Recognized best practice care for chronic low back pain

Key takeaways:

• Diagnosis should be based on pain mechanisms, medical screening and thorough assessment. Imaging is recommended only in specific circumstances.
• Pain education and pain self-management play a key role in recovery.
• By using a patient-centered and personalized multimodal approach, long-term pain relief is possible.

There is no doubt that chronic low back pain is complex, costly and often comes with many adverse side effects. As the field of chronic pain expands and new research emerges, outdated treatment practices expire, increasing the need for effective evidence-based guidelines. Today, there are a wide range of strategies available that not only manage the symptoms but also target the root cause, making prolonged pain relief possible. To determine the best practices for chronic low back pain management, we took a deep dive into the literature and identified the following core principles:

Pain relief - the main target

Providing pain relief that is clinically significant and sustained while minimizing adverse effects should be the main target of chronic low back pain management . In the past 15-20 years, many practitioners were taught to prioritize quality of life and regaining of daily function over pain relief. While these are also important goals to aim for, the discrepancy between a patient’s treatment goal (pain relief) and a practitioner’s treatment goal (improved function) has led to a culture of pain management that minimizes the patient's perspective. 

In addition, recent neuroscientific discoveries have shown that chronic pain changes the brain, causing the brain to “learn” to perpetuate pain. The good news is that with proper therapeutic interventions, the brain can also unlearn pain and actually be rewired back to its original, pain-free state - making pain relief a realistic goal. Therefore, management success should be tracked with outcome measures (0-10 numerical rating scale) and validated questionnaires to track symptom severity and/or how much pain interferes with daily function.

Patient-centered and personalized

Guidelines emphasize the importance of individualized patient-centered care in the diagnosis and treatment of chronic low back pain. Your pain is unique to you, which is why understanding the characteristics of your pain, learning about your personal needs and values, and developing a personalized care plan that adapts to your unique context and cultural background, should be at the forefront of care. This means tailoring your treatment according to your pain experience, personality, and personal goals, rather than relying on a one-size-fits-all approach.

Guidelines also highlight shared decision making as a way to increase therapeutic alliance and promote optimal patient outcomes. Communication lies at the heart of a good patient-clinician relationship, and an open dialogue aimed at helping patients make informed decisions about their care is an important element of successful pain management. A good pain management doctor is compassionate, respectful and empathetic, and fosters a collaborative relationship for finding the right treatment combinations that fit your pain relief goals.

Diagnostics: pain mechanisms, screening, imaging

The assessment of chronic low back pain is challenging due to its complex multimodal nature. Therefore a thorough assessment that includes your personal history, current psychosocial risk factors, and underlying pain mechanisms must be considered when making a diagnostic classification. Diagnosis should also include appropriate medical screening such as

a)    Screening for “red-flags”, which are signs and symptoms of more serious pathology. For more information on red flags, click here.

b)    Conducting a physical examination, which may include evaluation of mobility, muscle strength, and potentially neurological function depending on symptoms.

For a given individual chronic pain may include a variety of separate pain mechanisms that interact, including inflammatory pain, mechanical processes, central sensitization, neuropathic pain, and/or emotional learning. Most doctors and practitioners do not have formal education needed to diagnose based on pain mechanisms, which is why we always recommend practitioners with specialized training in pain management.

Radiological imaging only in specific circumstances

The overuse of imaging is a common problem in chronic low back pain care. In addition, research has shown that many chronic pain conditions are not linked to abnormal findings on scans or X-rays and can actually be unhelpful when it comes to managing persistent pain. The current guidelines now recommend seeking radiological imaging only if there are signs of serious pathology, conservative treatment has not improved pain, symptoms have worsened, and/or if imaging results would meaningfully impact pain management. For more on common false alarms from medical imaging visit our blog.

Pain education and self-empowerment

Understand your pain is key to replacing uncertainty and fear with knowledge and empowerment

Learning about the science behind chronic pain can help you gain more control over your pain and life, which is why pain education is considered a key component of good clinical practice. Helping people better understand the mechanisms and factors underlying their persistent pain has been shown to reduce pain, decrease anxiety, and lead to long-term improvements in functioning and fear avoidance. The keys to recovery are understanding the intertwined relationship of the mind, brain and body, and recognising there are ways to break the cycle of chronic pain. With this knowledge you can begin to reconceptualize your pain, be better equipped to cope with it, and most importantly, begin taking ownership for your well-being.

Successful self-management

Self-management support is an important aspect of person-centered care that aims at promoting self-efficacy and autonomy. Ultimately, self-management is about empowering you to take an active role in your own pain management. Based on the factors contributing to your pain, suggested tools and strategies may include relaxation techniques, activity pacing and deep breathing, as well as action planning and goal setting. Lifestyle changes such as increasing physical activity, improving sleep quality, and promoting good nutrition can also support in managing your pain. As a result, you’ll find ways to effectively reduce your symptoms, prevent flare ups, and re-engage in life’s everyday activities. 

Multimodal pain management - The Golden Standard

Persistent back pain is far more complex than just the physical sensations in the back. In fact, modern research shows that psychological and emotional elements play a major role in the onset, duration, and severity of chronic pain, and can affect treatment adherence and disability status. This is why effective pain management should be based on a multimodal, biopsychosocial model of care, addressing pain from multiple angles – from physical and psychological to environmental. Simply put, the biopsychosocial model goes beyond just the physical symptoms, treating the person as a whole.

A multimodal approach may include medical interventions and medication, but its primary focus is on non-invasive, non-pharmacological treatments such as physical and psychological therapies. Treatment options range from cognitive behavioral therapy, mindfulness practices, to psychological support and exercise therapy, each of which have been proven to improve long-term outcomes in people with chronic pain. Supporting patients in continuing meaningful life activities and resume work (if applicable) should also be integrated with other treatments offered. While these may not be a direct or quick fix solution to pain, with consistency and patience, they have the potential to greatly reverse the effects of chronic pain and help you regain your quality of life.

Evidence-based treatment over surgery

If a patient shows no clear signs of pathology (red flags), pain management should follow evidence-based care guidelines before resorting to surgery. These may include a combination of psychological support, physical and behavioral therapy, lifestyle changes, and targeted medications. Surgery should be considered only if non-surgical approaches have not meaningfully benefited the patient and if clear indicators of pathology are identified.

Tracking and increasing physical activity

For chronic back pain, gradually increasing and tracking your physical activity plays an important role in building trust in your body and promoting your recovery. According to international and national guidelines, exercise is not only safe for most people with persistent back pain, but also provides short and long-term pain relief, increases functioning, and improves quality of life. Get creative in the ways you can add more movement into your daily routine while gently stretching your physical limitations, or have a well-informed health professional design a program tailored to your needs. You can also check out our guide to moving with chronic pain here.

Effective treatment meets technology

Unfortunately, significant barriers to effective pain care exist: multidisciplinary pain care can be costly, resource and time intensive, and for many, hard to access. That’s where Aivo’s highly personalized digital pain reversal treatment comes in. The Aivo program provides you with the only science-backed pain management program for chronic low back pain that continuously adapts to your symptoms, personality, and pain relief goals. Our program is based on recommended practices and is comparable to the best interdisciplinary pain clinics - only much more affordable and convenient, making pain relief easily accessible for anyone, anywhere, at any time.