|Year : 2015 | Volume
| Issue : 1 | Page : 21-28
Nonspecific non-acute low back pain and psychological interventions: A review of evidence and current strategies
Gourav Banerjee1, Geoff P Bostick2
1 Centre for Pain Research, Faculty of Health and Social Sciences, Institute for Health and WellBeing, Leeds Beckett University, Leeds, United Kingdom
2 Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
|Date of Web Publication||1-Dec-2014|
Center for Pain Research, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds
Source of Support: None, Conflict of Interest: None
Nonspecific persistent and chronic low back pain (LBP) is one of the world's most significant burdens. Its management continues to be challenging despite advancements in medical diagnostics and therapeutics. The purpose of this narrative review is to update evidence-based, multidisciplinary assessment and treatment strategies for nonspecific non-acute LBP with special emphasis on the growing influence of psychological principles in physiotherapists' (PT) practice. An electronic literature search was performed to identify relevant clinical practice guidelines, from which an overarching summary was synthesized. All guidelines were consistent in their recommendations for the assessment of psychosocial factors and psychology-based interventions. In discussion, we underlined psychological processes and psychology-based strategies that are clinically relevant to, and within the professional competency and scope of PT practice.
Keywords: Psychologically informed practice, persistent low back pain, chronic low back pain
|How to cite this article:|
Banerjee G, Bostick GP. Nonspecific non-acute low back pain and psychological interventions: A review of evidence and current strategies. Indian J Pain 2015;29:21-8
|How to cite this URL:|
Banerjee G, Bostick GP. Nonspecific non-acute low back pain and psychological interventions: A review of evidence and current strategies. Indian J Pain [serial online] 2015 [cited 2020 Jan 21];29:21-8. Available from: http://www.indianjpain.org/text.asp?2015/29/1/21/145929
| Introduction|| |
Keeping abreast of the latest advances in pain science can be challenging given ever-increasing numbers of scientific publications,  and barriers such as time constraints, lack of access to paid journals, "incomprehensible" summaries, poor skills in literature searching and evaluation of research evidence.  Healthcare professionals in middle-income countries like India face escalated barriers related to limited resources in addition to those mentioned above.  These challenges and barriers can result in the lack of awareness of evidence-based practice. This narrative review aims to update nonspecific and non-acute low back pain (LBP) management and rehabilitation with special emphasis on the growing influence of psychological principles in physiotherapists' (PT) practice.
Low back pain is arguably one of the most extensively researched healthcare topics in the world. A simple PubMed search performed in May 2014 using keywords "low back pain" yielded 24748 results. LBP is a common and troublesome health problem in adults that adversely affects at personal, social, and economical levels  and can be associated with long-term disability.  LBP was once considered prevalent only in industrialized countries  but is now known that low- and middle-income countries are also affected. ,,,, Up to 80% of the general population will experience LBP once in their lifetime and about 15-30% are likely to be experiencing it at any given time. , Depending on the definition,  prevalence rates of LBP have been varyingly reported in the ranges of 0-33% for point, 0-65% for 1-year, and 70-84% for lifetime. ,, The economic burden of LBP relates to direct (medical care cost), and in-direct (sickness leaves, compensation) costs to businesses and governments. 
Low back pain is classified according to 'diagnostic triage' that focuses on excluding specific spinal pathology and nerve root pain from nonspecific causes.  LBP is multi-factorial  and may have identifiable or 'specific' causes (red flags) such as infection, tumor, and fracture that usually respond well to biomedical interventions. , However, in the majority (about 90%) of cases LBP can be nonspecific.  In other words, the person presenting with LBP will likely not have any demonstrable underlying pathology or apparent tissue damage relevant to the problem.  Nonspecific LBP can be defined as unidentifiable cause and source of pain and discomfort associated with soft tissue spasms or stiffness ranging from an area below the 12 th costal margin till above the inferior gluteal folds. , Its diagnosis is difficult as the pain often ebbs and flows and could be coming from any of the adjacent anatomical structures in the lumbar region. ,,, Recent studies have suggested some ,,,, pathophysiological mechanisms for LBP; however, the evidence is far from conclusive.
Nonspecific LBP in about 80-90% of cases tend to be acute (<4-6 weeks) and self-limiting that either resolves with little or no treatment and or may continue to persist or reoccur for months with negligible discomfort. However, in about 10% of cases LBP can be persistent and severely disabling beyond 6 weeks. ,, The biomedical model, unfortunately, in such cases-despite great advances in diagnostic techniques and treatment methods has proved unsuccessful in achieving complete recovery; ,,, alarmingly, the prevalence rate in recent years is on the rise.  Evidence-based pain management approach suggests that instead of emphasis on identifying patho-anatomy and targeting interventions at them, focus should be on factors that significantly influence the course of LBP, and are amenable to change - that is, psychological, social, and environmental factors. ,, Appropriate early management of LBP is crucial as it potentially could decrease the risk of developing chronic pain, absence from work, disability and associated morbidity. 
Non-acute persistent or chronic disabling LBP is an interrelating consequence of physical, psychosocial and or occupational factors. , As mentioned above, in the case of nonspecific LBP, psychological factors seem to take a predominant role in the development and maintenance of persistent LBP. , We searched electronic databases for clinical practice guidelines (CPGs) on LBP to summarize the evidence-based recommendations for the assessment of psychological factors in LBP as well as interventions that attempt to mitigate the impact of psychological factors on the recovery of LBP. CPGs are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances"  and others such as referral services and prognosis.  CPGs are built on frameworks of meticulous synthesis based on methodological quality and evidence hierarchy that could include meta-analyzes, systematic reviews, randomized controlled clinical trials, observational studies, case series and expert opinions available to healthcare providers and agencies, policy makers, educationalists, and employers in simple understandable summaries. ,,,,,
| Methods|| |
Clinical practice guidelines were identified in PubMed, CINAHL, EMBASE, National Guideline Clearinghouse, Guidelines International Network, National Institute for Health and Clinical Excellence, Scottish Intercollegiate Guidelines Network, and Canadian Medical Association InfoBase using relevant keywords "low back pain clinical practice guidelines" up to May 31, 2014. The criteria used to select CPGs in forming an overarching summary of assessment and management strategies are listed in [Table 1].
Five CPGs that met the defined criteria and were included in this review are Canada's TOP, 2011;  United Kingdom's NCCPC/RCGP, 2009;  United States of America's ACP/APS, 2007;  Europe's COST B13, 2006;  Italy's IRCCS, 2006.  There was ambiguity in how duration of LBP was defined in these guidelines [Table 2]. For the purpose of this review, we included recommendations for nonspecific non-acute LBP.
| Results|| |
Overview of assessment
The diagnosis of LBP or 'red flag' assessment is usually performed during initial presentation based on diagnostic triage using focused history, suitable physical, neurological, radiological, and electrophysical examinations (not discussed in this review). Nonspecific LBP is a diagnosis of exclusion. Refractory and severe cases that have become persistent and chronically disabling may need to be clinically re-assessed for specific medical causes. All five CPGs were consistent in the following recommendations:
- Do not advise lumbar radiographs (X-ray, magnetic resonance imaging (MRI), CT scan), single photon emission computed tomography, bone scanning, thermography, lumbar discography, facet nerve blocks, laboratory tests, electromyography (EMG), or other electrophysical tests - unless a specific cause is strongly suspected. Offer MRI only within the context of a referral for an opinion on spinal fusion.
- (Re)assessment of prognostic clinical, psychosocial and work-related factors (yellow, blue, and black flags) for chronicity, disability with work absenteeism, reduced quality of life and pain using suitable validated and standardized outcome measures.
The term "yellow flag" refers to modifiable normal psychological illnesses (e.g. fears and unhelpful beliefs). "Blue flag" and "Black flag" considerably overlap with each other and refer to social/environmental risk factors (e.g. workplace perceptions and contextual obstructions). For more information about flags related to clinic and workplace, refer to the work published by Kendall et al. 
Overview of management
[Table 3] presents a summary of LBP management strategies from guidelines identified above. An important observation is the unanimous emphasis on patient education, self-management techniques, physical exercise or exercise therapy and multidisciplinary rehabilitation involving psychology-based interventions like cognitive behavioral therapy (CBT).
| Discussion|| |
The reviewed guidelines clearly articulate the importance of psychosocial factors in the development and maintenance of persistent or chronic LBP. There is a convincing evidence to suggest that the patient participation in treatment and rehabilitative outcomes are influenced by pain beliefs, attitudes, emotions, and behaviors. , Assessment of psychosocial factors helps determining barriers to recovery and predicting patients who will have a poorer prognosis. ,[59,, The assessment should lead to targeted interventions  using cognitive behavioral approaches,  which will likely lead to good clinical and occupational outcomes. ,, Ignoring them, irrespective of biomedical interventions could lead to incomplete recovery and chronic pain-related disability. ,,
Potential psychological processes involved in persistent low back pain
Pain is an unpleasant subjective experience that has physiological and psychological components. Psychological factors are a "sequence of processes starting with initial awareness of a noxious stimulus, then cognitive processing, appraisal, and interpretation that leads people to act on their pain (i.e. their pain behavior). These processes are inﬂuenced by their consequences and are limited by the environment (e.g. cultural and social values)".  Linton and Shaw  have identified the following key factors:
- Attention or vigilance is awareness to noxious stimulus or threat; associated with psychological responses like fight-or-flight, worry, anxiety. Hypervigilance is an abnormal focus on pain  and can be associated with the development of chronic pain.  For example, the misdirected problem solving model  suggests that patients who are hypervigilant can become stuck in a perseverance loop whereby efforts to solve their chronic pain are overly focused on biomedical solutions, despite continued experiences of biomedical treatment failure. A PT might attempt to facilitate a re-direction of goals away from abolishing pain and toward goals relating to improved physical function.
- Interpretation is a result of highly complex cognitive and emotional processing of noxious stimuli that shapes behavior. Interpretation is influenced by:
- Beliefs (e.g. negative - "pain is harmful")
- Attitude (e.g. passive - "the doctor will fix my pain")
- Expectations (e.g. fictitious - "going to work will hurt even more")
- Distorted cognition (e.g. catastrophizing - "I'll end up in a wheelchair")
- Emotional distress (e.g. depression - "life's not worthy anymore").
Interpreting pain as harmful could lead a patient to avoid activity. The fear-avoidance model  would suggest that fear of activity can create further development of chronic pain through a cycle of catastrophizing, depression, deconditioning and disability. ,, It is a misbelief that all physical activity be avoided to reduce pain. PTs might use educational strategies ,,, to alter this belief with the intent of increasing physical function.
- Coping strategies are learned to attenuate noxious stimuli. It involves a combination of emotional, cognitive, and behavioral systems. Coping strategies that are passive in nature may impair a patient's capacity to manage their pain independently. In line with self-efficacy theory,  PTs should facilitate a shift in the responsibility of pain management toward the patient, to empower successful function despite pain.
- Pain-related Behavior is a set of behaviors that are gradually learned and influenced by emotions and cognitions. These can be helpful or unhelpful and are our only insight into the patient's experience of pain. Pain behavior is observable representations of the psychological processes described above and can also reciprocally influence these processes.
Psychologically informed practice and physiotherapists
Despite the emphasis of biomedical training in PT education, PTs are well placed to screen and manage 'normal' but 'unhelpful' psychosocial processes that are amenable to change. , A series of papers published in the American Physical Therapy Association's journal in 2011 (Physical Therapy, volume 91) discussed PTs' potential role in managing persistent LBP using psychological-based assessment and intervention strategies. It is, however, important to note that patients with psychopathology or 'abnormal' psychiatric symptoms ("orange flags" e.g. major depression, post-traumatic stress) must be referred to a mental health practitioner, that is, psychiatrist or clinical psychologist. ,, PTs in addition to psychological informed practice have been suggested to consider the workplace environment directly as well. Ergonomic and appropriate workplace modifications (e.g. transfer of manual labor to deskwork) can significantly influence work retention and early return-to-work.  Factors that are related to system and policies would need to have socio-political and economic considerations. 
AS identified in the CPG's, identifying psychosocial factors that could impede recovery is important. Prognostic indicators of LBP that are relevant to management strategies can be identified using tools like STarT Back Screening Tool.  This tool is quick to complete and easy to interpret. Patients identified as high risk are directed toward multidisciplinary management, or at least should receive management guided by psychological principles as discussed below. Interviewing techniques like Socratic style of interviewing  may also be required to gather insights about a patient's thought process. There are a number of tools available to evaluate different aspects of LBP-how the pain is perceived, how the patient responds to it, and how it affects the functional status and quality of life. Longo et al.  have overviewed tools that are commonly used clinically.
When chronic or complex pain is identified via the presence of yellow flags, a psychologically-informed approach is warranted. Nicholas and George  have identified opportunities for PTs to incorporate a psychologically-informed approach that is aimed at self-management, behavioral and cognitive changes. In addition, psychological principles for chronic pain management have been synthesized from a review by Roditi and Robinson. 
The aim is to establish voluntary control on self-regulatory physiological processes. For example, learning how to relax soft tissues and increasingly become aware of spasms around lower lumbar spine using EMG feedback.
Distraction and relaxation techniques
The aim is to reduce hypervigilance related to pain, and stress that may have developed in isolation or combination due to the complex interaction of physical, environmental, and emotional factors. Techniques like diaphragmatic deep breathing, progressive muscular relaxation, guided imagery helps activate the parasympathetic nervous system and enables greater awareness and control of factors that lead to stress and pain.
Operant behavior conditioning
This involves modifying or correcting conditioned maladaptive behaviors that are learned based on antecedents/experiences and consequences/anticipation. The overall aim is to improve emotional and functional well-being. This approach has embedded components of CBT. Techniques include:
- Education about neurophysiology of pain (in simple layman words) and the importance of physical exercise. Other important educational strategies include the use of positive self-statements to enhance coping skills, reassurance and promotion of physical activity, problem-solving approaches to overcoming potential barriers and setbacks, and restructuring certain cognitions (e.g. educating that resuming work at first may hurt but it does not mean harm and it should not set you back. It is a positive process toward rehabilitation).
- Graded-exercise approach that engages the patient with the activity in a controlled and time-limited fashion based on pre-negotiated activity quotas (as opposed to determining activity based on pain alone). The patient's baseline tolerance to activity is first determined by performing a physical task until a point is reached where pain restricts the ability to continue the task. A baseline (usually 50-75% of tolerance) is determined, and activity commences based on this quota. The PT positively reinforces the attainment of activity goals. With patient's agreement, the activity is gradually increased in subsequent sessions ("pacing up"). An e.g. upgrading walking time and distance upon successful attainment of previous task or sub-goal.
- Graded Exposure: In this technique, the patient is exposed to activities that are feared and avoided, and in subsequent sessions, the patient is instructed to gradually perform those activities broken down into individual movement components until the fear is abolished. E.g. a patient who avoids twisting of spine fearing pain aggravation is asked to do spinal rotation and side-flexion exercise in the supine, sitting, and standing positions, and finally activities related to daily living and work.
Goal setting is an integral component that starts with identifying mutually agreed goals between the PT and the patient. The identified goals are divided into specific sub-goals that can be gradually progressed in a stepwise fashion. The goals must be meaningful and realistic. The PT maintains effective communication at all times and monitors activities for responsiveness, modifications, and provides reinforcement.
Setting the right expectations
The aim is to optimize patient's expectations regarding functionally relevant, but realistic outcomes and minimize pessimism. The important aspect is to facilitate patient's expectations to managing pain and not curing it. Positive outcome expectancies will positively influence changes in cognitions and behaviors through interventions described above.
These approaches should be patient-centered by considering individual differences such as cultural background, socio-economic status, work-related demands, health habits, coping skills and other contextual factors.  It is important that once a case of nonspecific non-acute LBP has been made, there appears to be good evidence to diligently assess the role of psychological factors as opposed to solely focusing on anatomical or biomechanical causes of pain. Doing so may undermine efforts to mitigate maladaptive psychological processes during rehabilitation.  Finally, it is important to reaffirm that psychiatric fear, high-level anxiety (orange flag) will require expertise of a clinical psychologist or psychiatrist for advanced psychological interventions such as CBT and Acceptance and Commitment Therapy. Psychology-based therapy should be clearly delineated for PT's professional competency and scope of practice.
| Conclusion|| |
A paradigm shift toward psychologically informed PT practice will not be an easy transition - both at personal and patient levels. It is challenging to encourage patients to return to active lifestyles despite their pain and perceived disability. Moreover, it can be challenging to incorporate new management strategies that have not been traditionally a focus of PT training. However, there is a wealth of freely accessible resources such as the IASP Curriculum guidelines that clinicians and curriculum designers can use to guide pre-licensure and professional education. Continuing Professional Development programs that involve workshops, conferences, course, self-directed activities and E-learning can be a good way for disseminating knowledge and training.
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[Table 1], [Table 2], [Table 3]