Multidisciplinary Treatment May Benefit Patients With Chronic Low Back Pain

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Alan BROWN

MELBOURNE

http://www.medscape.com/viewarticle/567981?src=mp

December 27, 2007 --- Multidisciplinary treatment strategies are

effective for patients with chronic low back pain (CLBP) in all stages

of chronicity and should not only be given to those with lower grades of

CLBP, according to the results of a prospective longitudinal clinical

study reported in the December 15 issue of /Spine/.

" The treatment of choice for patients with CLBP seems to be a

multidisciplinary therapy incorporating multiple treatment components,

such as intensive physical exercises and biopsychosocial and behavioral

interventions, " write Matthias Buchner, MD, PhD, from the University of

Heidelberg in Germany, and colleagues. " This prospective clinical study

with a 6 months' duration is, to the authors' knowledge, the first to

evaluate separately the prognostic value of the chronicity stage in the

therapy outcome of patients with CLBP treated with a multidisciplinary

biopsychosocial therapy approach. "

In this study, 387 patients with CLBP for at least 3 months associated

with sick leave for at least 6 weeks underwent standardized

multidisciplinary therapy for 3 weeks. At baseline, patients were placed

in 3 groups of chronicity graded using the classification of von Korff

and colleagues (group A, grades I and II; group B, grade III; group C,

grade IV) and were followed prospectively.

At 6-month follow-up, the 3 groups were compared for back-to-work

status, generic health status measured with the 36-Item Short Form

Health Survey (SF-36), pain intensity measured with the visual analog

scale, functional capacity measured with the Hannover back capacity

score, and satisfaction with their therapy.

At baseline, patients in group C had a higher pain level, a longer pain

history, and more generalized as well as psychosomatic comorbidities vs

patients in groups A and B. From baseline to 6 months, all outcome

criteria improved significantly in all 3 treatment groups, and the

back-to-work rate in the total patient sample was 67.4%.

At the final follow-up, patients with lower grades of chronicity had

significantly better outcomes in functional capacity and pain level, but

these were mostly attributed to worse values at baseline. At 6 months,

there were no significant differences among groups in back-to-work rate,

satisfaction with therapy, and the Mental Component Summary of the SF-36.

" According to the results of this study, patients with chronic low back

pain also derive significant benefit from a multidisciplinary treatment

strategy in higher stages of chronicity, " the study authors write.

" Therefore, therapy should not be limited to the patients in lower

stages of chronicity. "

This study has received no external funding, and the study authors have

disclosed no relevant financial relationships.

/Spine/. 2007;32:3060-3066.

Clinical Context

CLBP is not only a serious problem for our healthcare system, but it

also has a significant socioeconomic effect. The major costs of CLBP are

the consequence of loss of productivity, work absenteeism, and

disablement. According to a study by von Korff and colleagues, CLBP

correlated strongly with chronic pain grade and unemployment rate,

functional limitations, depression, self-rated health, use of opioid

analgesics, and pain-related clinician visits at baseline and also at

1-year follow-up. Systematic reviews have supported multidisciplinary

therapy as the treatment of choice for CLBP. It incorporates multiple

treatment components, such as intensive physical exercises and

biopsychosocial and behavioral interventions.

The aim of the study was to analyze the outcome of different stages of

chronicity in patients with CLBP treated with multidisciplinary therapy.

Study Highlights

* In this prospective longitudinal clinical study, a total of 387

patients (241 women and 164 men; average age, 44.1 years) with

CLBP for 3 months or longer and a corresponding sick leave for

longer than 6 weeks underwent 3-week standardized

multidisciplinary therapy. They were followed up for 6 months.

* All patients had already undergone all conventional forms of

biomedical treatment before being referred to this study.

* At baseline (T0), patients were assigned into 3 groups of

chronicity grades according to the classification of von Korff and

colleagues (group A, grades I and II; group B, grade III; group C,

grade IV) and were followed prospectively. No patient in this

study was pain-free (grade 0).

* The multidisciplinary treatment is a biopsychosocial therapy

strategy based on biologic, social, and psychologic aspects.

* At the 6-month follow-up (T1), 5 different therapy outcomes were

analyzed and were compared in the 3 groups: back-to-work status,

generic health status (SF-36), pain intensity (visual analog

scale), functional capacity (Hannover back capacity score), and

satisfaction with the therapy.

* At T0, patients in group C had a higher pain level, a longer

history of pain, and more general and more psychosomatic

comorbidities than patients with lower levels of chronicity.

* Results revealed that all 3 treatment groups improved

significantly in all outcome criteria between T0 and T1.

* In the total group, the back-to-work rate was 67.4%.

* At the final follow-up, there were significantly better results in

functional capacity and pain level in patients with lower grades

of chronicity, mostly because of worse initial baseline values.

* Back-to-work rate, satisfaction with therapy, and the Mental

Component Summary of the SF-36 did not show a significant

difference at T1 among the groups analyzed.

Pearls for Practice

* The socioeconomic effect of CLBP is the costs associated with loss

of productivity, work absenteeism, and disablement.

* Multidisciplinary therapy for patients with CLBP can be

recommended for patients in all stages of chronicity.

Sebastian Scoles wrote:

>

>

> The hypothesis that low back pain is of psychosocial cause

> exclusively, has any scientific foundation?

>

> The evidence shows that in fact, LBP has psychosocial implications.

> Chronic pain is associated with more incidence of depression (Kothe

> et al 2007; Sullivan et al 1992; )and anxiety disorder (Demyttenaere

> et al 2007; Lachlan et al 2004).

> Psychological disturbances are one of the consequences of any kind

> of chronic pain, but not its cause (Gamsa 1990, Gamsa and Freibergs

> 1991). Some studies even show that those psychological disturbances

> disappear after the chronic pain resolution (Wallis et al 1997).

>

> References:

>

> *Kothe R, Kohlmann TH, Klink T, Ruther W, Klinger R (2007): " Impact

> of low back pain on functional limitations, depressed mood and

> quality of life in patients with rehumatoid arthritis " PAIN 127(1-

> 2):103-108

>

> *Sullivan M, Renor K, Mikail S, Fisher R (1992): " The treatment of

> depression in chronic low back pain " PAIN 50(1):5-13

>

> *Demyttenaere K, et al(2007): " Mental disorders among persons with

> chronic back pain " PAIN 129(3):332-342

>

> *Gamsa A (1990): " Is emotional disturbance a precipitator or a

> consequence of chronic pain? " PAIN. Aug; 42(2):183-95

>

> *Gamsa A and Freibergs V (1991): " Psychological events are both

> risks factors in, and consequence of, chronic pain " PAIN. Mar; 44

> (3):271-7

>

>

> Sebastián Scoles

> Buenos Aires, Argentina

>

>

>

>

>

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