Management of low back pain

We read with interest the clinical review ‘Management of low back
pain’. The stated aim of this clinical review was to provide an evidence
based overview of low back pain aimed at primary care physicians. The
review of publications involved searches of low back pain crossed with
various categories for each of the subsections including pharmacotherapy,
nerve blocks, surgery and alternative therapies. However one treatment
modality in the management of chronic low back pain (CLBP) not mentioned
in the review and available via referral from primary care physicians is a
pain management programme (PMP).

Whilst we are in agreement with the summary points including the fact
that most treatments for chronic low back pain have a small effect and/or
afford transient benefit we felt it important to highlight other options
available within the NHS setting which are recommended in the European
evidence based guidelines and more recently in the draft NICE guidelines
for the management of low back pain.

The European evidence based guidelines on preventing and managing
acute and chronic low back pain state that the most promising approaches
seem to be cognitive behavioural interventions encouraging
activity/exercise. Further to this they state that there is strong
evidence that intensive multidisciplinary biopsychosocial rehabilitation
with a functional restoration approach reduces pain and improves function
in patients with chronic LBP. To this end the approach of PMP’s are
recommended for CLBP.

A PMP is a rehabilitation programme delivered in a group setting.
The PMP differs from many treatments in that pain reduction is not the
primary goal. People living with chronic pain will already have developed
some skills to manage their pain. The PMP aims to develop these skills
further by introducing psychological, physical and practical techniques to
help manage pain better. PMPs were developed because of the need to
address both the physical and psychological impact of living with chronic
pain. After a programme, many people say that although they still have
pain they have learned that it is safe to keep active and they can manage
and cope with their pain better. They also often say they can take part
in activities that are important to them and as a result, they feel
happier and less concerned about their pain.

Reflecting on the case study used in the review demonstrating a
patient’s perspective it highlights the pathway that many patients take
before embarking on a pain management programme and the treatment of
choice for this lady having not found a cure for her pain through the
traditional route could be a pain management programme.

We would encourage primary care physicians in the UK to review
current guidelines and the option of referring patients into NHS services
which offer this approach of pain management when treatments fail to cure
or lessen the pain.

Relevant links include the British Pain Society website www.bps.co.uk
and the physiotherapy pain association www.ppaonline.co.uk.

Reference List

Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of
psychological interventions for chronic low back pain. Health Psychol
2007;26:1-9.

Morley S, Williams S, Hussain, S. Estimating the clinical
effectiveness of cognitive behavioural therapy in the clinic: Evaluation
of a CBT informed pain management programme. Pain 2008;137:670-680.

Morley S, Eccleston C, Williams A. Systematic review and meta-
analysis of randomized controlled trials of cognitive behaviour therapy
and behaviour therapy for chronic pain in adults, excluding headache.
Pain 1999;80:1-13.

Flor H, Fydrich T, Turk DC. Efficacy of multidiscplinary pain
treatment centers:a meta-analytic review. Pain 1992;49:221-230.

Competing interests:
Employed at the Manchester and Salford Pain Centre and involved in the delivery of Pain Mangement Programmes