PAIN EDUCATION Module 4: Treatment of chronic back pain

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1 The full version of this slide deck in MS PowerPoint format (containing presentation view and expanded notes) can be downloaded on please register! PAIN EDUCATION Module 4: Treatment of chronic back pain

2 2013 Excerpta Medica BV The material presented in this teaching slide deck is for educational purposes only. If you wish to reproduce, transmit in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, any part of the material presented, you will need to obtain all the necessary permissions by writing to the publisher, the original author, or any other current copyright owner. Please cite as: PAIN EDUCATION Teaching Slides, chapter: Treatment of chronic back pain, Available from No responsibility is assumed for any injury and/or damage to persons or property as a matter of products liability, through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, it is recommended that independent verification of diagnoses and drug dosages should be made. Produced by Excerpta Medica Radarweg NX Amsterdam Netherlands Supported by an unrestricted educational grant from Grünenthal. Produced in the Netherlands

3 Learning objectives Upon completion of this training module you should have gained an increased understanding of: The high burden of chronic back pain Back pain as a frequently under-treated condition Different chronic back pain conditions seen in practice The underlying mechanisms of back pain conditions Neuropathic pain components in chronic back pain Pharmacological and non-pharmacological treatment options for management of chronic back pain The classes of drugs used in managing back pain and the working mechanisms of various analgesic medications The rationale for combining analgesic medications in chronic pain management For additional information and further educational content related to the treatment of chronic back pain, please see Module 4 of the CME-accredited e-learning PAIN EDUCATION modules, available at

4 Chronic pain: a disease in its own right WHO recognizes pain as an important, global, public health concern Acute pain Need for improved, standardized management Chronic pain About 25% of Europeans are thought to have chronic pain conditions Chronic pain is multifaceted and involves the interaction of Physical factors Psychological factors Social factors Pain management plan development based on Good physician-patient communication Jointly agreed goals WHO = World Health Organisation. WHI European Commission

5 Inadequacy in current chronic pain management Chronic pain conditions are often poorly managed Of > 45,000 European telephone survey respondents with chronic pain > 30% experiences intolerable pain > 60% finds prescription medications inadequate 40% feels that pain is not well managed Improving these outcomes needs Understanding the effect of chronic pain on patients Appreciation of pain mechanisms The management plan must address the patient needs and the many facets of pain > 30% Intolerable pain > 60% Medications inadequate 40% Pain not well managed Breivik H, et al. Eur J Pain. 2006;10: Varrassi G, et al. Curr Med Res Opin. 2010;26:

6 Physical and psychological burden of severe pain The burden posed by severe and chronic pain is far-reaching Anxiety Reduced mobility Appetite disturbance Limited social functioning Depression Disturbed sleep Limited workplace functioning Reduced quality of life Becker N, et al. Pain. 1997;73: Breivik H, et al. Eur J Pain. 2006;10: Gore M, et al. J Pain. 2006;7: McDermott AM, et al. Eur J Pain. 2006;10:127-35, 3

7 Back problem Joint pain Neck Arthritis Surgery/medical procedure Fibromyalgia Preview for Incidence and costs of back pain Chronic back pain is the most frequently reported severe pain Incidence of back pain > 50,000 participants France, Germany, Italy, Spain, UK Severe pain: 3.5% Back pain: 66% Costs of back pain 49 billion Euros per year (Germany) > 1300 Euros per patient More than 50% attributable to indirect costs of back pain Highest indirect cost burdens of common medical illnesses ,3 Langley PC. Curr Med Res Opin. 2011;24: Kantar Health, Inc Princeton, NJ. Wenig CM, et al. Eur J Pain. 2009;13: Maniadakis N, et al. Pain. 2000;84:

8 Risk factors of back pain Physical behaviour Lack of healthy exercise Sedentary lifestyle Environmental factors Vibrations Poorly designed furniture Patient factors Age Height Physical conditions Weak trunk muscle Bad posture Psychological conditions Stress Depression Fear of movement The risk of back pain is highest during the working years, with a peak between 30 and 39 years Heliovaara M. Ann Med. 1989;21: Chou R, et al. Ann Intern Med. 2007; 147: Vlaeyen JWS, Linton SJ. Pain. 2000;85:317-32, 5

9 Localization and division of back pain Non-specific (90% of cases are non-radicular and pseudoradicular) Functional disorder through incorrect weight-bearing and wear (mechanical) Specific (10% of cases are radicular) Nerve root irritation and compression syndrome Prolonged pain (extravertebral or visceral) Intervertebral disc prolapse Metabolic (osteoporosis, fracture) Somatoform pain disorders/fibromyalgia Malignant (primary tumours/metastasis Inflammatory (rheumatic, infections) 6 Chou R, et al. Ann Intern Med. 2007; 147:

10 Natural course of back pain Back pain often starts with acute pain Acute pain is defined as pain lasting less than 4 weeks This episode may be followed by a period of subacute pain persisting for weeks to months Back pain that continues for more than 3 months is termed chronic back pain 5 10% of acute back pain cases become chronic Back pain in women tends to last longer than in men Most people experience acute back pain at least once in their lifetime Intensity and frequency can be influenced by psychological components Frank JW, et al. Spine (Phila Pa 1976). 1996;21: National Institute for Health and Clinical Excellence

11 Classification of back pain according to pain mechanisms Type of Pain Example Characteristic Nociceptive back pain Nociceptiveinflammatory pain Neuropathic back pain Dysfunctional back pain Mixed pain Osteoporosis Facet syndrome Nerve-root irritation syndrome No nervous system lesion or inflammation Pricking/burning pain sensation in response to nociceptive pain stimulus Actual or threatened damage to non-neural tissue due to inflammation Nerve damage involved Expression of maladaptive plasticity Fibromyalgia No obvious nerve damage Non-specific back pain, spinal canal stenosis No obvious nerve damage Overlapping components of nociceptive and neuropathic pain All types of pain are processed by the nervous system Deyo RA, Weinstein JN. N Engl J Med. 2001;344: Cohen SP, et al. BMJ. 2008;337:a2718. Woolf CJ, et al. Science. 2000;288: Marchand S. Rheum Dis Clin North Am. 2008;34: , 8

12 Patients (%) Preview for Neuropathic component in back pain 7,772 back pain patients: Neuropathic component likely Neuropathic component uncertain Neuropathic component unlikely 37.0% 27.7% 35.3% Neuropathic pain correlates with More intense pain More severe comorbidity Poorer quality of life n = 1,131 n = 4,254 n = 2, Freynhagen R et al. Curr Med Res Opin. 2006;22: Freynhagen R, et al. Curr Pain Headache Rep. 2009;13: Freynhagen R, et al. Curr Med Res Opin. 2006;22: Mild Moderate Severe Mainly neuropathic Unknown Mainly nociceptive

13 Central sensitization Chronification of pain May result from local tissue damage and inflammation Alteration of nociceptors by inflammatory mediators producing pain sensitization Lasting activity of damaged nerve fibres leads to neuroplastic changes in the CNS Central sensitization Reactivity nociceptive posterior horn neurons (wind up) Mechanoreceptors (Aβ-fibres) obtain contact to the nociceptive system Non-painful stimuli are recognized as painful (allodynia) CNS = central nervous system. Woolf CJ. Ann Intern Med. 2004;140: Woolf CJ, et al. Science. 2000;288: Latremoliere A, et al. J Pain. 2009;10:

14 Diagnosing back pain Red flags: Discovery of physical causes, in particular if specific or urgent treatment is required Yellow flags: Identification of risk factors for chronification of pain: assessment of psychosocial factors is a key component. Diagnostics Obtain objective evidence for physical symptoms and functional impairments to identify Non-specific back pain Back pain with radiculopathy or spinal stenosis Back pain with another potential cause Chou R, et al. Ann Intern Med. 2007;147: Savigny P, et al. BMJ. 2009;338:b1805. Rives PA, et al. J Am Board Fam Pract. 2004;17:S Cohen SP, et al. BMJ. 2008;337:a2718. Bratton RL. Am Fam Physician. 1999;60: , 11

15 Red flags and chronic pain Red flags to low back pain identified by the American college of radiology: Trauma, cumulative trauma Unexplained weight loss, insidious onset Age > 50 years, especially women, and males with osteoporosis or compression fracture Unexplained fever, history of urinary or other infection Immunosuppression, diabetes mellitus History of cancer Intravenous (IV) drug use Prolonged use of corticosteroids, osteoporosis Age > 70 Focal neurologic deficit(s) with progressive or disabling symptoms, cauda equina syndrome Duration longer than 6 weeks Prior surgery 12 Davis PC, et al. Reston (VA): American College of Radiology (ACR), 2011.

16 Yellow flags and chronic pain Yellow flags to low back pain identify psychosocial factors that increase the risk for developing or perpetuating chronic pain and long-term disability Psychosocial risk factors Inappropriate attitudes and beliefs about back pain Lifestyle habits Smoking, medicines (AT1 blockers) Poor working conditions Social class Educations Income Coexisting disease Cardio-respiratory diseases Psychiatric diseases Inappropriate pain behaviour Work-related problems or compensations issues Emotional problems 13 van Tulder M, et al. Eur Spine J. 2006;15:S

17 Back pain diagnosis The Lasegue test (straight leg raise test) The Schober test The Faber test Other simple tests Imaging The test is positive if the pain in the sciatic distribution is produced at degrees of passive inflexion of the straight leg. Lasegue s sign can be used to diagnose nerve-root irritation. This test measures the flexibility of the spine This test is frequently used to differentiate lumbar spinal problems from primary hip pathology Ask patients to walk on heels or toes Try pelvic tilts and range of motion of trunk movements Attempt finger-tofoot distance tests and chin-to-chest tests Ask patients to demonstrate chest expansion and their range of motion of the cervical spine Imaging is indicated in patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition Ask patients to sit on the floor with legs stretched out Chou R, et al. Ann Intern Med. 2011;154:81. Van Tulder M, et al. Eur Spine J. 2006;15S

18 Radicular and non-radicular back pain Diagnostic indicators Radicular back pain (10% of all chronic back pain Weakened muscles Pain the the legs/buttocks Sensitivity disorders Lasegue signs Non-radicular pain (90% of all chronic back pain) Aetiology Pressure on spinal nerve roots Changes in joints (intervertebral joints, iliosacral joint) Changes of ligaments muscles Intervertrebal changes (without prolapse) Causes Slipped disc Osseous stenosis Symptoms Stabbing or shooting pain Dull, aching, difficult to locate Pain location Legs/buttocks, rather than back Unilateral or bilateral in the region of the back or buttocks Pain often intensifies when position is changed or maintained for long periods and eases on movement Chou R, et al. Ann Intern Med. 2011;154:81. Van Tulder M, et al. Eur Spine J. 2006;15S

19 Managing acute back pain Physical Stimulation to movement as soon as possible Brief bed-rest/sick leave Heat/cold application Physical therapy Pharmacological Analgesics Co-analgesics Stimulation Acupuncture Interventional/surgical treatment if other methods unsuccessful Physicians should always consider the risks for acute pain becoming chronic and persistent If there is no improvement in 2 4 weeks, the physician must order futher tests Chou R, et al. Ann Intern Med. 2007;147: Savigny P, et al. BMJ. 2009;338:b

20 Managing chronic back pain Pharmacological e.g. paracetamol, NSAIDs, weak opioids, strong opioids, muscle relaxants, TCAs, SNRIs and MOR-NRI Non-pharmacological e.g. controlled exercise therapy, relaxation measures, ergotherapy, patient education, behavioural therapy Interventional e.g. surgical Multi-modal, long term Individually oriented to the current symptoms and to the pathophysiological causes Multimodal management to Help patients to self-manage their condition Reduce pain and its impact Physical and sport therapy Active Medical training therapy Psychological pain treatment Relaxation techniques Pain coping strategies Stimulation therapy Spinal cord stimulation Pharmacotherapy Analgesics Co-analgesics Chou R, et al. Ann Intern Med. 2007;147: Grabois M. Am J Phys Med Rehabil. 2005;84:S Savigny P, et al. BMJ. 2009;338:b1805. National Institute for Health and Clinical Excellence NSAIDs = non-steroidal anti-inflammatory drugs; MOR-NRIs = µ-opioid receptornorepinephrine reuptake inhibitors; SNRIs = selective noradrenaline reuptake inhibitors; TCAs = tricyclic antidepressants; TENS = transcutaneous electrical nerve stimulation. 17

21 Non-medical, non-surgical therapy Core stability exercises Massages Chiropractic Physiotherapy Acupuncture Behavioural therapy Psychological pain coping Strength training and fitness Non-medical, Non-surgical therapy Orthotic devices Relaxation techniques Yoga The National Institute for Health and Clinical Excellence (NICE) recommends 8 supervised, physical and exercise sessions over 12 weeks that can be combined with a psychological treatment programme of management. Hayden JA, et al. Cochrane Database Syst Rev. 2005;3:CD000335, Chou R, et al. Ann Intern Med. 2007;147: Savigny P, et al. BMJ. 2009;338:b1805. National Institute for Health and Clinical Excellence

22 Exercises and chronic pain GET and pacing strategies are employed as part of a multimodel, intensive management programme GET ensures that patients take exercise that builds to allow improved flexibility and endurance, helping relieve pain and contributing to better function Pacing strategies ensure that patients with back pain learn to pace their lives, taking account of their back problems and pain GET = graded exercise therapy. 19 Hayden JA, et al. Cochrane Database Syst. Rev. 2005;3:CD

23 Pharmacological treatment of pain: a mechanism-oriented approach Pain character/symptoms Affecting the muscular and skeletal system/exertiondependent/local/tender/no signs of inflammation Affecting the muscular and skeletal system/exertiondependent/signs of inflammation/local/pressingstabbing-probing Affecting the nervous system/burning/shooting/ concomitant neurological symptoms Multi-locular/no pathological findings/hypersensitive to pain/vegetative and/or mental symptoms Morlion B. Curr Med Res Opin. 2011;27: Diagnosis examples Arthrosis/myofascial pain syndrome Activated arthrosis/arthritis Diabetic polyneuropathy/ post-zoster neuralgia Fibromyalgia syndrome Nociceptive Nociceptive/ inflammatory Neuropathic Dysfunctional Mechanisms Nociceptor activation/reduced endogenous pain inhibition Nociceptor activation and sensitization/central sensitization Forming of new channels and receptors/ectopic impulse generation (spontaneous activity) Central sensitization Forming of new channels and receptors/ectopic impulse generation (spontaneous activity) Reduced endogenous pain inhibition and changed pain processing Pain therapy with medication Nonopioids/muslce relaxants/mor- NRI Opioids NSAIDs/(glucocorticoids)/ opioids/mor-nri Anticonvulsants (Na and Ca channel blockers)/antidepressants (here above all TCA)/MOR-NRI Anti-depressants (NSRIs)/opioids/topical agents (lidocaine plaster, topical capsaicin) Anti-depressants (NSRIs) MOR-NRI = µ-opioid receptor-norepinephrine reuptake inhibitor; NSAIDs = non-steroidal anti-inflammatory drugs; SNRIs = selective noradrenaline reuptake inhibitors; TCAs = tricyclic antidepressants. 20

24 Pharmacotherapy, including combinations, for chronic back pain Pharmacological management of back pain should treat both nociceptive and neuropathic components Nociceptive pain Paracetamol, NSAIDs and COX-2 inhibitors Largely ineffective on specific neuropathic pain mechanisms E.g. ibuprofen, diclofenac, acetylsalicylic acid Topical agents E.g. ibuprofen, diclofenac ointments Opioid therapies Target nociceptive and, to a lesser extent, neuropathic pain E.g. strong opioids (morphine, oxycodone, fentanyl, buprenorphine) and weak opioids (tramadol, codeine) Neuropathic pain Anti-depressants Agents that inhibit neurotransmitter uptake E.g. TCAs, SNRIs Anticonvulsant drugs E.g. pregabalin, gabapentin Topical agents Useful in managing localized neuropathic pain E.g. lidocaine plaster, capsaicin MOR-NRI (simultaneously targeting Nociceptive and Neuropathic pain) Two mechanisms of action opioidergic activity plus noradrenaline reuptake inhibitory activity E.g. tapentadol NSAIDs = non-steroidal anti-inflammatory drugs; SNRIs = selective noradrenaline reuptake inhibitors; TCAs = tricyclic antidepressants. Morlion B. Curr Med Res Opin. 2011;27: Roelofs PD, et al. Cochrane Database Syst Rev. 2008:CD

25 Rationale for mechanism-oriented pharmacotherapy Chronic pain Often involves more than one mechanism Seldom controlled by a single pharmacological principle Combining agents with different mechanisms of action increases the probability of interrupting the pain signal (additive/synergistic effect) Use drugs with complementary pharmacokinetic profiles instead of a higher-dose single agent treatment Methods of combining drugs include use of Single, loose-drug combinations (e.g. oxycodone and pregabalin) Fixed combination preparations (formulated to contain 2 agents, e.g. paracetamol/tramadol) Use of agents with more than one mechanism of action in a single molecule (e.g. tapentadol) Warning: Certain agents are associated with risk of severe side effects Some patients have treatment-related Morlion B. Curr Med Res Opin. 2011;27: National Institute for Health and Clinical Excellence adverse side-effects Roelofs PD, et al. Cochrane Database Syst Rev. 2008;1:CD Varrassi G, et al. Curr Med Res Opin. 2010;26:

26 Summary Back pain is highly prevalent with a high socio-economic and clinical burden Chronic back pain is often non-specific in nature History and physical examination are important in distinguishing potential causes of back pain Management of back pain should be multi-modal involving programmes of exercise, relaxation, psychosocial support and pharmacological intervention tailored to patient needs and relevant to the mechanisms underlying pain 23