With Chronic Low Back Pain Patients, Focus on Preventing Future Episodes

While a lot of attention is paid to how you treat an episode of low back pain, it’s more important to focus on preventing future episodes, said Jeffrey N. Katz, MD, MS, professor of medicine and orthopedic surgery at Harvard Medical School, during a presentation on the diagnosis, treatment, and management of low back and leg pain at the annual scientific meeting of the American College of Rheumatology in Washington, DC.

The good news, Katz said, was that 90% of lumbago episodes resolve within three months. And fewer than 1% of episodes of lumbago will persist and become a chronic low back pain syndrome. “But the bad news from a natural history or epidemiologic standpoint is that among people who have an episode of lumbago in a particular year, 80% will have a recurrent episode within the subsequent 12 months,” said Katz. “So our attention really needs to be focused on trying to prevent subsequent episodes.”

A more contemporary understanding of garden variety low back pain or lumbago is a chronic disease where any particular episode tends to resolve, but they tend to recur. It is the recurrence, the chronicity of these episodes that over time amounts to a lot of aggregate disability, said Katz, who also practices at Brigham and Women’s Hospital in Boston.

Managing chronic low back pain

Chronic low back pain is not a syndrome that a practitioner can really solve himself or herself, Katz said. It requires a multidisciplinary approach. “Probably the most important partner in this team approach is the patient, who in some ways needs to get on the bus or not,” said Katz.

According to Katz, patients do better when they can accept that their chronic low back pain is at least for the time being a reality, and that their pain relief expectations are less likely to be met than functional goals. “They can do extremely well if they can make that jump from pain to function,” said Katz.

Katz has this talk with patients to get them to focus on coping with the chronic pain, rather than pinning their hopes on a cure. He says that perhaps 80% sign on. What he usually says to patients goes something like this: “By this time you’ve seen a lot of doctors, you’ve had a lot of tests, and although I don’t know that your pain will be lifelong, it’s unlikely that it will. But it would be foolish to bet against your time over the next two weeks or perhaps even next two months. So, what are you going to do between now and then? Hope that your pain goes away or set some functional goals, because the walls are closing in on you?”

He said that he then asks patients “What would you like to be doing that you can’t do? Let’s figure out how to get you there.” From there, patients can begin gradual programs of functional restoration and begin to improve.

While it can be a difficult but ultimately rewarding road for the patient and for their clinicians, when the patient manages to switch their focus to regaining function, Katz said, the clinician and patient are now dealing with goals that they can work on together.