a wellness behavior. Generally, three behavioral treatment approaches can be distinguished (149, 150):

Operant treatment, which is based on the operant conditioning principles of Skinner (151) and applied to pain by Fordyce (152) consists of the positive reinforcement of healthy behaviors;
Cognitive treatment, which aims to identify and modify the patient’s cognitions regarding his/her pain and disability;
Respondent treatment, which aims to modify the physiological response system directly.

The first therapeutic aim is to forecast the positive effects of treatment results by acting on external events. This approach allows the patient to move from a control pain model, typical of the acute phase while improving behavioral and functional ability through communication, education, and motivation, which are methodological instruments peculiar to the cognitive-behavioral model. Communication must be efficacious and bidirectional in order to educate the patient in viewing his health condition from the correct perspective. Physicians and therapists should ensure that the patient understands his/her problem and that they are ready to help. Only in this way they can gain the patient’s confidence, which is necessary to ensure good compliance with the treatment. The advantage of the educational program is to offer the patient explanations about the true extent of the problem through easy lessons about anatomy and physiology until the patient can be clearly informed in regard to CLBP. It is useful to encourage the patient to manage his/her pain instead of simply suffering, and giving him/her simple means to be applied in his/her everyday life. This is done by explaining how this active approach to LBP influences, in a crucial way, the perception of pain and the disability correlated to it. This does not signify the minimization of the problem, but instead it helps the patient face it, rid himself from incorrect beliefs and the behaviors of pain avoidance that only serve to strengthen the pain.

The methodology applied is not simply “learn to change” but also “test the change.” To follow this model it is necessary to establish, before treatment begins, certain realistic aims, and to document the improvements through self-evaluation techniques for involving the patient so that he/she will be responsible for the change. The operating setup of this theoretical warning is to test during daily living what the patient learns and to make him/her aware of improvements. Central to diagnostic evaluation is an understanding of the deep interactions between the physical and psychosocial factors, and how they can support themselves according to a vicious circle, since disability in this kind of patient also means chronic pain, physical dysfunction, and illness behavior.

Educational Tools

A primary objective of LBP management is to provide the patient with accurate information. LBP treatment strategies have changed through the past few decades, thanks to the results of various clinical trials conducted during this period. An emblematic example of this is the general consensus regarding the recommendation of remaining active as much as possible during cases of ALBP (153). However, while it is an important element of LBP primary care, this consensus is not a widely held belief and many people continue to believe their patients need rest.

Accordingly, an updated collection of data to adequately address the issue is an important tool in modifying popular beliefs. In the case of ALBP, it is crucial to reassure the patient and inform him or her of the appropriate methods for managing symptoms (106). In the case of SALBP, the information must be particularly targeted toward the prevention of chronicity by providing the patient with useful advice on how to identify any behavior that could delay healing (106). As for CLBP, the information should include advice on how to manage pain, control catastrophism, and decrease avoidance behavior (106, 111).

Certainly, an informational brochure is the most common educational tool (154, 155). Many experiments have been carried out to quantify the brochure’s tangible effectiveness in changing common perceptions among patients, modifying behavior, and having an impact on pain and disability. For ALBP patients, the information contained in a brochure seems to be quite effective in reducing pain and the likelihood of relapse (156), as well as in decreasing fear-avoidance behavior (154). The brochure has also been used among the institutionalized elderly, and has shown a positive impact on improving disability in the 6 months following its use (157).

Back schools have been proposed in the past as a possible important tool for LBP treatment (106, 109), and for a period of time they were quite popular. However, they have been widely criticized (158) because the original proposals (159, 160, 161, 162) were mainly based on ergonomic assumptions and a disease-oriented model of illness that was clearly overcome by the actual biopsychosocial one. Nevertheless, the back school can be considered a therapeutic tool that can be filled with the most actual contents and/or according to the individual needs and/or clinical realities, more than a schematically uniform treatment. In everyday clinics this is the reality, because there are as many back schools as there are therapists applying them. Today there are some proofs of
efficacy, mainly in specific professional settings (109). As a therapeutic tool, if it is used as a cognitive behavioral exercisebased group approach to nonspecific SALBP and/or CLBP, the back school can be important as a low-cost approach to large numbers of patients (9).

Media is another interesting information tool for educational purposes. With a multimedia information campaign, a significant change can be observed in popular beliefs, with a considerable number of people abandoning the notion that they need rest when experiencing pain and instead embracing the correct idea of remaining active (163). This change in behavior is cost-effective and continues for several years after the end of the information campaign (25).

Lastly, various studies have shown that a crucial element in reducing the cost of LBP primary care management is the awareness of getting family physicians to adopt the right behavior (164), in which a multimedia campaign could play a part.

Main Pain Management Tools of PRM Interest

These approaches have different backgrounds, according to the pathoanatomic hypotheses proposed by the different authors and schools who have developed or use each of the tools. Some have a certain efficacy, but not in all patients: In an evidence-based clinical practice view they should be regarded not for their theory but only for their efficacy. Moreover, to date there is no consensus on how to choose each single treatment for each single patient (9). Presumably, and as far as we know today, the best way is through trial and error, starting with what is preferred by the patient and the treating physician. What should be avoided is absolute approach, coming from the idea of superiority of the PO treatment proposed versus any other, and based on specific diagnoses (diagnostic labels) (165, 166) not scientifically sound: in fact it has been shown that such a medical style highly increases the probability of chronicization (96, 165, 167), constituting an important, iatrogenic yellow flag.

Manual Approaches

Hands are probably the most ancient tool man has employed in bringing relief for LBP. Both written evidence and artistic representations show that manual methods were highly valued even when very simple techniques were used, because there was little knowledge of anatomy and the mechanisms of joint physiology. Over the centuries, the progress of knowledge and wider experience have led to the development of various manual techniques for the treatment of LBP.

The term “manual therapy” includes techniques aimed primarily at the treatment of soft tissues, such as massage, mobilization techniques carried out to increase the range of motion, and techniques based on the application of small-amplitude high-velocity thrusts, such as manipulation (168). Theories proposed on the way of action of manual therapies are almost as many as the different schools (34); terminologies such as “ostheopatic lesion,” “minor vertebral derangement,” all supposing little injuries of the mobile segment mainly at the zygapophyseal joints, have been proposed; nonetheless, until any of these possible lesions will be proved this treatment is definitely a PO one.

Massage is undoubtedly the most ancient and widely used form of manual therapy. It is practiced in every region of the world and through a variety of techniques. Massage has also spurred considerable scientific interest, and this is shown in the large number of systematic reviews conducted by Cochrane to explore the effectiveness of its use. The results of these reviews on massage and LBP (169) have led to the conclusion that massage is effective in SALBP and CLBP, particularly when combined with exercise and education. The authors recommend further studies that would corroborate these conclusions and properly assess the cost-benefit ratio of manual therapy, its long-term impact, and the resumption of work.

Osteopathy and manipulation are two other manual therapy techniques widely used to fight LBP. While there is not much literature on the benefits of the former for treating LBP, there is considerably more in regard to the latter. One such review by Cochrane shows that in the treatment for ALBP and CLBP, manipulations are only more effective than sham therapies. There is no evidence that they are more beneficial than traditional treatments such as exercise or painkillers (170). Considering the low benefits and high cost, the effectiveness of these treatments is also low. However, it should be noted that when therapeutic techniques are characterized by a close relationship between the patient and the therapist—as in the case of manual therapy—even in those cases of treatment failure only 50% of the patients require alternative therapies, most likely because the ties forged with the therapist enable the patient to better face the symptoms and disability (171).

Modalities of Physical Therapy

Modalities of physical therapy include a wide variety of devices that apply physical principles in treating many problems in rehabilitative medicine. Actually, it is frequently proposed in LBP management in everyday clinical practice, sometimes alone but sometimes as part of a more complex approach. Despite the specific principle behind the action of each device, it can be considered a PO therapy because they act mainly on pain perception and transmission, even if they are supposed to possibly act on cell membrane or on inflammation.

Electricity is probably the main physical principle applied in this field, and within this group TENS is probably the form most commonly used. The development and application of TENS was based on the Gate Control Theory conceptualized by Melzack and Wall (172). According to this theory, the stimulation of large-diameter (A-β) primary sensory afferents activates inhibitory interneurons in the substantia gelatinosa of the spinal cord dorsal horn, thereby accentuating the transmission of nociceptive signals from small-diameter A-δ and C-fibers (172, 173). Supraspinal mechanisms involving the endogenous opioid system have also been described (174, 175, 176, 177). In summary, the postulated effect of TENS is to “close the gate” and dampen the perception of pain (172). Despite its rationale and well-documented biological effects, TENS as
a single treatment for LBP is probably ineffective (101, 115). Other forms of electrical therapy have been proposed, and some papers have been published (178, 179), even if we still lack a substantial basis for them.

Ultrasound has for many years been used in the treatment of musculoskeletal conditions. Laboratory research has demonstrated the application of ultrasound results in the promotion of cellular metabolic rate and increased viscoelastic properties of collagen (180). In animal studies, an exposure to 1 MHz ultrasound at 50 J/cm² is reported to be sufficient for the increase of tissue temperature (181). This rise in temperature is assumed to be the mediating mechanism for tissue repair, enhancement of soft-tissue extensibility, promotion of muscle relaxation, augmentation of blood flow, and alleviation of inflammatory reactions of soft tissue (180, 182, 183, 184). Despite the theoretical benefits and widespread use, conclusive evidence on the effectiveness of ultrasound therapy in CLBP is not yet available.

LLLT is currently used by some as a therapeutic intervention for musculoskeletal disorders such as LBP (185, 186). LLLT is a light-source treatment that generates light of a specific wavelength. It emits no heat, sound, or vibration. Instead of producing a thermal effect, LLLT may act through nonthermal or photochemical reactions in cells. It is also referred to as photobiology or biostimulation (187, 188). LLLT is thought to affect fibroblast function and accelerate the repair of connective tissue (189). It has also been reported that LLLT has anti-inflammatory effects due to its action in reducing prostaglandin synthesis (190). Some studies suggest that LLLT has a beneficial anti-inflammatory and pain-attenuation effect in humans (191). A possible mechanism of the effect of LLLT on pain relief is its anti-inflammatory and connective-tissue repair process, which have been shown in some in-vitro and in-vivo studies (190, 192). The effectiveness of laser therapy in painful disorders is still unclear and should therefore be examined more rigorously (185, 193).

Pulsed magnetic field therapy (PMFT) is a simple, noninvasive technique used extensively for the treatment of muscle pain (194). This technique is based on changes in the cell membrane induced by magnetic fields (MF) and, to a limited extent, the electric field. Exposure to pulsed MF has been shown to have a therapeutic benefit in both animals and humans. MF exposure does not affect basic human perception but can increase pain thresholds in a manner indicative of an analgesic response (194). Nevertheless, no data is available regarding the effect of MF on CLBP.

All the aforementioned physical therapies have some basic research studies and have been widely applied, but conclusive research on their efficacy is lacking. These approaches can be considered in the PO phase of an integrated rehabilitative process, but until there is further proof they should be avoided as stand-alone LBP treatments.

Drugs

Pharmacological treatment is the first way to control pain in patients with LBP. There are various kinds of medications, and each one has a unique balance of risks and benefits. A systematic Cochrane review (97) of NSAIDs—which are widely used in LBP—demonstrated that there is a moderate evidence that NSAIDs are not more effective than other drugs for ALBP, and there is a strong evidence that various type of NSAIDs (including COX-2 NSAIDs) are equally effective. COX-2 NSAIDs had statistically significantly fewer side-effects than traditional NSAIDs, but recent studies have shown that COX-2 inhibitors are associated with increased cardiovascular risk in specific patient populations.

The use of muscle relaxants (195) in the management of nonspecific LBP is controversial even if they seem to be effective. However, the adverse effects—particularly, the effects on the central nervous system—require caution in the use of muscle relaxants. The potential for tolerance and withdrawal, combined with the risk of misuse and dependency, lead clinicians to restrict the prescription of opioids, even if they are commonly used for CLBP and may be efficacious for short-term pain relief. The long-term efficacy (>16 weeks) is unclear (114, 196). A Cochrane review (113) reported that there is no clear evidence that antidepressants are more effective than placebo, even if such findings do not imply that severely depressed patients with LBP should not be treated with antidepressants.

A pharmacological strategy for the treatment of LBP, particularly in regard to leg pain, is the epidural injection of corticosteroids, for which (92) there does not appear to be any evidence to support the current common practice of a series of injections. Abdi et al. (197) reported that there is limited evidence regarding the lumbar spine for long-term relief for interlaminar epidurals and moderate long-term improvement in managing nerve-root pain for transforaminal epidural steroid injection.

A review of evidence for an American Pain Society/American College of Physicians (198) recently summarized this knowledge in terms of good short-term evidence with moderate effectiveness for NSAIDs, acetaminophen, and skeletal muscle relaxant (for ALBP), while the minimal one proposed on tricyclic antidepressant for CLBP has been overcome, according to the last Cochrane review (113). They also found a reasonable amount of evidence that opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief as opposed to systemic corticosteroids, which the evidence strongly suggested was ineffective. The authors found that evidence is insufficient to identify one medication as offering a clear overall net advantage due to the complex tradeoffs between benefits and objectives. This leads to the choice of one or more medications after a specific analysis for each patient, taking into account the comorbidity and others drugs just assumed.

Low Back Pain

We definitively recognize, according to the actual knowledge, the term “LBP” as a diagnosis instead of being merely a symptom. LBP diagnosis is made by exclusion through a triage (5): in such cases other terms such as “sprain,” “injury,” “trouble,” or “lumbago” have been used for years, in most cases supposing and supporting the idea of different specific pathoanatomic background. Today the scientific community has abandoned this approach: the most up-to-date classification
of LBP is based on the localization and on the duration of pain (3, 8, 9, 10). Even if this could appear as an epidemiologic framework unduly applied to the clinical field, actually it is the only real way to differentiate patients with different prognoses and pathologies. Hopefully in the future it will be possible to deepen this broad classification, but it is already a good way to arrive at clinical and rehabilitative everyday choices.

Research thus continues its gradual progress toward the subclassification of different syndromes, mainly with the objective of increasing the quality of approach (62, 122, 124). However, this process will take years to reach a satisfactory conclusion.

The incidence, prevalence, and costs of LBP are incredibly high (59, 199, 200, 201, 202, 203, 204, 205). ALBP life prevalence is more than 80% of the population, year prevalence counts up to 30%, and costs in terms of absenteeism rank second in importance, following only cold and flu. However, over 90% of ALBP resolve in less than 30 days; on the other side, CLBP is an everyday experience for 4% to 7% of the population. It consumes 75% to 80% of the entire enormous costs of LBP and less than 5% of patients achieve a complete resolution of pain. SALBP has scarcely been studied and today we have no reliable epidemiological data, even if this stage of pathology should deserve the highest attention.

Acute LBP

Definition and Pathogenesis

ALBP is defined as pain or discomfort in the lumbar region, on one or both sides, eventually irradiating to the buttocks and lasting no more than a month (3, 8, 9

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