Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making. Answering the question “what is the pain generator” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet Joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

Mechanisms of low back pain: a guide for diagnosis and therapy

Background: Almost 80% of people have low back pain at least once in their life. Clinical guidelines emphasize the use of conservative physiotherapy and the importance of staying active. While the psychological factors predicting poor recovery following surgical intervention are understood, the psychosocial factors associated with poor outcomes following physiotherapy have yet to be identified.
Methods: Electronic searches of PubMed, Medline, CINAHL, PsycINFO and EBSCO were conducted using terms relating to psychosocial factors, chronic low back pain, disability and physiotherapy. Papers examining the relationship between psychosocial factors and pain and disability outcomes following physiotherapy were included. Two reviewers selected, appraised and extracted studies independently.
Results: In total, 10 observational studies were identified that suggested an association between fear of movement, depression, self-efficacy and catastrophizing in modifying pain and disability outcomes following physiotherapy.
Discussion: Although limited by methodological shortcomings of included studies, and heterogeneity of physiotherapy interventions and measures of disability and psychosocial outcomes, the findings are consistent with other research in the context of back pain and physiotherapy, which suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist. However, a direct relationship cannot be concluded from this study.
Conclusion: Findings suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist, which warrants further study.

https://journals.sagepub.com/doi/pdf/10.1177/2050312118757387

Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: A systematic review.

The social determinants of health (SDH) are known to differentially impact outcomes from many noncommunicable diseases; however, their potential role in low back pain (LBP) is poorly defined. This review endeavours to comprehensively inform the field of their relevance. Our research question was: "How do the broad range of SDH and chronic LBP (CLBP) relate?" The primary aim of this review was to synthesise evidence of relationships between SDH and the frequency or severity of CLBP. Secondary aims were to identify relationships between SDH and LBP-related disability, work absenteeism, and opioid prescription. We included studies involving adult participants that evaluated relationships between one or more of the SDH and CLBP frequency or LBP outcomes (beyond 3 months). Two reviewers screened studies, extracted data, and assessed risk of bias. We synthesized the results narratively and applied PROGRESS to organise our findings. Database searches identified 7018 records. Forty-one studies were included, containing data from 2,161,617 adults from 17 countries. Twenty-four percent and 19% of the relationships included were classified as having a high risk of bias due to confounding and missing data, respectively. We reported 166 relationships representing the majority of the PROGRESS domains. An array of independent and interdependent relationships between the SDH and CLBP were identified with the strongest evidence for associations related to educational attainment and socioeconomic status. Our findings suggest that greater recognition of the contribution of SDH to disparities in LBP outcomes is warranted and this has the potential to usefully inform strategies to impact burden.

Low back pain and the social determinants of health: a systematic review and narrative synthesis.

Mechanisms of low back pain: A guide for diagnosis and therapy [version 1; referees: 3 approved]

We aimed to identify patient characteristics associated with favourable long-term outcomes after lumbar total disc replacement (TDR). We analysed a cohort of 82 patients with degenerative disc and chronic low back pain (LBP) who were treated with TDR and originally participated in a randomised trial comparing TDR and multidisciplinary rehabilitation. Potential predictors were measured at baseline, and the outcomes assessed 8 years after they received allocated treatment. Outcome measures were dichotomised according to whether the participants achieved a clinically important functional improvement (15 points or more on the Oswestry Disability Index, ODI) (primary outcome) and whether they were employed at 8-year follow-up (secondary outcome). Associations between potential predictors and outcomes were modelled using logistic regression. For the secondary outcome, the results were also organised in a prediction matrix and expressed as probabilities. For 71 patients treated with TDR according to protocol, the follow-up time was 8 years. For a subgroup of 11 patients randomised to rehabilitation who crossed over and received TDR, the median postoperative follow-up time was 72 (range 41–88) months. Of all assessed baseline variables, only presence of Modic changes (type 1 and/or 2) was statistically significantly associated with an improvement of ≥ 15 ODI points. The probability of employment at 8-year follow-up was 1% for patients with ≥ 1 year of sick leave, comorbidity, ODI ≥ 50 and ≤ 9 years of education prior to treatment, and 87% for patients with < 1 year of sick leave, no comorbidity, ODI < 50 and higher education. Patients with Modic changes prior to the TDR surgery were more likely to report a clinically important functional improvement at long-term follow-up. Comorbidity, low level of education, long-term sick leave and high ODI score at baseline were associated with unemployment at long-term follow-up.

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Lumbar total disc replacement: predictors for long-term outcome

Many factors influence the return to work of workers with chronic low back pain (CLBP). They have been said to vary according to socio-professional group. This study first aimed to compare prognostic factors influencing the return to work of CLBP healthcare workers (HCWs) and other workers (non-HCWs) after rehabilitation coupled with an occupational intervention. The second objective was to improve the evolution of indicators such as clinical examination, psychosocial impact and pain impact. Between 2007 and 2012, a cohort of 217 CLBP workers (54.8 %-women; mean age = 41.3 ± 9.5 years, 118 non-HCWs; 99 HCWs mainly from the public sector) was included in an ambulatory rehabilitation program (standard physiotherapy or intensive network physiotherapy) coupled with an occupational intervention. Workers completed a questionnaire and had a clinical examination at baseline and after 24 months’ follow up. Physical, social and occupational data was collected at the same time. Statistical analyses were performed to evaluate prognostic factors for return to work and compare the two worker populations. There was no difference between groups for the rate of OP (occupational physician) intervention or type of physiotherapy. 77.3 % of workers returned to work after 2 years following inclusion. To be an HCW (OR 0.1; 95 % CI [0.03–0.34]), to have less than 112 sick- leave days (OR 1.00; 95 % CI [0.93–1.00]), a small fingertip-floor distance (OR 0.96; 95 % CI [0.93–0.99]), a low anxiety/depression score (OR 0.97; 95 % CI [0.95–1.00]), a low impact of CLBP on daily life (OR 0.96; 95 % CI [0.93–1.00]), and on quality of life (OR 0.98; 95 % CI [0.95–1.00]) at baseline were statistically associated with return to work after 2 years of follow up. Only the profession (workplace) was statistically associated with return to work after 2 years of follow up using multivariate analysis. To our knowledge, this is the first cohort study concerning predictive factors of RTW among CLBP workers after 2 years of follow up. Interventions in the work environment did not seem to predict job retention significantly. But only 50 % of the employees in both groups (HCW and non-HCW) had one intervention at their workplace after 2 years. This study underlined the fact that the type of physiotherapy with a well-trained physiotherapist used to take care of CLBP could not impact on the RTW forecast. To develop these initial results, it might be interesting to study the comparison between private and public sectors and to randomize the physiotherapeutic intervention.

/pdf/chronic-low-back-pain-among-french-healthcare-workers-and-1x7na5vzxe.pdf

C. Paget

Papers

Chronic low back pain among French healthcare workers and prognostic factors of return to work (RTW): a non-randomized controlled trial.