Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms

Abstract

Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients’ lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians’ knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.

Diagnosis: Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments.

Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.

Conclusions: This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.

Keywords:

• Biopsychosocial
• Chronic low back pain
• Multifactorial
• Multimodal treatment
• Neuropathic
• Nociceptive
• Synergistic analgesia

Transparency

Declaration of funding

This manuscript was funded by Grünenthal GmbH.

Declaration of financial/other relationships

G.M.-S. has disclosed that he has received sponsorship from Grünenthal GmbH. B.M. has disclosed that he has acted as a consultant/advisor for Astellas, Boehringer Ingelheim, Grünenthal GmbH, Janssen Pharmaceuticals Inc., Mundipharma and TEA, and has received honoraria from Grünenthal GmbH and Mundipharma for speaking at meetings. K.A. has disclosed that he has acted as a consultant/advisor for Grünenthal GmbH. E.A. has disclosed that he has acted as a consultant/advisor for Dompé. F.C. has disclosed that she has acted as a consultant/advisor for Grünenthal GmbH. F.H. has disclosed that he has acted as a consultant/advisor for Grünenthal GmbH. W.J. has disclosed that he has acted as a consultant/advisor for Grünenthal GmbH. M.K.-K. has disclosed that she has acted as a consultant/advisor for Mundipharma International Ltd and STADA Arzneimittel AG. H.-G.K. has disclosed that he has acted as a consultant/advisor for bene-Arzneimittel GmbH, Bionorica Ethics GmbH, Boehringer Ingelheim, Grünenthal GmbH and Mundipharma International Ltd, and has also received honoraria for speaking at meetings from Astellas, Dr. Reddy’s, Grünenthal GmbH, Teva Pharmaceutical Industries Ltd, Institut Biochimique SA, CSC/Angelini, Janssen Pharmaceutical KK and Mundipharma International Ltd. A.C.M. has disclosed that she has acted as a consultant/advisor for Grünenthal GmbH. C.M.F. has disclosed that he acted as a consultant/advisor for the Pain in Europe report, which was sponsored by Mundipharma International Ltd. A.N. has disclosed that he has received sponsorship to attend a meeting and training from Boston Scientific Inc. J.P. has disclosed that he has acted as a consultant/advisor for Grünenthal GmbH, Purdue Pharma, Mundipharma, Johnson & Johnson, Depomed and Daiichi Sankyo Inc., and has received honoraria from Grünenthal GmbH, Purdue Pharma, Mundipharma, Depomed and Daiichi Sankyo Inc. for speaking at meetings. M.S. has disclosed that he has acted as a consultant/advisor for Grünenthal GmbH and Regeneron Pharmaceuticals. P.S. has disclosed that he has received sponsorship from Grünenthal GmbH. S.C., E.K., P.M., and C.P.H. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Editorial assistance in the preparation of this manuscript was provided by Derrick Garwood of Derrick Garwood Ltd, Cambridge, United Kingdom. Support for this assistance was funded by Grünenthal GmbH.

Previous presentation: This article was based on a meeting held in Amsterdam, The Netherlands, 23–24 January 2015, which was supported by an unrestricted educational grant from Grünenthal GmbH, Aachen, Germany.