New approaches show promise in helping people with lower back pain

Common causes include injury, arthritis and degenerative changes in the spine. It usually begins in middle age with the natural wear and tear of aging. But there’s often no clearly identifiable physical cause, leaving patients to experience one ineffective treatment after another—including highly addictive prescription opioids.

Now researchers are working on personalized treatment plans that can address the physical, emotional and psychological characteristics of individual patients that affect the pain they feel. Physical therapy, exercise, diet and lifestyle choices often play an important role. Some research is also looking at ways to retrain the brain to think differently about pain.

To be sure, lower back pain can be a sign of something life-threatening, such as cancer or a serious spinal condition that requires surgery. As a result, chronic low back pain should be fully evaluated. But once the “red flags” are eliminated, doctors need a more precise way to determine what will work for individual patients, says Dr. Matt Mauck, a researcher and pain medicine physician at the University of North Carolina Chapel Hill, UNC Pain Management Center.

UNC is part of the Back Pain Research Consortium, or Bacpac, funded by the National Institutes of Health as part of a broader effort to improve the understanding, treatment and management of pain and reduce opioid abuse and addiction. In a multi-site study across the country, researchers are testing the effectiveness of four non-surgical treatments in relation to specific patient characteristics. Each treatment has been proven to work, although not equally well for everyone.

Four treatments: acceptance and commitment therapy, which helps people learn new skills to cope with pain; duloxetine, a drug used for depression, anxiety, and chronic musculoskeletal pain; an online program with personalized messages to teach lifestyle skills for pain management; and a form of exercise therapy with stretching, strength training, and hands-on treatment by a physical therapist or chiropractor.

Study participants are randomly assigned to an initial treatment for three months, which can then be changed depending on how they respond. This may involve switching to another treatment or combining two treatments.

Studies have shown that non-surgical approaches can be more effective and less expensive than surgery. A recent University of Pittsburgh study of nearly 30,000 patient records over three years found that patients who seek physical therapy or chiropractic first have better outcomes and lower costs. In contrast, patients presenting to the emergency department for the first time were more likely to receive expensive imaging and steroid injections; and more than half received prescriptions for opioids, compared to only 11% among those who first sought chiropractic care and physical therapy.

One of the most puzzling aspects of back pain is that patients who have had physical damage to their lower back may have no pain at all, while others who have little visible damage may have severe pain.

“What we see on an X-ray or MRI may not tell the whole story, so we need to address all aspects of a person’s condition to better characterize who needs what type of treatment,” says Dr. Gwendolyn Sowa, director of the UPMC Rehabilitation Institute at UPMC. , a large healthcare provider affiliated with the University of Pittsburgh.

Part of the Bacpac Consortium, UPMC is one of a growing number of health care providers that take a holistic approach. In their spine health program, experts assess sleep habits, diet, exercise, social engagement and lifestyle. Patients can see pain psychologists, physical therapists specially trained in spine care, surgeons and physiatrists, doctors specializing in non-surgical treatment of back pain.

dr. Christopher Standaert, a UPMC physiatrist who oversees the program, says the center has had success helping patients identify what works best for their pain, with a small percentage needing surgery or steroid injections and the majority benefiting from physical therapy and other modalities. of life and mental health interventions.

“Patients are not only afraid of pain; they fear what might come of it—’Will I be able to play with my children or work in my garden?’ ” says Standaert. By overcoming fear and reconnecting patients with movement and activities they enjoy, “they can live well, age well and adapt successfully.”

Vinny Rossitto, 67, a former naval officer and retired businessman, says his back first hurt in 1986 and he had recurring and often severe bouts of pain. He took anti-inflammatory drugs and Valium and regularly visited a chiropractor, but things only got worse over time.

By 2017, diagnosed with degenerative disc disease, lumbar spinal stenosis and scoliosis, it was difficult for him to walk. He underwent treatments including physical therapy, opioids and other drugs, steroid injections, antidepressants and anticonvulsants. The stenosis and scoliosis worsened by 2022, but he says he was not considered a good candidate for surgery.

“I was in a downward spiral and mentally I was resigned and depressed. I gave myself a year before I thought I’d be in a wheelchair,” he says.

At that point, he was referred to the UPMC Spine Health Program, where he says specific spine-specific physical therapy helped him start feeling better after three weeks, strengthening his abdominal muscles and giving him exercises he could do at home. A spinal health psychologist helped him better manage his mental outlook and adapt his lifestyle to his situation, he says. A dietician recommended an anti-inflammatory diet with more fresh fruit and whole grains, and a medical masseuse helped him relax his troubled muscles, improving his gait enough to walk on uneven paths with the use of canes. He started Pilates classes to build core strength and improve balance.

Rossitto says the program has helped him take more control of his pain and reduce stress and anxiety. He no longer uses opioids or other pain medications and sticks to his home exercise and stretching regimen. From an average day with a pain level of 7 or 8 out of 10 in 2017, “‘I’m at about a 5 now, and on good days I’m at a 4.’

Researchers are also investigating a treatment called pain reprocessing therapy, or PRT, which focuses on retraining the brain to help people recover from chronic pain. The brain creates pain as a warning signal to limit movement and let the body recover from the injury. But in many cases of chronic pain, changes in the brain can cause pain to persist even after the injury has healed, says Yoni Ashar, an assistant professor in the department of internal medicine at the University of Colorado Anschutz Medical Campus.

Ashar says the incorrect belief that chronic pain means injury can promote fear, avoidance of activity, and persistence of pain. In PRT, trained therapists help patients move in ways they’ve been afraid of and reassess feelings they perceive as malfunctioning brain pathways rather than signs of injury. This helps the brain perceive such pain signals as less threatening, measurably reducing or eliminating pain, Ashar says.

In the first clinical trial of PRT, led by Ashar, 151 people with mild to moderate back pain were randomized into three groups. One received four weeks of intensive PRT, one received a placebo saline injection in the back, and one received care as usual. With PRT, 66% reported no or almost no pain after treatment, while only 20% of people on placebo and 10% of those on usual care reported similar improvements.

Study participants who were initially skeptical of the idea that the mind or brain processes were driving their pain described a change in their thinking after the therapy, according to interviews published in a follow-up study. “I was actually less afraid of pain,” said one. “Now if I feel a little pain, I deal with it.”

Laura Landro is the former assistant managing editor of The Wall Street Journal and the author of “Survivor: Taking Control of Your Fight Against Cancer.” You can get it at reports@wsj.com.