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Chronic Low Back Pain Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. Low back pain that has been present for longer than three months is considered chronic, although there is still no consensus about the definition of CLBP. Specific causes of LBP are uncommon, and in approximately 90% of patients a specific generator cannot be identified with certainty. More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode. It is estimated that seven million adults in the United States have activity limitations as a result of chronic low back pain Chronic low back pain (CLBP) has been associated with neurochemical, structural, and functional cortical changes of several brain regions including the somatosensory cortex. Complex processes of peripheral and central sensitisation may influence the evolution of acute to chronic pain. Relevant Anatomy The lumbar region is situated under the thoracic region of the spine. The lower back consists of five vertebrae (L1- L5). It has a slight inward curve known as lordosis. The fifth lumbar vertebrae is connected with the top of the sacrum. The vertebrae of the lumbar spine are connected in the back by facet joints, which allow for forward and backward extension, as well as twisting movements.The two lowest segments in the lumbar spine, L5-S1 and L4-L5, carry the most weight and have the most movement, this makes the area prone to injury. In between vertebrae are spinal discs, they provide support. Discs in the lumbar region of the spine are most likely to herniate or degenerate, which can cause pain in the lower back, or radiating pain to the legs and feet. The spinal cord travels from the base of the skull to the joint at T12-L1, where the thoracic spine meets the lumbar spine. At this segment, nerve roots branch out from the spinal cord, forming the cauda equina. Some lower back conditions may compress these nerve roots, resulting in pain that radiates to the lower extremities, known as radiculopathy. The lower back region also contains large muscles that support the back and allow for movement in the trunk of the body. These muscles can spasm or become strained, which is a common cause of lower back pain. 5-10% of all low back pain patients will develop CLBP. CLBP prevalence rates are lower in individuals aged 20-30 years, increasing from the third decade of life, and reaching the highest prevalence between 50-60 years. However the prevalence rates stabilise in the seventh decade of life. There’s no difference in CLBP prevalence at different periods of the year or in different places. There is higher CLBP prevalence in females, people of lower economic status, people with less schooling and smokers. There’s indication that prevalence has doubled over time. This may be due to important changes in lifestyle (obesity) and in the work industry. Factors as a family history of disabling back pain, radiating pain, advice to rest upon back pain consultation, occupational LBP or LBP caused by traffic injury are all associated with chronic disabling back pain over lifetime. Job satisfaction and psychosocial factors also play a role in the development of CLBP. Clinical Presentation Most patients that suffer from CLBP experience pain in the lower area of the back (lumbar and sacroiliac regions) and mobility impairment. Pain can also radiate in the lower extremities, or generalized pain can be present. Patients with CLBP can also experience movement and coordination impairments. This could affect the control of voluntary movements of the patient. It can be challenging for the patient to maintain the neutral position, malalignment of the body can occur. It can also be found difficult to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities. Carrying things in the arms, or bending can also provoke complaints. Daily activities, such as cleaning, sports and other recreational occupations can become a big task for people with CLBP. When pain is generalized, sensory experiences of the patient can also become altered; fear-avoidance beliefs, pain catastrophic and depressive thoughts can appear. If symptoms like these occur, Central sensitization can be present. It is important to monitor these Yellow Flags, as well as it is important to monitor blue flags and black flags. The complaints are recurring and occur longer than three months. It is possible that CLBP passes in episodes. Some episodes are more severe than others, but overall the patient is affected by the impairments. Eventually, social contact and work environment will suffer from this great impact on the patient's health and well being. Prevention Identifying risk factors allows development of healthcare strategies (and prevention) to reduce the burden of chronic pain. Some risk factors cannot be changed, but others can be modified. Risk factors include socio-demographic, clinical, psychological and biological factors. For example anxiety, depression and catastrophizing beliefs (yellow flags) are associated with chronic pain and with a poor prognosis. Operant treatment approaches can be integrated into standard pain management for acute/subacute low back pain. Graded activity and behavioural education are promising treatment approaches for the prevention of CLBP and explaining the physiology of pain can also work preventive. Medical management Pharmacology: Recent clinical guidelines on the management of chronic low back pain from United Kingdom, Belgium and United States have recommended changes to the use of pharmacotherapy when treating chronic low back pain. Where non-pharmacological interventions have not been successful medication should only be prescribed at the lowest doses for the shortest amount of time.However it’s important to advise patients of the known potential harms and benefits. Pharmacotherapy should only be used as a tool to stay active and to engage in treatment, rather than as a solution itself. Multidisciplinary approach When treating patients with chronic LBP it has been shown that having been treated by a multidisciplinary team yields improvements. The multidisciplinary approach includes treating the physical, psychological, emotional, and socio professional aspects of the disorder "Fear of pain in turn is supposed to initiate worrying about the consequences of pain and hence increases avoidance behavior, leading in the long term to increased pain, functional disability, and depression." In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment. Physical Therapy Management Interventions: Advice: For nonspecific low back pain the general advice on self-management is to remain active. This is also the case in CLBP. It is frequently assumed that a firm mattress has beneficial effects on low back pain. In fact, for patients with chronic nonspecific low back pain (with no referred pain), a medium-firm mattress is found to be superior. Patients experience less pain and disability during the day and overnight. Giving advice only will probably not suffice. It is important to combine multiple treatment means to avoid recurrency. Stretching and flexibility exercises: are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion. The aim is to reduce pain, improve movement, and improve functional limitations of movement. Exercise therapy Exercise therapy has been shown to have beneficial effects for the management of chronic low back pain and is recommended in all three recently published clinical guidelines. Utilization of trunk coordination, strengthening, and endurance exercises reduces low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments. Moderate- to high-intensity exercise will be considered for patients with CLBP without generalized pain. For patients with CLBP with generalized pain incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies will be considered. Core strengthening exercises: are used to restore the coordination and control of the trunk muscles to improve control of the lumbar spine and pelvis. These exercises aim to restore the strength and endurance of the trunk muscles to meet the demands of control. Core exercise may be more effective than general exercise in relieving pain and improving back-specific function for patients with CLBP in the short term. No significant differences were found in the long term. Motor control exercise Sensory discrimination training Traction Tecar therapy Laser therapy Deep heating pain relieving modalities.