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FACT SHEETS

Supported Self-Management of Back Pain from a Clinician’s Perspective

Published

9 July 2021

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When those living with back pain are able to engage in self-management techniques, they are likely to be more resilient and self-sufficient which can lead to better quality of life.

Back pain is the most prevalent and, therefore, most important chronic pain condition across the world with clinical, social, economic, and public health implications [1]. Back pain tends to recur or become chronic (CBP). Risk factors for chronification are well-documented [2]. This fact sheet focuses on patients with chronic local and regional CBP of nonspecific origin only. CBP can occur in combination with nonspecific neck pain or as part of a more general chronic pain condition. Regardless of the clinical presentation, treatment should focus on improving a patient’s self-management skills.  

In order to grade chronic low back pain, the following must be assessed: individually perceived pain severity, days with impaired daily activities, and the extent of impairment of daily living, leisure, and ability to work [2]. Becoming active – physically, mentally and socially – even when in pain, should be one of the most important targets of any CBP therapy in order for the individual to develop coping strategies and therefore reduce the burden of pain on their everyday activities. 

Consequently, any therapy should focus on enabling those living with CBP to self-manage their pain condition. This is reflected in the gold-standard guidelines on low back pain which strongly recommend focusing on patient self-management [3-8].

Enabling patients requires a successful working alliance of patients and health care providers across disciplines including general practitioners, physiotherapists, occupational therapists, psychotherapists and more. This working alliance can be characterized through the use of good communication skills by the health care providers such as listening, validation of pain, using simple language, shared decision making, patience, and a common sense approach to diagnosing and treating, so as to avoid overmedicalisation.

These features of a successful working alliance will enable patients in back pain by education and abilities [9, 10] such as: 

  • being informed that CBP is not harming.
  • knowing the efficacy and advantages of regular physical activity and the risks of over medication [11, 12]
    • Patients may choose any physical activity by individual preference [13-16]. It is important to find movement that one enjoys, as that will help ensure people continue with it; it can be exercise, cycling, walking, running, going to the gym, gardening, dancing, or any other activity that gets you moving regularly. In addition to pain modulation and the physical effects, movement can also provide positive psychological effects.
  • knowing about calming strategies. They can help regulate one’s parasympathetic nervous system. Effective relaxation techniques include deep, controlled breathing, mindfulness, and meditation.
  • knowing about meaningful activities such as reading, enjoying one’s hobby, volunteering or any activity that has meaning and purpose to the person living with pain. 
  • knowing about the impact of social connections with friends or family.
  • knowing that medication such as NSAIDs or coxibs should only be used in order to resume physical activities and relaxation and should only be taken for a few days.
  • knowing that a physician should be visited if 
    • there is an acute injury to the back
    • new neurologic deficits in the legs and/or to bladder and rectum are recognized
    • fever arose with aggravated BP.

When those living with back pain are able to engage in self-management techniques, they are likely to be more resilient and self-sufficient which can lead to better quality of life. Resilience also fosters flexibility in regards to external and internal demands such as new pain episodes. Those living with pain successfully self-manage by acting, reassuring and distracting by:

  • knowing that back pain can vary according to time and activity without this indicating harm and will manage episodes with greater impairment.
  • finding time for physical activity and relaxation.
  • knowing how to boost self-motivation to be able to continuously perform physical activity and relaxation. 

REFERENCES

[1] Manchikanti L, Kaye AD, Hirsch JA. Proposed Medicare Physician Payment Schedule for 2017: Impact on Interventional Pain Management Practices. Pain Physician. 2016 Sep-Oct;19(7):E935-55. 

[2] Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain. 1992;50(2):133-49.

[3] (AWMF) AdWMF. Nationale Versorgungsleitlinie Nicht-spezifischer Kreuzschmerz 2017 [Available from: https://www.awmf.org/uploads/tx_szleitlinien/nvl-007l_S3_Kreuzschmerz_2017-03.pdf.

[4] O’Connell NE, Cook CE, Wand BM, Ward SPJBp, rheumatology rC. Clinical guidelines for low back pain: a critical review of consensus and inconsistencies across three major guidelines. 2016;30(6):968-80.

[5] Bekkering GE, Van Tulder MW, Hendriks EJ, Koopmanschap MA, Knol DL, Bouter LM, et al. Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. 2005;85(6):544-55.

[6] Wong J, Côté P, Sutton D, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. 2017;21(2):201-16.

[7] Qaseem A, Wilt TJ, McLean RM, Forciea MAJAoim. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. 2017;166(7):514-30.

[8] Bernstein IA, Malik Q, Carville S, Ward SJB. Low back pain and sciatica: summary of NICE guidance. 2017;356.

[9] Barbari V, Storari L, Ciuro A, Testa MJPe, counseling. Effectiveness of communicative and educative strategies in chronic low back pain patients: a systematic review. 2020;103(5):908-29.

[10] Du S, Hu L, Dong J, Xu G, Chen X, Jin S, et al. Self-management program for chronic low back pain: a systematic review and meta-analysis. 2017;100(1):37-49.

[11] Hayden JA, Van Tulder MW, Tomlinson GJAoim. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. 2005;142(9):776-85.

[12] Van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MWJBp, et al. Exercise therapy for chronic nonspecific low-back pain. 2010;24(2):193-204.

[13] Wewege MA, Booth J, Parmenter BJJJob, rehabilitation m. Aerobic vs. resistance exercise for chronic non-specific low back pain: A systematic review and meta-analysis. 2018;31(5):889-99.

[14] Saragiotto BT, Maher CG, Yamato TP, Costa LO, Costa LCM, Ostelo RW, et al. Motor control exercise for nonspecific low back pain: a cochrane review. 2016;41(16):1284-95.

[15] Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo RW, Cabral CM, et al. Pilates for low back pain: complete republication of a cochrane review. 2016;41(12):1013-21.

[16] Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation. 2015;29(12):1155-67.

AUTHORS

Marcus Schiltenwolf, MD
Conservative Orthopaedics and Pain Management
Clinic for Orthopaedics and Traumatology
University Hospital Heidelberg, Heidelberg, Germany
marcus.schiltenwolf@med.uni-heidelberg.de 

Ann-Christin Pfeifer, PhD
Conservative Orthopaedics and Pain Management
Clinic for Orthopaedics and Traumatology
University Hospital Heidelberg, Heidelberg, Germany

REVIEWERS

Johnannes Flechtenmacher, Dr. med.
Ortho-Zentrum, Karlsruhe, Germany

Björn Gerdle
Professor Emeritus
Linköping University, Sweden

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