Back Pain

Back Clinic Back Pain Chiropractic Treatment Team. At the El Paso Back Clinic, we take back pain very seriously.

After diagnosing the root cause of your discomfort/pain, we’ll do everything within our power to cure the area and relieve your symptoms.

Common causes of back pain:
There is an infinite number of forms of back pain, and a variety of injuries and diseases may cause discomfort in this area of the body. One of the most Frequent ones we see one of our patients in East Side El Paso and surrounding areas comprise:

Disc Herniation
Inside the backbone are flexible discs that cushion your bones and absorb shock. Whenever these discs are broken, they may compress a nerve leading to lower extremity numbness. StressWhen a muscle at the trunk is overexerted or hurt, causing stiffness and pain, this type of injury is generally classified as a back strain. This can be the consequence of attempting to lift an item that can result in excruciating pain and impairment and is too heavy. Diagnosing the underlying cause of your pain.

Osteoarthritis
Osteoarthritis is characterized by the slow wearing down of protective cartilage. When the back is affected by this condition, it causes damage to the bones that results in chronic pain, stiffness, and limited mobility. SprainIf ligaments in your spine and back are stretched or torn, it’s called a spine sprain. Typically, this injury causes pain in the region. Spasms cause back muscles to overwork they may start to contract, and can even stay contracted– also called a muscle spasm. Muscle spasms can present with pain and stiffness until the strain resolves.

We want to accomplish the diagnosis straight away, integrating a background and exam along with state-of-the-art imaging, so we can provide you with the most efficient therapy choices. To begin, we will speak with you regarding your symptoms, which will provide us with critical information regarding your underlying condition. We’ll then perform a physical exam, during which we’ll check for posture issues, evaluate your spine and assess your backbone. If we guess injuries, like a disk or neurological injury, we’ll probably order imaging tests to obtain an analysis.

Regenerative remedies to your back pain. At the El Paso Back Clinic, you may be certain that you’re in the best possible hands with our Doctor of Chiropractic and Massage Therapist. Our purpose during your pain treatment isn’t only to relieve your symptoms — but also to avoid a recurrence and to treat your pain.

Work Injury Health Guidelines for Low Back Pain in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Chronic Pain, Randomized Controlled Trial

Low back pain represents one of the most common complaints in healthcare settings. While various injuries and conditions associated with the musculoskeletal and nervous system can cause low back pain, many healthcare professionals believe that work injury may have a prevalent connection to low back pain. For instance, improper posture and repetitive movements may often cause work-related injuries. In other cases, environmental accidents at work may cause work injuries. In any case, diagnosing the source of a patient’s low back pain to correctly determine which would be the best treatment method to restore the individual’s original health and wellness is generally challenging.

First and foremost, getting the right doctors for your specific source of low back pain is essential for finding relief from your symptoms. Many healthcare professionals are qualified and experienced in treating work-related low back pain, including doctors of chiropractic or chiropractors. As a result, several work injury treatment guidelines have been established to manage low back pain in healthcare settings. Chiropractic care focuses on diagnosing, treating, and preventing various injuries and conditions, such as LBP, associated with the musculoskeletal and nervous system. By carefully correcting the misalignment of the spine, chiropractic care can help improve symptoms of low back pain, among other symptoms. The purpose of the following article is to discuss occupational health guidelines for the management of low back pain.

Occupational Health Guidelines for the Management of Low Back Pain: an International Comparison

Name: El Paso Back Clinic | Spine Specialists - El Paso, TX
Price range: $$

Abstract

Background: The enormous socioeconomic burden of low back pain emphasizes the need to manage this problem, especially in an occupational context effectively. To address this, occupational guidelines have been issued in various countries.
Aims: To compare available international guidelines for managing low back pain in an occupational health care setting.
Methods: The guidelines were compared regarding generally accepted quality criteria using the AGREE instrument and also summarised regarding the guideline committee, the presentation, the target group, and assessment and management recommendations (that is, advice, return to work strategy, and treatment).
Results and Conclusions: The results show that the guidelines variously met the quality criteria. Common flaws concerned the absence of proper external reviewing in the development process, lack of attention to organizational barriers and cost implications, and lack of information on the extent to which editors and developers were independent. There was general agreement on numerous issues fundamental to occupational health management of back pain. The assessment recommendations included diagnostic triage, screening for red flags and neurological problems, and identifying potential psychosocial and workplace barriers to recovery. The guidelines also agreed on advice that low back pain is a self-limiting condition and that remaining at work or an early (gradual) return to work, if necessary with modified duties, should be encouraged and supported.

Dr. Alex Jimenez’s Insight

Low back pain is one of the most prevalent health issues treated in chiropractic offices. Although the following article describes low back pain as a self limiting condition, the cause of an individual’s LBP can also trigger debilitating and severe pain and discomfort of left untreated. It’s important for an individual with symptoms of low back pain to seek proper treatment with a chiropractor to properly diagnose and treat their health issues as well as prevent them from returning in the future. Patients who experience low back pain for more than 3 months are less than 3 percent likely to return to work. Chiropractic care is a safe and effective alternative treatment option which can help restore the original function of the spine. Furthermore, a doctor of chiropractic, or chiropractor, can provide lifestyle modifications, such as nutritional and fitness advice, to speed up the patient’s recovery process. Healing through movement is essential for LBP recovery.

Low back pain (LBP) is one of the industrial countries’ most common health problems. Despite its benign nature and sound course, LBP is commonly associated with incapacity, productivity loss due to sick leave, and high societal costs.[1]

Because of that impact, there is an obvious need for effective management strategies based on scientific evidence derived from studies of sound methodological quality. Usually, these are randomized controlled trials (RCTs) on the effectiveness of therapeutic interventions, diagnostic studies, or prospective observational studies on risk factors or side effects. The scientific evidence, summarised in systematic reviews and meta-analyses, provides a solid basis for guidelines on managing LBP. In a previous paper, Koes et al. compared various existing clinical guidelines for managing LBP targeted at primary healthcare professionals, showing a considerable commonality.[2]

The problems in occupational health care are different. Management focuses mainly on counseling the worker with LBP and addressing the issues of assisting them to continue working or return to work (RTW) after sick listing. However, LBP is also an important issue in occupational health care because of the associated incapacity for work, productivity loss, and sick leave. Several guidelines, or sections of guidelines, have now been published dealing with the specific issues of management in an occupational health care setting. Since the evidence is international, it would be expected that the recommendations of different occupational guidelines for LBP would be more or less similar. However, it is not clear whether the guidelines meet currently accepted quality criteria.

This paper critically appraises available occupational guidelines on managing LBP and compares their assessment and management recommendations.

Main Messages

In various countries, occupational health guidelines are issued to improve the management of low back pain in an occupational context.
Common flaws of these guidelines concern the absence of proper external reviewing in the development process, lack of attention to organizational barriers and cost implications, and lack of information on the independence of editors and developers.
In general, the assessment recommendations in the guidelines consisted of diagnostic triage, screening for red flags and neurological problems, and identifying potential psychosocial and workplace barriers to recovery.
There is general agreement on advice that low back pain is a self-limiting condition and that remaining at work or an early (gradual) return to work, if necessary with modified duties, should be encouraged and supported.

Methods

Guidelines on the occupational health management of LBP were retrieved from the authors’ personal files. Retrieval was checked by a Medline search using the keywords low back pain, guidelines, and occupational up to October 2001, and personal communication with experts in the field. Policies had to meet the following inclusion criteria:

Guidelines aimed at managing workers with LBP (in occupational health care settings or addressing occupational issues) or separate sections of policies that dealt with these topics.
Guidelines are available in English or Dutch (or translated into these languages).

The exclusion criteria were:

Guidelines on primary prevention (that is, prevention before the onset of the symptoms) of work-related LBP (for example, lifting instructions for workers).
Clinical guidelines for the management of LBP in primary care.[2]

The quality of the included guidelines was appraised using the AGREE instrument, a generic tool designed primarily to help guideline developers and users assess the methodological quality of clinical practice guidelines.[3]

The AGREE instrument provides a framework for assessing the quality on 24 items (table 1), each rated on a four-point scale. The full operationalization is available on www.agreecollaboration.org.

Two reviewers (BS and HH) independently rated the quality of the guidelines and then met to discuss disagreements and to reach a consensus on the ratings. When they could not agree, a third reviewer (MvT) reconciled the remaining differences and decided on the ratings. To facilitate analysis in this review, ratings were transformed into dichotomous variables of whether each quality item was or was not met.

The assessment recommendations were summarised and compared to recommendations on advice, treatment, and return to work strategies. The selected guidelines were further characterized and reached regarding the guideline committee, the presentation of the procedure, the target group, and the extent to which the recommendations were based on available scientific evidence. All of this information was extracted directly from the published guidelines.

Policy Implications

The management of low back pain in occupational health care should follow evidence-based guidelines.
Future occupational guidelines for managing low back pain and updates of those guidelines should consider the criteria for proper development, implementation, and evaluation of approaches as suggested by the AGREE collaboration.

Results

Selection of Studies

Our search found ten guidelines, but four were excluded because they dealt with the management of LBP in primary care,[15] were aimed at the guidance of sick-listed employees in general (not specifically LBP),[16] were intended for the primary prevention of LBP at work,[17] or were not available in English or Dutch.[18] The final selection, therefore, consisted of the following six guidelines, listed by date of issue:

(1) Canada (Quebec). A scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Quebec Canada (1987).[4]

(2) Australia (Victoria). Guidelines for the management of employees with compensable low back pain. Victorian WorkCover Authority, Australia (1996).[5] (This is a revised version of guidelines developed by the South Australian WorkCover Corporation in October 1993.)

(3) the USA. Occupational Medicine Practice Guidelines. American College of Occupational and Environmental Medicine. USA (1997).[6]

(4) New Zealand

(a)Active and working! Managing acute low back pain in the workplace. Accident Compensation Corporation and National Health Committee. New Zealand (2000).[7]

(b)Patient guide to acute low back pain management. Accident Compensation Corporation and National Health Committee. New Zealand (1998).[8]

(c) Assess psychosocial yellow flags in acute low back pain. Accident Compensation Corporation and National Health Committee. New Zealand (1997).[9]

(5) the Netherlands. Dutch guideline for managing occupational physicians of employees with low back pain. Dutch Association of Occupational Medicine (NVAB). Netherlands (1999).[10]

(6) the UK

(a)Occupational health guidelines for managing low back pain at work principal recommendations. Faculty of Occupational Medicine. UK (2000).[11]

(b)Occupational health guidelines for managing low back pain at work leaflet for practitioners. Faculty of Occupational Medicine. UK (2000).[12]

(c)Occupational health guidelines for managing low back pain at work evidence review. Faculty of Occupational Medicine. UK (2000).[13]

(d)The Back Book, The Stationery Office. UK (1996).[14]

Two guidelines (4 and 6) could not be evaluated independently from additional documents to which they refer (4bc, 6bd), so these documents were also included in the review.

Appraisal of the Quality of the Guidelines

Initially, there was an agreement between the two reviewers regarding 106 (77%) of the 138 item ratings. After two meetings, the consensus was reached for all but four items, which required adjudication by the third reviewer. Table 1 presents the final ratings.

All included guidelines presented the different options for managing LBP in occupational health. In five of the six policies, the overall objectives of the procedure were explicitly described,[46, 1014] the target users of the system were clearly defined,[514] easily identifiable key recommendations were included,[4, 614] or critical review criteria were presented for monitoring and audit purposes.[49, 1114]

The results of the AGREE appraisal showed that none of the guidelines paid sufficient attention to potential organizational barriers and cost implications in implementing the recommendations. It was also unclear for all included guidelines whether or not they were editorially independent of the funding body and whether or not there were conflicts of interest for the members of the guideline development committees. Furthermore, it was unclear for all guidelines whether experts had externally reviewed the policies before publication. Only the UK guideline clearly described the method used to formulate the recommendations and provided for updating the approach.[11]

Table 1 Ratings of the Occupational Health Guidelines

Development of the Guidelines

Table 2 presents background information on the development process of the guidelines.

The target users for the guidelines were physicians and other healthcare providers in the field of occupational healthcare. Several policies were also directed at informing employers, workers [68, 11, 14], or members of organizations interested in occupational health.[4] The Dutch guideline was only targeted at the occupational health physician.[10]

The guideline committees responsible for developing the guidelines were generally multidisciplinary, including disciplines like epidemiology, ergonomics, physiotherapy, general practice, occupational medicine, occupational therapy, orthopedics, and representatives of employers’ associations and trade unions. Chiropractic and osteopathic representatives were in the guideline committee of the New Zealand guidelines.[79] The Quebec task force (Canada) also included representatives of rehabilitation medicine, rheumatology, health economics, law, neurosurgery, biomechanical engineering, and library sciences. In contrast, the guideline committee of the Dutch guideline consisted only of occupational physicians.[10]

The guidelines were issued as a separate document,[4, 5, 10] as a chapter in a textbook,[6] or as several interrelated documents.[79, 1114]

The UK,[13] the USA,[6] and Canadian[4] guidelines provided information on the search strategy applied to the identification of relevant literature and the weighing of the evidence. On the other hand, the Dutch[10] and the Australian[5] guidelines supported their recommendations only by references. The New Zealand guidelines showed no direct links between suggestions and concerns [79]. The reader was referred to other literature for background information.

Table 2 Background Information of the Guidelines

Table 3 Occupational Guidelines Recommendations

Table 4 Occupational Guidelines Recommendations

Patient Population and Diagnostic Recommendations

Although all guidelines focused on workers with LBP, it was often unclear whether they dealt with acute or chronic LBP or both. Acute and chronic LBP were often not defined, and cut-off points were given (for example, <3 months). It was usually unclear whether these referred to the onset of symptoms or absence from work. However, the Canadian guideline introduced a classification system (acute/subacute/ chronic) based on the distribution of claims of spinal disorders by time since absence from work.[4]

All guidelines distinguished specific and non-specific LBP. Specific LBP concerns the potentially serious red flag conditions like fractures, tumors, or infections, and the Dutch and UK guidelines also distinguish the radicular syndrome or nerve root pain.[1013] All procedures were consistent in their recommendations to take a clinical history and to carry out a physical examination, including neurological screening. In cases of suspected specific pathology (red flags), x-ray examinations were recommended by most guidelines. In addition, New Zealand and the US guideline also recommended an x-ray examination when symptoms did not improve after four weeks.[6, 9] The UK guideline stated that x-ray examinations are not indicated and do not assist occupational health management of the patient with LBP (distinct from any clinical indications).[1113]

Most guidelines considered psychosocial factors as yellow flags as obstacles to recovery that healthcare providers should address. The New Zealand[9] and UK guidelines [11, 12] explicitly listed factors and suggested questions to identify those psychosocial yellow flags.

All guidelines addressed the importance of the clinical history identifying physical and psychosocial workplace factors relevant to LBP, including physical demands of work (manual handling, lifting, bending, twisting, and exposure to whole-body vibration), accidents or injuries, and perceived difficulties in returning to work or relationships at work. The Dutch and the Canadian guidelines contained recommendations to carry out a workplace investigation[10] or an assessment of occupational skills when necessary.[4]

Summary of Recommendations for the Assessment of LBP

Diagnostic triage (non-specific LBP, radicular syndrome, specific LBP).
Exclude red flags and neurological screening.
Identify psychosocial factors and potential obstacles to recovery.
Identify workplace factors (physical and psychosocial) that may be related to the LBP problem and return to work.
X-Ray examinations are restricted to suspected cases of specific pathology.

Recommendations Regarding Information and Advice, Treatment, and Return to Work Strategies

Most guidelines recommended reassuring the employee and providing information about LBP’s self-limiting nature and good prognosis. Encouragement of return to ordinary activity as generally as possible was frequently advised.

In line with the recommendation to return to regular activity, all guidelines also stressed the importance of returning to work as rapidly as possible, even if there is still some LBP and, if necessary, starting with modified duties in more severe cases. Work duties could then be increased gradually (hours and tasks) until total return to work was reached. The US and Dutch guidelines provided detailed time schedules for return to work. The Dutch approach proposed a return to work within two weeks with an adaptation of duties when necessary.[10] The Dutch system also stressed the importance of time-contingent management about a return to work.[10] The US guideline proposed every attempt to maintain the patient at maximal levels of activity, including work activities; targets for disability duration in terms of return to work were given as 02 days with modified duties and 714 days if modified duties are not used/available.[6] In contrast to the others, the Canadian guideline advised return to work only when symptoms and functional restrictions had improved.[4]

The most frequently recommended treatment options in all the included guidelines were: medication for pain relief,[5, 7, 8] gradually progressive exercise programs,[6, 10] and multidisciplinary rehabilitation.[1013] The US guideline recommended referral within two weeks to an exercise program consisting of aerobic exercises, conditioning exercises for trunk muscles, and exercise quota.[6] The Dutch guideline recommended that if there is no progress within two weeks of work absence, workers should be referred to a graded activity program (gradually increasing exercises) and, if there is no improvement by four weeks, to a multidisciplinary rehabilitation program.[10] The UK guideline recommended that workers who have difficulty returning to regular occupational duties by 412 weeks should be referred to an active rehabilitation program. This rehabilitation program should include education, reassurance and advice, a progressive vigorous exercise and fitness program, and pain management according to behavioral principles; it should be embedded in an occupational setting and directed firmly toward a return to work.[11-13] Extensive lists of possible treatment options were presented in the guidelines of Canada and Australia [4, 5], although most of these were not based on scientific evidence.

Summary of Recommendations Regarding Information, Advice, Return to Work Measures, and Treatment in Workers with LBP

Reassure the worker and provide adequate information about LBP’s self-limiting nature and good prognosis.
Advise the worker to continue ordinary activities or to return to regular exercise and work as soon as possible, even if there is still some pain.
Most workers with LBP return to more or less regular duties quite rapidly. Consider temporary adaptations of work duties (hours/tasks) only when necessary.
When a worker fails to return to work within 212 weeks (there is considerable variation in the time scale in different guidelines), refer them to a gradually increasing exercise program, or multidisciplinary rehabilitation (exercises, education, reassurance, and pain management following behavioral principles). These rehabilitation programs
should be embedded in an occupational setting.

Discussion

The management of LBP in an occupational health setting must address the relation between low back complaints and work and develop strategies aimed at a safe return to work. This review compared available occupational health guidelines from various countries. Policies are rarely indexed in Medline, so when searching for guidelines, we had to rely primarily on personal files and personal communication.

Quality Aspects and Development Process of the Guidelines

The assessment by the AGREE instrument[3] showed some differences in the quality of the guidelines reviewed, which may partly reflect the variation in the dates of development and publication of the guidelines. The Canadian guideline, for example, was published in 1987 and the Australian guideline in 1996.[4, 5] The other guidelines were more recent and incorporated a more extensive evidence base and more up to date guideline methodology.

Several common flaws related to the development process of the guidelines were shown by the assessment by the AGREE instrument. Firstly, it is important to make clear whether a guideline is editorially independent from the funding body, and whether there are conflicts of interest for the members of the guideline committee. None of the included guidelines clearly reported these issues. Further, reported external review of the guideline by clinical and methodological experts prior to publication was also lacking in all guidelines included in this review.

Several guidelines provided comprehensive information on the way relevant literature was searched and translated into recommendations.[4, 6, 11, 13] Other guidelines supported their recommendations by references,[5, 7, 9, 10] but this does not permit assessment of the robustness of the guidelines or their recommendations.

Guidelines depend on the scientific evidence, which changes over time, and it is striking that only one guideline provided for future update.[11, 12] Possibly there are updates planned for the other guidelines but they are not explicitly stated (and conversely stating there will be future update does not mean it will actually occur). This lack of reporting may also hold true for other AGREE criteria that we rated negatively. The use of the AGREE framework as a guide for both the development and the reporting of guidelines should help to improve the quality of future guidelines.

Assessment and Management of LBP

The diagnostic procedures recommended in the occupational health guidelines were largely similar to the recommendations of clinical guidelines,[2] and, logically, the main difference was the emphasis on addressing occupational issues. The reported methods for addressing workplace factors in the assessment of LBP of the individual worker concerned the identification of difficult tasks, risk factors, and obstacles for return to work by occupational histories. Obviously, these obstacles for return to work not only concern physical load factors, but also work related psychosocial problems regarding responsibilities, cooperation with co-workers, and the social atmosphere at the workplace.[10] Screening for work related psychosocial yellow flags may help to identify those workers who are at risk for chronic pain and disability.[1113]

A potentially important feature of the guidelines is that they were consistent regarding their recommendations to reassure the employee with LBP, and to encourage and support return to work even with some persisting symptoms. There is general consensus that most workers do not have to wait until they are completely free of pain before returning to work. The lists of treatment options provided by the Canadian and Australian guidelines may reflect the lack of evidence at that time,[4, 5] leaving users of the guidelines to choose for themselves. It is, however, questionable whether such lists really contribute to improved care, and in our view guideline recommendations should be based on sound scientific evidence.

The US, Dutch, and UK occupational guidelines[6, 1013] recommend that active multidisciplinary treatment is the most promising intervention for return to work, and this is supported by strong evidence from RCTs.[19, 20] However, more research is still needed to identify the optimum content and intensity of those treatment packages.[13, 21]

Despite some evidence for a contribution of workplace factors in the aetiology of LBP,[22] systematic approaches for workplace adaptations are lacking, and are not offered as recommendations in the guidelines. Perhaps this represents a lack of confidence in the evidence on the overall impact of workplace factors, a difficulty of translation into practical guidance, or because these issues are confounded with local legislation (which was hinted at in the UK guideline[11]). It may be that the participatory ergonomics intervention, which proposes consultations with the worker, the employer, and an ergonomist, will turn out to be a useful return to work intervention.[23, 24] The potential value of getting all the players onside[25] was stressed in the Dutch and the UK guidelines,[1113] but further evaluation of this approach and its implementation is required.

Development of Future Guidelines in Occupational Health Care

The purpose of this review was to give both an overview and a critical appraisal of occupational guidelines for the management of LBP. The critical appraisal of the guidelines is meant to help direct future development and planned updates of guide- lines. In the still emerging field of guideline methodology we consider all past initiatives as laudable; we recognise the need for clinical guidance, and appreciate that guidelines developers cannot wait for research to provide all the methodology and evidence required. However, there is room for improvement and future guidelines and updates should consider the criteria for proper development, implementation, and evaluation of guidelines as suggested by the AGREE collaboration.

The implementation of the guidelines is beyond the scope of this review, but it was noted that none of the guideline documents specifically described implementation strategies, so it is uncertain to what extent the target groups may have been reached, and what effects that may have had. This may be a fruitful area for further research.

The very existence of these occupational health guidelines shows that existing primary care clinical guidelines for LBP2 are considered inappropriate or insufficient for occupational health care. There is a clear perception internationally that the needs of the worker experiencing back pain are intrinsically linked to a variety of occupational issues not covered by usual primary care guidance and, consequently, practice. What emerges is that, despite the methodological flaws, considerable agreement is evident on a range of fundamental occupational health strategies for managing the worker with back pain, some of which are innovative and challenge previously held views. There is agreement on the fundamental message that prolonged work loss is detrimental, and that early work return should be encouraged and facilitated; there is no need to wait for complete symptom resolution. Although the recommended strategies vary somewhat, there is considerable agreement on the value of positive reassurance and advice, availability of (temporary) modified work, addressing workplace factors (getting all the players onside), and rehabilitation for workers having difficulty returning to work.

Acknowledgements

This study was supported by the Dutch Health Care Insurance Council (CVZ), grant DPZ no. 169/0, Amstelveen, Netherlands. J B Staal is currently working at the Department of Epidemiology, Maastricht University, PO Box 616 6200 MD Maastricht, Netherlands. W van Mechelen is also part of the Research Centre on Physical Activity, Work and Health, Body@work TNO-VUmc.

In conclusion, symptoms of low back pain are one of the most common health issues associated with work injuries. Because of it, several occupational health guidelines have been established for the management of low back pain. Chiropractic care, among other treatment methods, may be utilized in order to help the patient find relief from their LBP. Furthermore, the article above demonstrated the safety and effectiveness of a variety of traditional as well as alternative treatment options in the diagnosis, treatment and prevention of a variety of low back pain cases. However, further research studies are required in order to properly determine the efficiency of each individual treatment method. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

blog picture of cartoon paperboy big news

EXTRA IMPORTANT TOPIC: Migraine Pain Treatment

Management and Treatment Guidelines for Low Back Pain in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Chronic Pain

According to the American Chiropractic Association, approximately 31 million people in the United States experience low back pain throughout their lifetime. Low back pain can occur due to a variety of injuries and/or conditions and it can range in severity. Trauma from an injury or an aggravated condition can cause symptoms ranging from mild and annoying to intense and debilitating. The most common type of low back pain is described as a dull, achy, burning or spasming sensation.

Diagnosing the source of a patient’s low back pain can be challenging, however, several healthcare professionals are qualified and experienced in the treatment of spinal health issues, including chiropractors and physical therapists. As a matter of fact, new guidelines from the American Medical Association, or the AMA, have suggested that people affected with low back pain should seek chiropractic care before seeking treatment from conventional medical doctors because chiropractors primarily focus on the diagnosis, treatment and prevention of injuries and/or conditions affecting the musculoskeletal and nervous system.

Chiropractic care is a well-known alternative treatment option commonly utilized to treat injuries and/or conditions causing low back pain. Regular chiropractic care can provide safe and effective, non-invasive treatment without the need to utilize drugs and/or medications. A chiropractor, or doctor of chiropractic, will commonly use spinal adjustments and manual manipulations to carefully correct any spinal misalignment, or subluxation, along the lumbar spine which may be causing symptoms of low back pain. Other treatment methods commonly utilized in chiropractic care include, hot or cold compresses, massage and physical therapy modalities like interferential therapy or transcutaneous electrical nerve stimulations, or TENS and spinal decompression therapy. A chiropractor may also offer nutritional advice and fitness plans to speed up the patient’s recovery process.

By restoring the original alignment of the spine, a chiropractor can help improve the function of the spine by reducing pain and discomfort, decreasing inflammation, and improving range of motion and flexibility as well as increasing strength. Chiropractic care allows the human body to naturally heal itself in order to better be able to manage symptoms associated with low back pain. Based on the diagnosis of a patient, a doctor of chiropractic may also refer patients to other healthcare professionals for further treatment. The purpose of the following article is to demonstrate an overview of updated clinical treatment guidelines for the proper management of non-specific low back pain in a primary care setting.

An Updated Overview of Clinical Guidelines for the Management of Non-Specific Low Back Pain in Primary Care

Abstract

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.

Keywords: Low back pain, Clinical guidelines, Review, Diagnosis, Treatment

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Low back pain is one of the most common reasons for doctor office visits each year. In fact, about 80 percent of the population in the United States will suffer from back pain at least once throughout their lifetime. Regular chiropractic care can help prevent, treat and manage low back pain symptoms. Chiropractic care can provide many other benefits as well. Patient’s who have received chiropractic care for injuries and/or conditions affecting the musculoskeletal and nervous systems have experienced improvements to their digestive health and have reported better and deeper sleep after a visit to a chiropractor office. Furthermore, research studies have demonstrated that chiropractic care can help build your immune system. Chiropractic care has even been associated with stress management, reducing depression and anxiety levels. Chiropractic care can provide low back pain relief and improve overall health and wellness.

Introduction

Low back pain remains a condition with a relatively high incidence and prevalence. Following a new episode, the pain typically improves substantially but does not resolve completely during the first 4�6 weeks. In most people the pain and associated disability persist for months; however, only a small proportion remains severely disabled [1]. For those whose pain does resolve completely, recurrence during the next 12 months is not uncommon [2, 3].

There is a wide acceptance that the management of low back pain should begin in primary care. The challenge for primary care clinicians is that back pain is but one of many conditions that they manage. For example while back pain, in absolute numbers, is the eighth most common condition managed by Australian GPs, it only accounts for 1.8% of their case load [4]. To assist primary care practitioners to provide care that is aligned with the best evidence, clinical practice guidelines have been produced in many countries around the world.

The first low back pain guideline was published in 1987 by the Quebec Task Force with authors pointing to the absence of high-quality evidence to guide decision making [5]. Since that time there has been a strong growth in research addressing diagnosis and prognosis but especially research on therapy. As an example of this growth, at the time of the Spitzer guideline [5] there were only 108 randomised controlled trials evaluating physiotherapy treatments for low back pain but as at April 2009 there were 958.1 The Cochrane database (Central) currently lists more than 2500 controlled trials evaluating treatment for back and neck pain. The evidence from these trials for most interventions is summarised in systematic reviews and meta-analysis. The Cochrane Back Review Group, for example, has now published 32 systematic reviews of randomised controlled trials evaluating interventions for low back pain. In the near future, systematic reviews of studies evaluating diagnostic intervention for low back pain will also be included in the Cochrane Library.

This dramatic growth in research would be a comfort to those who were members of the original Quebec Task Force but perhaps a challenge to those who served on committees for later guidelines. With a large and ever increasing research base to inform guidelines two potential problems arise. The first and most obvious is that the recommendations in the guidelines may become out of date. The second is that with a wealth of information to consider, the various committees producing guidelines may produce quite different treatment recommendations. At the same time one can argue that if more precise and valid information becomes available recommendations will become more similar. A previous systematic review of clinical practice guidelines was conducted in 2001 [6]. In that review we assessed the available clinical guidelines from 11 countries and concluded that the guidelines provided generally similar recommendations regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features were the early and gradual activation of patients, the discouragement of prescribed bed rest, and the recognition of psychosocial factors as risk factors for chronicity. However, there were discrepancies for recommendations regarding exercise therapy, spinal manipulation, muscle relaxants, and patient information.

Bouwmeester et al. [7] concluded recently that the quality of mono- and multidisciplinary clinical guidelines for the management of low back pain, as measured with the AGREE instrument has improved over time. The present article focuses on the actual content of national clinical guidelines on low back pain which have been issued since 2001. These guidelines are compared regarding the content of their recommendations, the target group, the guideline committee and its procedures, and the extent to which the recommendations were based on the available literature (the scientific evidence). We also highlight any changes in recommendations that have occurred over time in comparison with our previous review [6].

Methods

Clinical guidelines were searched using electronic databases covering the period 2000�2008: Medline (key words: low back pain, clinical guidelines), PEDro (key words: low back pain, practice guidelines, combined with AND), National Guideline Clearinghouse (www.guideline.gov; key word: low back pain), and National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk; key word: low back pain). Guidelines used in the previous review were checked for updates. We also checked the content and reference list of relevant reviews on guidelines, included a search on the Web of Science citation index for articles citing the previous review and asked experts in the field. To be included in this review, the guidelines had to meet the following criteria: (1) the guideline concerned the diagnosis and clinical management of low back pain, (2) the guideline was targeted at a multidisciplinary audience in the primary care setting, and (3) the guideline was available in English, German, Finnish, Spanish, Norwegian or Dutch because documents in these languages could be read by the reviewers. Only one guideline was included per country unless there were separate guidelines for acute and chronic low back pain. Where more than one eligible guideline was available for a country, we included the most recent guideline issued by a national body. Guidelines from the following countries/regions and agencies (year of publication) were included:

Australia, National Health and Medical Research Council (2003) [8];
Austria, Center for Excellence for Orthopaedic Pain Management Speising (2007) [9];
Canada, Clinic on Low back Pain in Interdisciplinary Practice (2007) [10];
Europe, COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care (2004) [11];
Europe, COST B13 Working Group on Guidelines for the Management of Chronic Low Back Pain in Primary Care (2004) [12];
Finland, Working group by the Finnish Medical Society Duodecim and the Societas Medicinae Physicalis et Rehabilitationis Fenniae. Duodecim (2008) [13];
France, Agence Nationale d�Accreditation et d�Evaluation en Sante (2000) [14];
Germany, Drug Committee of the German Medical Society (2007) [15];
Italy, Italian Scientific Spine Institute (2006) [16];
New Zealand, New Zealand Guidelines Group (2004) [17];
Norway, Formi & Sosial- og helsedirectorated (2007) [18];
Spain, the Spanish Back Pain Research Network (2005) [19];
The Netherlands, The Dutch Institute for Healthcare Improvement (CBO) (2003) [20];
United Kingdom, National Health Service (2008) [21]; and
United States, American College of Physicians and the American Pain Society (2007) [22].

Data regarding the diagnostic and therapeutic recommendations as well as background information of the guideline process were extracted from the guidelines by four of the authors, each assessing 3�4 guidelines. The Finnish and Norwegian guidelines were assessed by colleagues with relevant language skills from The Netherlands and Finland. The focus was on the process of guideline development and the recommendations for diagnosis and treatment. We used the same data categories as in the previous review to facilitate comparisons (see Tables 1, ?,2,2, ?,33).

Results

Patient Population

Each of the guidelines considered the duration of symptoms but they vary in their scope and definitions. For example, the guidelines from Australia and New Zealand focus on acute low back pain whereas the guidelines from Austria and Germany consider acute, subacute, chronic and recurrent low back pain. The cut-off for chronic is not always specified but when it was, 12 weeks was used. Sometimes the word persistent rather than chronic was used. Two guidelines (Austrian and German) provide recommendations for recurrent low back pain but do not explicitly define �recurrent�.

Diagnostic Recommendations

Table 1 compares the diagnostic classification and the recommendations on diagnostic procedures in the various guidelines. All guidelines recommend a diagnostic triage where patients are classified as having (2) non-specific low back pain, (2) suspected or confirmed serious pathology (�red flag� conditions such as tumour, infection or fracture) and (3) radicular syndrome. Some guidelines, e.g. the Australian and New Zealand guidelines, do not distinguish between non-specific low back pain and radicular syndrome. The German guideline also classifies a group of patients who are at risk for chronicity, based on �yellow flags�.

All guidelines are consistent in their recommendations that diagnostic procedures should focus on the identification of red flags and the exclusion of specific diseases (sometimes including radicular syndrome). Red flags include, for example, age at onset (<20 or >55 years), significant trauma, unexplained weight loss and widespread neurologic changes. The types of physical examination and physical tests that are recommended show some variation. Some, such as the European guideline, limit the examination to a neurological screen whereas others advocate a more comprehensive musculoskeletal (including inspection, range of motion/spinal mobility, palpation, and functional limitation) and neurological examination. The components of the neurologic screening are not always explicit but where they are, comprise testing of strength, reflexes, sensation and straight leg raising.

None of the guidelines recommend routine use of imaging, with imaging recommended at the initial visit only for cases of suspected serious pathology (e.g. Australian, European) or where the proposed treatment (e.g. manipulation) requires the exclusion of a specific cause of low back pain (French). Imaging is sometimes recommended where sufficient progress is not being made but the time cut-off varies from 4 to 7 weeks. Guidelines often recommend MRI in cases with red flags (e.g. European, Finland, Germany).

All guidelines mention psychosocial factors associated with poor prognosis with some describing them as �yellow flags�. There is, however, considerable variation in the amount of details given about how to assess �yellow flags� or the optimal timing of the assessment. The Canadian and the New Zealand guidelines provide specific tools for identifying yellow flags and clear guidelines for what should be done once yellow flags are identified.

Summary of Common Recommendations

Therapeutic Recommendations

Table 2 compares therapeutic recommendations given in the various guidelines. Patient advice and information is recommended in all guidelines. The common message is that patients should be reassured that they do not have a serious disease, that they should stay as active as possible and progressively increase their activity levels. Compared with the previous review, the current guidelines increasingly mention early return to work (despite having low back pain) in their list of recommendations.

Recommendations for the prescription of medication are generally consistent. Paracetamol/acetaminophen is usually recommended as a first choice because of the lower incidence of gastrointestinal side effects. Nonsteroidal anti-inflammatory drugs are the second choice in cases where paracetamol is not sufficient. There is some variation between guidelines with regard to recommendations for opioids, muscle relaxants, steroids, antidepressant and anticonvulsive medication as co-medication for pain relief. Where the mode of consumption of analgesics is described, time-contingent rather than pain-contingent use, is advocated.

There is now broad consensus that bed rest should be discouraged as a treatment for low back pain. Some guidelines state that if bed rest is indicated because of severity of pain, then it should not be advised for more than 2 days (e.g., Germany, New Zealand, Spain, Norway). The Italian guideline advises 2�4 days of bed rest for major sciatica but does clearly describe how major sciatica differs from sciatica where bed rest is contraindicated.

There is also consensus that a supervised exercise programme (as distinct from encouraging resumption of normal activity) is not indicated for acute low back pain. Those guidelines that consider subacute and chronic low back pain recommend exercise but note that there is no evidence that one form of exercise is superior to another. The European guideline advises against exercise that requires expensive training and machines. The one area of therapy that is contentious is the use of spinal manipulation. Some guidelines do not recommend the treatment (e.g. Spanish, Australian), some advise that it is optional (e.g. Austrian, Italian) and some suggest a short course for those who do not respond to the first line of treatment (e.g. US, the Netherlands). For some it is optional only in the first weeks of an episode in acute low back pain (e.g. Canada, Finland, Norway, Germany, New Zealand). The French guideline advises that there is no evidence to recommend one form of manual therapy over another.

Summary of Common Recommendations 2

Setting. Table 3 shows some background variables related to the development of the guidelines in the various countries. Most of the guidelines focus on primary care though some also include secondary care. The Spanish guideline is written for health professions that treat low back pain.

Guideline committee. The various committees responsible for the development and publication of guidelines appear to be different in size and in the professional disciplines involved. Most committees are characterised by their multidisciplinary membership. These usually included primary care physicians, physical and manual therapists, orthopaedic surgeons, rheumatologists, radiologists, occupational and rehabilitation physicians. The number of members varied from 7 to 31. Only three committees included consumer representation (Australia, New Zealand, the Netherlands).

Evidence-based review. All guidelines are more or less based on a comprehensive literature search, including Cochrane Library, Medline, Embase. Some committees (Austria, Germany, Spain) based their recommendations, entirely or in part, on the European guidelines. Most guidelines use an explicit weighting of the strength of the evidence.

The Dutch, UK, European, Finnish, German, Norwegian and Australian guidelines give direct links between the actual recommendations and the evidence (via specific references) on which the recommendations are based. Other guidelines do not present a direct link but state that for recommendation there is at least moderate or fair evidence (New Zealand, US). Most committees use consensus methods, mostly by group discussions when the evidence was not convincing or not available.

Presentation and implementation. The activities related to the publication and dissemination of the various guidelines show some differences and some similarities. In most cases, the guidelines are accompanied by easily accessible summaries for practitioners and booklets for patients. Systematic implementation activities are rare. In most cases, the printed versions of the guidelines are published in national journals and/or disseminated through professional organisations to the target practitioners. Most guidelines are available on the websites of participating organisation. In many countries, regular updates of the guidelines are planned with time horizons of 3�5 years.

Discussion

In the past decade many countries have issued (updated) clinical guidelines for the management of low back pain. In general these guidelines provide similar advice on the management of low back pain. Common recommendations are the diagnostic triage of patients with low back pain, restricted use of radiographs, advice on early and progressive activation of patients, and the related discouragement of bed rest. The recognition of psychosocial factors as a risk factor for chronicity is also consistent across all guidelines, though with varying emphasis and detail. There are also differences in the recommendations provided by the guidelines, but these are few and probably less than could expected for different health care systems and cultures. One of the reasons for the similarity of the guidelines might be that guideline committees are usually aware of the content of other guidelines and are motivated to produce similar recommendations that are deemed sensible and relevant. In some instances the guidelines are a national adaptation (e.g. in Spain) of the European guidelines.

We do not present an exhaustive overview of all clinical guidelines available, but focused on national multidisciplinary guidelines. This enables a reasonable comparison of recommended approaches across countries. A limitation is thus that not all available guidelines, including mono-disciplinary guidelines, are included.

Use of Available Evidence

Most reviews are based on extensive literature reviews. Cochrane reviews are frequently used, comprehensive searches in databases such as Medline, Embase and PEDro. Increasingly the literature reviews of other and previous guidelines are used as starting point for the (additional) searches. Most committees also use some kind of weighting system and rating of the evidence. There is some variation in the way the recommendations are presented. In some guidelines all the recommendations are directly linked with references to the supporting evidence, and in others a general remark is made that for all recommendations that there is at least moderate evidence available.

Differences in Recommendations

Recommendations about the prescription of analgesic medication remain fairly consistent. Most guidelines recommend paracetamol as the first option and nonsteroidal anti-inflammatory preparations as the second option. Further recommendations about other drugs like opioids, muscle relaxants and benzodiazepines and antidepressants vary quite considerably. Part of these variations might reflect the setting and custom in different countries. Since all the guidelines were issued within a relative short time frame, the availability of underlying evidence did not vary much.

The recommendations regarding spinal manipulation continue to show some variation. In some guidelines manipulation is recommended, or presented as a therapeutic option, usually for short-term benefit, but others do not recommend it. This holds true for acute as well as chronic low back pain. The reasons for these differences remain speculative. Probably the underlying evidence is not strong enough to result in similar recommendations regarding manipulation across all guidelines, leaving the committees some more room for interpretation, but also local or political reasons may be involved.

There is now relatively large consensus across the various guidelines that specific back exercises (as opposed to the advice to stay active, including for example walking, cycling) are not recommended for patients with acute low back pain. At the same time back exercises are recommended in chronic low back pain. Most guidelines do not recommend a particular type of exercises for chronic low back pain, but some state that they should be intense.

Recommendations in guidelines are based not only on scientific evidence but also on consensus and discussion in the guideline committees. Usually it is stated that consensus was based on group discussion, but the details of these discussions are seldom reported. It is also generally unclear which recommendations are based mainly on scientific evidence and which are based on (mainly) consensus.

There is little information on whether cost-effectiveness played an important role as a basis for the recommendation in a guideline. Of course, there are not yet many cost-effectiveness studies available [23], but it is not fully clear to what extent the published studies were used.

Most guidelines state that the prognosis of an episode of low back pain is good. This holds especially true for patients with acute episodes of low back pain. For patients presenting with a longer duration with low back pain or with recurrent low back pain the prognosis may be less favourable. More individualised and precise estimates of the prognosis of an episode of low back pain may be desirable in the future.

Few Changes in Management Recommendations Over Time

This update showed that overall the recommendations in the current guidelines regarding diagnosis and treatment of low back pain did not change substantially compared to the guidelines issued about a decade ago. This may well illustrate the lack of new evidence showing better results with new diagnostic and therapeutic approaches and/or new evidence showing the inefficacy of existing interventions. A less nihilistic view could be that already a decade ago the most valid recommendations for the management of low back pain were identified. Some may argue that this is indeed the case, and that much more effort should now be given to implementation of guidelines (see below).

Some recommendations did change over time. We now see diagnostic recommendations appearing concerning the value of MRI and CT scans (i.e. in relation to exclusion and further diagnosis of red flags and serious spinal disorders). However, these recommendations are not yet strong, possibly because there are not many diagnostic studies available evaluating the value of MRI in patients with low back pain. Also, the recommendations regarding the assessment of psychosocial risk factors for chronicity are more firm in the current guidelines than that a decade ago. This reflects the insight of the importance of these risk factors for the development of chronicity and future disability. At the same time we must conclude that we are not yet very successful in effective screening of the patients at risk and subsequent therapeutic management of them [24].

Most apparent changes regarding therapeutic interventions include the advice to continue work (despite having low back pain) and or return to work as soon as possible. There are now more recommendations of second line medications such as antidepressants, opioids, benzodiazepines and compound medications. But these recommendations are not consistent across countries, potentially because of weak underlying evidence. There are now also more firm recommendations in favour of exercise therapy in patients with subacute and chronic low back pain. The latter is partly due to the fact that currently more guidelines include recommendation for the management of chronic low back pain as compared to a decade ago. Finally, the reasons and options for referral within primary care and secondary care are now more explicitly presented. It appears that the global approach regarding the management of low back pain remained largely unchanged in the past decade, although some refinements have been suggested.

Implementation

The extent to which currently available guidelines are used and followed in the various countries remains largely unknown. A few studies evaluating various implementation strategies for low back pain guidelines show that changing clinical practice is not an easy task [25, 26]. The publication and dissemination of guidelines alone is usually not enough to change the behaviour of health care providers [27]. The development of effective implementation strategies in this area remains a challenge.

Future Developments in Research and Guideline Development

The present study was primary aimed at presenting an update of the current clinical guidelines for the management of low back pain in primary care. Clinical guidelines focused at secondary care settings, occupational care settings, or specific subgroups of patients with lumbosacral radicular syndrome were not considered. Separate studies need to be undertaken to present an overview for these settings.

We assessed various aspects of the guideline development in Table 3. A formal assessment of the quality, e.g. with the AGREE instrument was not included. This was the topic of a separate paper which concluded that the quality of the guidelines indeed has improved over time [7].

The development of future guidelines in this field may benefit from previous experiences, evidence-based reviews, and various (inter) national guidelines as presented in this overview. The previous review of clinical guidelines listed the following recommendations (slightly modified) for the development of future guidelines in this field. Similar to a recent review on the quality of guidelines [7], this review shows that the quality of guidelines has improved over time and some of the recommendations have been followed. This includes recommendations 1, 3, and 4 (see below). For others, there still is room for improvement Recommendation 2 is not consistently applied. Recommendations 5 and 6 have improved over time, but not all recommendations in the guidelines are directly linked to the underlying evidence, and the process of the consensus methods used is not well described. Finally, the implementation strategies and the time frame of future updates are not well presented.

Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Footnotes

Based upon search of PEDro database April 29, 2009.

In conclusion,�low back pain is a prevalent medical complaint which affects million of people in the United States alone. Although it may seem difficult to diagnose low back pain because of its many possible causes, a chiropractor, or doctor of chiropractic, can properly diagnose the source of a patient’s low back pain to treat as well as prevent a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. Chiropractic care utilizes spinal adjustments and manual manipulations, among other treatment methods, to carefully restore the original alignment of the spine, allowing the human body to naturally heal itself. The purpose of the article above is to present updated treatment guidelines fot the management of low back pain in a primary care setting.� Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

blog picture of cartoon paperboy big news

EXTRA IMPORTANT TOPIC: Migraine Pain Treatment

Chiropractic Care For Lower Back Pain | El Paso, TX. | Video

by Dr Alex Jimenez | Back Pain, Clinical Case Reports, Lower Back Pain, Testimonies, Video

David Garcia is a proud father and maintenance facility worker at the Region 19 Education Services Center in El Paso, TX. However, Mr. Garcia’s daily life is often affected by his chronic lower back pain. After experiencing worsening symptoms for approximately two years, David Garcia was recommended to seek chiropractic care with Dr. Alex Jimenez by his sister, a previous patient of Dr. Jimenez. Mr. Garcia has since experienced tremendous relief from his lower back pain and he is grateful to Dr. Alex Jimenez and his staff for providing him with education regarding his health issues as well as properly caring for his injuries and/or conditions. David Garcia recommends Dr. Alex Jimenez as the non surgical choice for lower back pain.

Chiropractic Care For Lower Back Pain

Low back pain is not a specific injury or condition but rather a symptoms which may be caused by a wide variety of underlying health issues, all of varying levels of severity. The majority of low back pain does not have a clear cause but is believed to be the result of non-serious musculoskeletal problems, including sprains or strains. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture and poor sleeping positions have also been attributed to develop low back pain.A full list of possible causes includes many less common conditions. Physical causes may include osteoarthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an infection or tumor of the spine.

Share Free Ebook

If you have enjoyed this video and/or we have helped you in any way please feel free to subscribe and share us.

Thank You & God Bless.
Dr. Alex Jimenez DC, C.C.S.T

Facebook Clinical Page: www.facebook.com/dralexjimenez/

Facebook Sports Page: www.facebook.com/pushasrx/

Facebook Injuries Page: www.facebook.com/elpasochiropractor/

Facebook Neuropathy Page: www.facebook.com/ElPasoNeuropathyCenter/

Facebook Fitness Center Page: www.facebook.com/PUSHftinessathletictraining/

Yelp: El Paso Rehabilitation Center: goo.gl/pwY2n2

Yelp: El Paso Clinical Center: Treatment: goo.gl/r2QPuZ

Clinical Testimonies: www.dralexjimenez.com/category/testimonies/

Information:

LinkedIn: www.linkedin.com/in/dralexjimenez

Clinical Site: www.dralexjimenez.com

Injury Site: personalinjurydoctorgroup.com

Sports Injury Site: chiropracticscientist.com

Back Injury Site: elpasobackclinic.com

Rehabilitation Center: www.pushasrx.com

Fitness & Nutrition: www.push4fitness.com/team/

Pinterest: www.pinterest.com/dralexjimenez/

Twitter: twitter.com/dralexjimenez

Twitter: twitter.com/crossfitdoctor

Chiropractic Clinic Extra: Non-Surgical Options

Pregnancy Low Back Pain: Chiropractic Can Help | El Paso, TX.

by Dr Alex Jimenez | Back Pain, Conditions Treated, Lower Back Pain, Pregnancy

If you are pregnant and have back pain, you are not alone. An estimated 50 to 70 percent of women who are pregnant experience back pain, according to the American Pregnancy Association. While pregnancy and childbirth is one of the most incredible experiences a woman can have, it is also very hard on her body. There are many dramatic changes that take place during that 9 to 10 month of gestation so it is understandable that she is going to feel some aches and pains along the way.

There are a number of reasons why a pregnant woman may experience back pain including:

Natural changes to her body such as softening of ligaments and loosening of joints as her body prepares to give birth
A shift in her center of gravity as her girth increases.
Weight gain.
Position of the baby.
Her posture.
Stress, exhaustion, and worry.

Is Chiropractic Care Safe During Pregnancy?

Chiropractic care has long been held as a viable method for relieving back pain in pregnant women. Historically, midwives and other natural or alternative practitioners were the ones advocating its many benefits. This resulted in minimal data from clinical studies existing on the topic.

However, in the last decade or so, researchers have been looking closer at chiropractic and its many benefits. In one study of pregnant women and chiropractic, 94 percent of the participants experienced dramatic improvement in their pain in just 5 days.

Today many doctors and obstetricians are sending their pregnant patients to chiropractors to help them manage their back and joint pain. It is perfectly safe for both mother and baby � and both can benefit from it.

Benefits Of Chiropractic Care During Pregnancy

While chiropractic care during pregnancy can be used as a safe, non-invasive, and drug free method of pain relief, women may also enjoy other benefits which include:

A healthier, happier pregnancy.
Improved mood and less anxiety.
More mobility.
Decreased morning sickness and nausea.
Easier, faster labor and delivery.
Better flexibility.
In some cases, prevent cesarean delivery.
Improved sleep.
Faster recovery time.
Relief of pain in the back, joints, and neck.

By keeping the body in proper alignment, chiropractic care can help a woman have a healthier, happier pregnancy. She can enjoy the many benefits and experience less pain so that she can better focus on the joy of pregnancy and the wonder of bringing a new life into the world.

Why You Should Have Chiropractic Care During Pregnancy

Pregnancy brings about many changes in a woman�s body. Hormonal changes as well as physiological ones occur at rapid speeds as her body creates and maintains a perfect environment where her baby will develop and grow. These changes can cause the spine or joints to become misaligned. When this occurs, painful conditions can be created, including:

Increased curvature of the back.
Pelvic changes.
Protruding abdomen that puts pressure on the back.
Changes in posture.

Keeping the pelvis and lower back well balanced and aligned is integral to preventing lower back pain during pregnancy. What�s more, when the pelvis and spine are not in alignment, it can limit the amount of room the baby has in the womb. This condition is called intrauterine constraint. This can also inhibit the baby�s ability to get in an optimal position for delivery.

Keeping the body, including the spine, in proper alignment is vital to mobility, flexibility, and overall wellness of the body even when it is not pregnant. However, pregnancy puts specific stress on the body, creating certain needs that chiropractic care can meet. It is safe, it is effective, it is fast, and it works.

Chiropractic Clinic Extra: Stress Management Care & Treatments

Back Pain Treatment El Paso, TX | Video

by Dr Alex Jimenez | Back Pain, Chronic Back Pain, Injury Care, Video

Back Pain Treatment: Carlos Hermosillo is a small contractor in El Paso, Tx, who’s known Dr. Alex Jimenez for several years. As a result of the physical demands of his job, Mr. Hermosillo often experiences lower back pain and back pain symptoms which tremendously limit his ability to perform his normal physical activities, fortunately, Dr. Alex Jimenez provides him with the chiropractic care he regularly needs to return to work as soon as possible. After being involved in an accident, Carlos Hermosillo once again turned to chiropractic care for relief of his symptoms. Mr. Hermosillo highly recommends Dr. Alex Jimenez as the non surgical choice for back pain treatment.

Back pain can originate from the muscles, nerves, bones, joints or other structures in the spine. Internal structures such as the gallbladder, pancreas, aorta, and kidneys may also cause referred pain in the back. The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible, to restore the individual’s ability to function in everyday activities, to help the patient cope with residual pain, to assess for side-effects of therapy, and to facilitate the patient’s passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long-term pain relief.

Please Recommend Us: If you have enjoyed this video and/or we have helped you in any way please feel free to recommend us. Thank You & God Bless.

Recommend: Dr. Alex Jimenez � Chiropractor

Health Grades:�� www.healthgrades.com/review/3SDJ4

Facebook Clinical Page:� www.facebook.com/dralexjimenez/reviews/

Facebook Sports Page: www.facebook.com/pushasrx/

Facebook Injuries Page: www.facebook.com/elpasochiropractor/

Facebook Neuropathy Page: www.facebook.com/ElPasoNeuropathyCenter/

Yelp:�� goo.gl/pwY2n2

Clinical Testimonies: www.dralexjimenez.com/category/testimonies/

Information: Dr. Alex Jimenez � Chiropractor

Clinical Site: www.dralexjimenez.com

Injury Site: personalinjurydoctorgroup.com

Sports Injury Site: chiropracticscientist.com

Back Injury Site: elpasobackclinic.com

Linked In:�� www.linkedin.com/in/dralexjimenez

Pinterest:�� www.pinterest.com/dralexjimenez/

Twitter:�� twitter.com/dralexjimenez

Twitter: twitter.com/crossfitdoctor

Recommend: PUSH-as-Rx ��

Rehabilitation Center: www.pushasrx.com

Facebook:�� www.facebook.com/PUSHftinessathletictraining/

PUSH-as-Rx:�� www.push4fitness.com/team/

Chiropractic Clinic Extra: Back Pain Care & Treatments

Lower Back Pain During Pregnancy Treatment El Paso, TX | Video

by Dr Alex Jimenez | Back Pain, Case Control Studies, Conditions Treated, Injury Care, Lower Back Pain, Testimonies

Truide Torres, office manager, first received chiropractic care with Dr. Alex Jimenez during her pregnancy for her lower back pain. Mrs. Torres experienced aggravating symptoms throughout the progression of her pregnancy, which led her to seek a natural treatment approach for her own health as well as that of her own baby. Once Truide Torres started chiropractic treatment with Dr. Alex Jimenez, she recovered her quality of life and was able to return to her original state of well-being. As an office manager, Truide Torres also receives regular chiropractic care for any lower back pain which may occur as a result of her job. Mrs. Truide expresses how important it is to continue her spinal maintenance and she highly recommends Dr. Alex Jimenez as the non-surgical choice for a variety of health issues.

Low back pain (LBP) is a frequent health issue involving the muscles, nerves, and bones of the spine. Pain may differ from a dull persistent pain to a sudden sharp sensation. Low back pain can be classified by length and severity (pain lasting less than 6 months), sub-chronic (6 to 12 months), or chronic (over 12 months). The status could be further categorized by the underlying cause as both bodily, non-mechanical, or referred pain. The symptoms of low back pain may generally improve in a couple weeks from the time they begin, however, some cases may require additional treatment. In the majority of episodes of lower back pain, a specific underlying cause isn’t identified or properly cared for, and healthcare professionals may attribute it to mechanical issues like joint or muscle strain.

Prenatal Yoga Exercises For Low Back Pain

Back Clinic News Extra: Migraine Pain Treatment With Chiropractic

Damaris Foreman suffered from migraines for about 23 years. After receiving traditional treatment for her migraine pain without much improvement, she was finally recommended to seek migraine pain treatment with Dr. Alex Jimenez, a chiropractor in El Paso, TX. Damaris greatly benefitted from chiropractic care and she experienced a tremendous sense of relief following her first spinal adjustment and manual manipulation. Damaris Foreman was able to confront many of her misconceptions and she learned very much about her migraine pain. Damaris describes Dr. Alex Jimenez’s migraine pain treatment as one of the best treatment she’s received and she highly recommends chiropractic care as the best non-surgical choice for improving and managing her migraines.

A migraine can be identified as a primary headache disorder characterized by recurrent headaches characterized from moderate to severe in intensity. Typically, the headaches affect one half of the head, are pulsating in nature, and can last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The pain may be aggravated by physical activity. Up to one-third of people who suffer from migraines experience migraine with aura: typically a brief period of visual disturbance that signals that the headache will soon happen. An aura can occur with little or no headache pain following it.

Please Recommend Us: If you have enjoyed this video and/or we have helped you in any way please feel free to recommend us. Thank You.

Recommend: Dr. Alex Jimenez � Chiropractor

Health Grades:�� www.healthgrades.com/review/3SDJ4

Facebook Clinical Page:� www.facebook.com/dralexjimenez/reviews/

Facebook Sports Page: www.facebook.com/pushasrx/

Facebook Injuries Page: www.facebook.com/elpasochiropractor/

Facebook Neuropathy Page: www.facebook.com/ElPasoNeuropathyCenter/

Yelp:�� goo.gl/pwY2n2

Clinical Testimonies: www.dralexjimenez.com/category/testimonies/

Information: Dr. Alex Jimenez � Chiropractor

Clinical Site: www.dralexjimenez.com

Injury Site: personalinjurydoctorgroup.com

Sports Injury Site: chiropracticscientist.com

Back Injury Site: elpasobackclinic.com

Linked In:�� www.linkedin.com/in/dralexjimenez

Pinterest:�� www.pinterest.com/dralexjimenez/

Twitter:�� twitter.com/dralexjimenez

Twitter: twitter.com/crossfitdoctor

Recommend: PUSH-as-Rx ��

Rehabilitation Center: www.pushasrx.com

Facebook:�� www.facebook.com/PUSHftinessathletictraining/

PUSH-as-Rx:�� www.push4fitness.com/team/

Psychology, Headache, Back Pain, Chronic Pain and Chiropractic in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Chronic Pain, Migraine, Physical Rehabilitation, Randomized Controlled Trial, Stress, Treatments

Everyone experiences pain from time to time. Pain is a physical feeling of discomfort caused by injury or illness. When you pull a muscle or cut your finger, for instance, a signal is sent through the nerve roots to the brain, signaling you that something is wrong in the body. Pain may be different for everyone and there are several ways of feeling and describing pain. After an injury or illness heals, the pain will subside, however, what happens if the pain continues even after you’ve healed?

Chronic pain is often defined as any pain which lasts more than 12 weeks. Chronic pain can range from mild to severe and it can be the result of previous injury or surgery, migraine and headache, arthritis, nerve damage, infection and fibromyalgia. Chronic pain can affect an individual’s emotional and mental disposition, making it more difficult to relieve the symptoms. Research studies have demonstrated that psychological interventions can assist the chronic pain recovery process. Several healthcare professionals, like a doctor of chiropractic, can provide chiropractic care together with psychological interventions to help restore the overall health and wellness of their patients. The purpose of the following article is to demonstrate the role of psychological interventions in the management of patients with chronic pain, including headache and back pain.

The Role of Psychological Interventions in the Management of Patients with Chronic Pain

Abstract

Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress � improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.

Keywords: chronic pain management, psychology, multidisciplinary pain treatment, cognitive behavioral therapy for pain

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Chronic pain has previously been determined to affect the psychological health of those with persistent symptoms, ultimately altering their overall mental and emotional disposition. In addition, patients with overlapping conditions, including stress, anxiety and depression, can make treatment a challenge. The role of chiropractic care is to restore as well as maintain and improve the original alignment of the spine through the use of spinal adjustments and manual manipulations. Chiropractic care allows the body to naturally heal itself without the need for drugs/medications and surgical interventions, although these can be referred to by a chiropractor if needed. However, chiropractic care focuses on the body as a whole, rather than on a single injury and/or condition and its symptoms. Spinal adjustments and manual manipulations, among other treatment methods and techniques commonly used by a chiropractor, require awareness of the patient’s mental and emotional disposition in order to effectively provide them with overall health and wellness. Patients who visit my clinic with emotional distress from their chronic pain are often more susceptible to experience psychological issues as a result. Therefore, chiropractic care can be a fundamental psychological intervention for chronic pain management, along with those demonstrated below.

Introduction

Pain is a ubiquitous human experience. It is estimated that approximately 20%�35% of adults experience chronic pain.[1,2] The National Institute of Nursing Research reports that pain affects more Americans than diabetes, heart disease, and cancer combined.[3] Pain has been cited as the primary reason to seek medical care in the United States.[4] Furthermore, pain relievers are the second most commonly prescribed medications in physicians� offices and emergency rooms.[5] Further solidifying the importance of adequate assessment of pain, the Joint Commission on the Accreditation of Healthcare Organizations issued a mandate requiring that pain be evaluated as the fifth vital sign during medical visits.[6]

The International Association for the Study of Pain (IASP) defines pain as �an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage�.[7] The IASP�s definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Chronic pain is typically differentiated from acute pain based on its chronicity or persistence, its physiological maintenance mechanisms, and/or its detrimental impact on an individual�s life. Generally, it is accepted that pain that persists beyond the expected period of time for tissue healing following an injury or surgery is considered chronic pain. However, the specific timeframe constituting an expected healing period is variable and often difficult to ascertain. For ease of classification, certain guidelines suggest that pain persisting beyond a 3�6 month time window is considered chronic pain.[7] Nevertheless, classification of pain based solely on duration is a strictly practical and, in some instances, arbitrary criterion. More commonly, additional factors such as etiology, pain intensity, and impact are considered alongside duration when classifying chronic pain. An alternative way to characterize chronic pain has been based on its physiological maintenance mechanism; that is, pain that is thought to emerge as a result of peripheral and central reorganization. Common chronic pain conditions include musculoskeletal disorders, neuropathic pain conditions, headache pain, cancer pain, and visceral pain. More broadly, pain conditions may be primarily nociceptive (producing mechanical or chemical pain), neuropathic (resulting from nerve damage), or central (resulting from dysfunction in the neurons of the central nervous system).[8]

Unfortunately, the experience of pain is frequently characterized by undue physical, psychological, social, and financial suffering. Chronic pain has been recognized as the leading cause of long-term disability in the working- age American population.[9] Because chronic pain affects the individual at multiple domains of his/her existence it also constitutes an enormous financial burden to our society. The combined direct and indirect costs of pain have been estimated to range from $125 billion to $215 billion, annually.[10,11] The widespread implications of chronic pain include increased reports of emotional distress (eg, depression, anxiety, and frustration), increased rates of pain-related disability, pain-related alterations in cognition, and reduced quality of life. Thus, chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences.

Pain Management

Given the widespread prevalence of pain and its multi-dimensional nature, an ideal pain management regimen will be comprehensive, integrative, and interdisciplinary. Current approaches to the management of chronic pain have increasingly transcended the reductionist and strictly surgical, physical, or pharmacological approach to treatment. Current approaches recognize the value of a multidisciplinary treatment framework that targets not only nociceptive aspects of pain but also cognitive-evaluative, and motivational-affective aspects alongside equally unpleasant and impacting sequelae. The interdisciplinary management of chronic pain typically includes multimodal treatments such as combinations of analgesics, physical therapy, behavioral therapy, and psychological therapy. The multimodal approach more adequately and comprehensively addresses pain management at the molecular, behavioral, cognitive-affective, and functional levels. These approaches have been shown to lead to superior and long-lasting subjective and objective outcomes including pain reports, mood, restoration of daily functioning, work status, and medication or health care use; multimodal approaches have also been shown to be more cost-effective than unimodal approaches.[12,13] The focus of this review will be specifically on elucidating the benefits of psychology in the management of chronic pain.

Dr. Jimenez performing physical therapy on a patient.

Patients will typically initially present to a physician�s office in the pursuit of a cure or treatment for their ailment/acute pain. For many patients, depending on the etiology and pathology of their pain alongside biopsychosocial influences on the pain experience, acute pain will resolve with the passage of time, or following treatments aimed at targeting the presumed cause of pain or its transmission. Nonetheless, some patients will not achieve resolution of their pain despite numerous medical and complementary interventions and will transition from an acute pain state to a state of chronic, intractable pain. For instance, research has demonstrated that approximately 30% of patients presenting to their primary-care physician for complaints related to acute back pain will continue to experience pain and, for many others, severe activity limitations and suffering 12 months later.[14] As pain and its consequences continue to develop and manifest in diverse aspects of life, chronic pain may become primarily a biopsychosocial problem, whereby numerous biopsychosocial aspects may serve to perpetuate and maintain pain, thus continuing to negatively impact the affected individual�s life. It is at this point that the original treatment regimen may diversify to include other therapeutic components, including psychological approaches to pain management.

Psychological approaches for the management of chronic pain initially gained popularity in the late 1960s with the emergence of Melzack and Wall�s �gate-control theory of pain�[15] and the subsequent �neuromatrix theory of pain�.[16] Briefly, these theories posit that psychosocial and physiological processes interact to affect perception, transmission, and evaluation of pain, and recognize the influence of these processes as maintenance factors involved in the states of chronic or prolonged pain. Namely, these theories served as integral catalysts for instituting change in the dominant and unimodal approach to the treatment of pain, one heavily dominated by strictly biological perspectives. Clinicians and patients alike gained an increasing recognition and appreciation for the complexity of pain processing and maintenance; consequently, the acceptance of and preference for multidimensional conceptualizations of pain were established. Currently, the biopsychosocial model of pain is, perhaps, the most widely accepted heuristic approach to understanding pain.[17] A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain.[17] As the utility of a broader and more comprehensive approach to the management of chronic pain has become evident, psychologically-based interventions have witnessed a remarkable rise in popularity and recognition as adjunct treatments. The types of psychological interventions employed as part of a multidisciplinary pain treatment program vary according to therapist orientation, pain etiology, and patient characteristics. Likewise, research on the effectiveness of psychologically based interventions for chronic pain has shown variable, albeit promising, results on key variables studied. This overview will briefly describe frequently employed psychologically based treatment options and their respective effectiveness on key outcomes.

Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. As such, they target the frequently overlooked behavioral, emotional, and cognitive components of chronic pain and factors contributing to its maintenance. Informed by the framework offered by Hoffman et al[18] and Kerns et al,[19] the following frequently employed psychologically-based treatment domains are reviewed: psychophysiological techniques, behavioral approaches to treatment, cognitive behavioral therapy, and acceptance-based interventions.

Psychophysiological Techniques

Biofeedback

Biofeedback is a learning technique through which patients learn to interpret feedback (in the form of physiological data) regarding certain physiological functions. For instance, a patient may use biofeedback equipment to learn to recognize areas of tension in their body and subsequently learn to relax those areas to reduce muscular tension. Feedback is provided by a variety of measurement instruments that can yield information about brain electrical activity, blood pressure, blood flow, muscle tone, electrodermal activity, heart rate, and skin temperature, among other physiological functions in a rapid manner. The goal of biofeedback approaches is for the patient to learn how to initiate physiological self-regulatory processes by achieving voluntary control over certain physiological responses to ultimately increase physiological flexibility through greater awareness and specific training. Thus a patient will use specific self-regulatory skills in an attempt to reduce an undesired event (eg, pain) or maladaptive physiological reactions to an undesired event (eg, stress response). Many psychologists are trained in biofeedback techniques and provide these services as part of therapy. Biofeedback has been designated as an efficacious treatment for pain associated with headache and temporomandibular disorders (TMD).[20] A meta-analysis of 55 studies revealed that biofeedback interventions (including various biofeedback modalities) yielded significant improvements with regard to frequency of migraine attacks and perceptions of headache management self-efficacy when compared to control conditions.[21] Studies have provided empirical support for biofeedback for TMD, albeit more robust improvements with regard to pain and pain-related disability have been found for protocols that combine biofeedback with cognitive behavioral skills training, under the assumption that a combined treatment approach more comprehensively addresses the gamut of biopsychosocial problems that may be encountered as a result of TMD.[22]

Behavioral Approaches

Relaxation Training

It is generally accepted that stress is a key factor involved in the exacerbation and maintenance of chronic pain.[16,23] Stress can be predominantly of an environmental, physical, or psychological/emotional basis, though typically these mechanisms are intricately intertwined. The focus of relaxation training is to reduce tension levels (physical and mental) through activation of the parasympathetic nervous system and through attainment of greater awareness of physiological and psychological states, thereby achieving reductions in pain and increasing control over pain. Patients can be taught several relaxation techniques and practice them individually or in conjunction with one another, as well as adjuvant components to other behavioral and cognitive pain management techniques. The following are brief descriptions of relaxation techniques commonly taught by psychologists specializing in the management of chronic pain.

Diaphragmatic breathing. Diaphragmatic breathing is a basic relaxation technique whereby patients are instructed to use the muscles of their diaphragm as opposed to the muscles of their chest to engage in deep breathing exercises. Breathing by contracting the diaphragm allows the lungs to expand down (marked by expansion of abdomen during inhalation) and thus increase oxygen intake.[24]

Progressive muscle relaxation (PMR). PMR is characterized by engaging in a combination of muscle tension and relaxation exercises of specific muscles or muscle groups throughout the body.[25] The patient is typically instructed to engage in the tension/relaxation exercises in a sequential manner until all areas of the body have been addressed.

Autogenic training (AT). AT is a self-regulatory relaxation technique in which a patient repeats a phrase in conjunction with visualization to induce a state of relaxation.[26,27] This method combines passive concentration, visualization, and deep breathing techniques.

Visualization/Guided imagery. This technique encourages patients to use all of their senses in imagining a vivid, serene, and safe environment to achieve a sense of relaxation and distraction from their pain and pain-related thoughts and sensations.[27]

Collectively, relaxation techniques have generally been found to be beneficial in the management of a variety of types of acute and chronic pain conditions as well as in the management of important pain sequelae (eg, health-related quality of life).[28�31] Relaxation techniques are usually practiced in conjunction with other pain management modalities, and there is considerable overlap in the presumed mechanisms of relaxation and biofeedback, for instance.

Operant Behavior Therapy

Operant behavior therapy for chronic pain is guided by the original operant conditioning principles proposed by Skinner[32] and refined by Fordyce[33] to be applicable to pain management. The main tenets of the operant conditioning model as it relates to pain hold that pain behavior can eventually evolve into and be maintained as chronic pain manifestations as a result of positive or negative reinforcement of a given pain behavior as well as punishment of more adaptive, non-pain behavior. If reinforcement and the ensuing consequences occur with sufficient frequency, they can serve to condition the behavior, thus increasing the likelihood of repeating the behavior in the future. Therefore, conditioned behaviors occur as a product of learning of the consequences (actual or anticipated) of engaging in the given behavior. An example of a conditioned behavior is continued use of medication � a behavior that results from learning through repeated associations that taking medication is followed by removal of an aversive sensation (pain). Likewise, pain behaviors (eg, verbal expressions of pain, low activity levels) can be become conditioned behaviors that serve to perpetuate chronic pain and its sequelae. Treatments that are guided by operant behavior principles aim to extinguish maladaptive pain behaviors through the same learning principles that these may have been established by. In general, treatment components of operant behavior therapy include graded activation, time contingent medication schedules, and use of reinforcement principles to increase well behaviors and decrease maladaptive pain behaviors.

Graded activation. Psychologists can implement graded activity programs for chronic pain patients who have vastly reduced their activity levels (increasing likelihood of physical deconditioning) and subsequently experience high levels of pain upon engaging in activity. Patients are instructed to safely break the cycle of inactivity and deconditioning by engaging in activity in a controlled and time-limited fashion. In this manner, patients can gradually increase the length of time and intensity of activity to improve functioning. Psychologists can oversee progress and provide appropriate reinforcement for compliance, correction of misperceptions or misinterpretations of pain resulting from activity, where appropriate, and problem-solve barriers to adherence. This approach is frequently embedded within cognitive-behavioral pain management treatments.

Time-contingent medication schedules. A psychologist can be an important adjunct healthcare provider in overseeing the management of pain medications. In some cases, psychologists have the opportunity for more frequent and in-depth contact with patients than physicians and thus can serve as valuable collaborators of an integrated multidisciplinary treatment approach. Psychologists can institute time-contingent medication schedules to reduce the likelihood of dependence on pain medications for attaining adequate control over pain. Furthermore, psychologists are well equipped to engage patients in important conversations regarding the importance of proper adherence to medications and medical recommendations and problem-solve perceived barriers to safe adherence.

Fear-avoidance. The fear-avoidance model of chronic pain is a heuristic most frequently applied in the context of chronic low back pain (LBP).[34] This model draws largely from the operant behavior principles described previously. In essence, the fear-avoidance model posits that when acute pain states are repeatedly misinterpreted as danger signals or signs of serious injury, patients may be at risk of engaging in fear-driven avoidance behaviors and cognitions that further reinforce the belief that pain is a danger signal and perpetuate physical deconditioning. As the cycle continues, avoidance may generalize to broader types of activity and result in hypervigilance of physical sensations characterized by misinformed catastrophic interpretations of physical sensations. Research has shown that a high degree of pain catastrophizing is associated with maintenance of the cycle.[35] Treatments aimed at breaking the fear-avoidance cycle employ systematic graded exposure to feared activities to disconfirm the feared, often catastrophic, consequences of engaging in activities. Graded exposure is typically supplemented with psychoeducation about pain and cognitive restructuring elements that target maladaptive cognitions and expectations about activity and pain. Psychologists are in an excellent position to execute these types of interventions that closely mimic exposure treatments traditionally used in the treatment of some anxiety disorders.

Though specific graded exposure treatments have been shown to be effective in the treatment of complex regional pain syndrome type I (CRPS-1)[36] and LBP[37] in single-case designs, a larger-scale randomized controlled trial comparing systematic graded exposure treatment combined with multidisciplinary pain program treatment with multidisciplinary pain program treatment alone and with a wait-list control group found that the two active treatments resulted in significant improvements on outcome measures of pain intensity, fear of movement/injury, pain self-efficacy, depression, and activity level.[38] Results from this trial suggest that both interventions were associated with significant treatment effectiveness such that the graded exposure treatment did not appear to result in additional treatment gains.[38] A cautionary note in the interpretation of these results highlights that the randomized controlled trial (RCT) included a variety of chronic pain conditions that extended beyond LBP and CRPS-1 and did not exclusively include patients with high levels of pain-related fear; the interventions were also delivered in group formats rather than individual formats. Although in-vivo exposure treatments are superior at reducing pain catastrophizing and perceptions of harmfulness of activities, exposure treatments seem to be as effective as graded activity interventions in improving functional disability and chief complaints.[39] Another clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with graded activity or graded exposure for patients with acute and sub-acute LBP.[40] Outcomes revealed that there were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment among treatment groups, although graded exposure and TBC yielded larger reductions in fear-avoidance beliefs at 6 months.[40] Findings from this clinical trial suggest that enhancing TBC with graded activity or graded exposure does not lead to improved outcomes with regard to measures associated with the development of chronic LBP beyond improvements achieved with TBC alone.[40]

Cognitive-Behavioral Approaches

Cognitive-behavioral therapy (CBT) interventions for chronic pain utilize psychological principles to effect adaptive changes in the patient�s behaviors, cognitions or evaluations, and emotions. These interventions are generally comprised of basic psychoeducation about pain and the patient�s particular pain syndrome, several behavioral components, coping skills training, problem-solving approaches, and a cognitive restructuring component, though the exact treatment components vary according to the clinician. Behavioral components may include a variety of relaxation skills (as reviewed in the behavioral approaches section), activity pacing instructions/graded activation, behavioral activation strategies, and promotion of resumption of physical activity if there is a significant history of activity avoidance and subsequent deconditioning. The primary aim in coping skills training is to identify current maladaptive coping strategies (eg, catastrophizing, avoidance) that the patient is engaging in alongside their use of adaptive coping strategies (eg, use of positive self-statements, social support). As a cautionary note, the degree to which a strategy is adaptive or maladaptive and the perceived effectiveness of particular coping strategies varies from individual to individual.[41] Throughout treatment, problem-solving techniques are honed to aid patients in their adherence efforts and to help them increase their self-efficacy. Cognitive restructuring entails recognition of current maladaptive cognitions the patient is engaging in, challenging of the identified negative cognitions, and reformulation of thoughts to generate balanced, adaptive alternative thoughts. Through cognitive restructuring exercises, patients become increasingly adept at recognizing how their emotions, cognitions, and interpretations modulate their pain in positive and negative directions. As a result, it is presumed that the patients will attain a greater perception of control over their pain, be better able to manage their behavior and thoughts as they relate to pain, and be able to more adaptively evaluate the meaning they ascribe to their pain. Additional components sometimes included in a CBT intervention include social skills training, communication training, and broader approaches to stress management. Via a pain-oriented CBT intervention, many patients profit from improvements with regard to their emotional and functional well-being, and ultimately their global perceived health-related quality of life.

Dr. Alex Jimenez engaging in fitness exercise and physical activity.

CBT interventions are delivered within a supportive and empathetic environment that strives to understand the patient�s pain from a biopsychosocial perspective and in an integrated manner. Therapists see their role as �teachers� or �coaches� and the message communicated to patients is that of learning to better manage their pain and improve their daily function and quality of life as opposed to aiming to cure or eradicate the pain. The overarching goal is to increase the patients� understanding of their pain and their efforts to manage pain and its sequelae in a safe and adaptive manner; therefore, teaching patients to self-monitor their behavior, thoughts, and emotions is an integral component of therapy and a useful strategy to enhance self-efficacy. Additionally, the therapist endeavors to foster an optimistic, realistic, and encouraging environment in which the patient can become increasingly skilled at recognizing and learning from their successes and learning from and improving upon unsuccessful attempts. In this manner, therapists and patients work together to identify patient successes, barriers to adherence, and to develop maintenance and relapse-prevention plans in a constructive, collaborative, and trustworthy atmosphere. An appealing feature of the cognitive behavioral approach is its endorsement of the patient as an active participant of his/her pain rehabilitation or management program.

Research has found CBT to be an effective treatment for chronic pain and its sequelae as marked by significant changes in various domains (ie, measures of pain experience, mood/affect, cognitive coping and appraisal, pain behavior and activity level, and social role function) when compared with wait-list control conditions.[42] When compared with other active treatments or control conditions, CBT has resulted in notable improvements, albeit smaller effects (effect size ~ 0.50), with regard to pain experience, cognitive coping and appraisal, and social role function.[42] A more recent meta-analysis of 52 published studies compared behavior therapy (BT) and CBT against treatment as usual control conditions and active control conditions at various time-points.[43] This meta-analysis concluded that their data did not lend support for BT beyond improvements in pain immediately following treatment when compared with treatment as usual control conditions.[43] With regard to CBT, they concluded that CBT has limited positive effects for pain disability, and mood; nonetheless, there are insufficient data available to investigate the specific influence of treatment content on selected outcomes.[43] Overall, it appears that CBT and BT are effective treatment approaches to improve mood; outcomes that remain robust at follow-up data points. However, as highlighted by several reviews and meta-analyses, a critical factor to consider in evaluating the effectiveness of CBT for the management of chronic pain is centered on issues of effective delivery, lack of uniform treatment components, differences in delivery across clinicians and treatment populations, and variability in outcome variables of interest across research trials.[13] Further complicating the interpretation of effectiveness findings are patient characteristics and additional variables that may independently affect treatment outcome.

Acceptance-Based Approaches

Acceptance-based approaches are frequently identified as third-wave cognitive-behavioral therapies. Acceptance and commitment therapy (ACT) is the most common of the acceptance-based psychotherapies. ACT emphasizes the importance of facilitating the client�s progress toward attaining a more valued and fulfilling life by increasing psychological flexibility rather than strictly focusing on restructuring cognitions.[44] In the context of chronic pain, ACT targets ineffective control strategies and experiential avoidance by fostering techniques that establish psychological flexibility. The six core processes of ACT include: acceptance, cognitive defusion, being present, self as context, values, and committed action.[45] Briefly, acceptance encourages chronic pain patients to actively embrace pain and its sequelae rather than attempt to change it, in doing so encouraging the patient to cease a futile fight directed at the eradication of their pain. Cognitive defusion (deliteralization) techniques are employed to modify the function of thoughts rather than to reduce their frequency or restructure their content. In this manner, cognitive defusion may simply alter the undesirable meaning or function of negative thoughts and thus decrease the attachment and subsequent emotional and behavioral response to such thoughts. The core process of being present emphasizes a non-judgmental interaction between the self and private thoughts and events. Values are utilized as guides for electing behaviors and interpretations that are characterized by those values an individual strives to instantiate in everyday life. Finally, through committed action, patients can realize behavior changes aligned with individual values. Thus, ACT utilizes the six core principles in conjunction with one another to take a holistic approach toward increasing psychological flexibility and decreasing suffering. Patients are encouraged to view pain as inevitable and accept it in a nonjudgmental manner so that they can continue to derive meaning from life despite the presence of pain. The interrelated core processes exemplify mindfulness and acceptance processes and commitment and behavior change processes.[45]

Results of research on the effectiveness of ACT-based approaches for the management of chronic pain are promising, albeit still warranting further evaluation. A RCT comparing ACT with a waitlist control condition reported significant improvements in pain catastrophizing, pain-related disability, life satisfaction, fear of movements, and psychological distress that were maintained at the 7 month follow-up.[46] A larger trial reported significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance.[47] A recent meta-analysis evaluating acceptance-based interventions (ACT and mindfulness-based stress reduction) in patients with chronic pain found that, in general, acceptance-based therapies lead to favorable outcomes for patients with chronic pain.[48] Specifically, the meta-analysis revealed small to medium effect sizes for pain intensity, depression, anxiety, physical wellbeing, and quality of life, with smaller effects found when controlled clinical trials were excluded and only RCTs were included in the analyses.[48] Other acceptance-based interventions include contextual cognitive-behavioral therapy and mindfulness-based cognitive therapy, though empirical research on the effectiveness of these therapies for the management of chronic pain is still in its infancy.

Expectations

An important and vastly overlooked common underlying element of all treatment approaches is consideration of the patient�s expectation for treatment success. Despite the numerous advances in the formulation and delivery of effective multidisciplinary treatments for chronic pain, relatively little emphasis has been placed on recognizing the importance of expectations for success and on focusing efforts on enhancement of patients� expectations. The recognition that placebo for pain is characterized by active properties leading to reliable, observable, and quantifiable changes with neurobiological underpinnings is currently at the vanguard of pain research. Numerous studies have confirmed that, when induced in a manner that optimizes expectations (via manipulation of explicit expectations and/or conditioning), analgesic placebos can result in observable and measurable changes in pain perception at a conscious self-reported level as well as a neurological pain-processing level.[49,50] Analgesic placebos have been broadly defined as simulated treatments or procedures that occur within a psychosocial context and exert effects on an individual�s experience and/or physiology.[51] The current conceptualization of placebo emphasizes the importance of the psychosocial context within which placebos are embedded. Underlying the psychosocial context and ritual of treatment are patients� expectations. Therefore, it is not surprising that the placebo effect is intricately embedded in virtually every treatment; as such, clinicians and patients alike will likely benefit from recognition that therein lies an additional avenue by which current treatment approaches to pain can be enhanced.

It has been proposed that outcome expectancies are core influences driving the positive changes attained through the various modes of relaxation training, hypnosis, exposure treatments, and many cognitive-oriented therapeutic approaches. Thus, a sensible approach to the management of chronic pain capitalizes on the power of patients� expectations for success. Regrettably, too often, health care providers neglect to directly address and emphasize the importance of patients� expectations as integral factors contributing to successful management of chronic pain. The zeitgeist in our society is that of mounting medicalization of ailments fueling the general expectation that pain (even chronic pain) ought to be eradicated through medical advancements. These all too commonly held expectations leave many patients disillusioned with current treatment outcomes and contribute to an incessant search for the �cure�. Finding the �cure� is the exception rather than the rule with respect to chronic pain conditions. In our current climate, where chronic pain afflicts millions of Americans annually, it is in our best interest to instill and continue to advocate a conceptual shift that instead focuses on effective management of chronic pain. A viable and promising route to achieving this is to make the most of patients� positive (realistic) expectations and educate pain patients as well as the lay public (20% of whom will at some future point become pain patients) on what constitutes realistic expectations regarding the management of pain. Perhaps, this can occur initially through current, evidence-based education regarding placebo and nonspecific treatment effects such that patients can correct misinformed beliefs they may have previously held. Subsequently clinicians can aim to enhance patients� expectations within treatment contexts (in a realistic fashion) and minimize pessimistic expectations that deter from treatment success, therefore, learning to enhance their current multidisciplinary treatments through efforts guided at capitalizing on the improvements placebo can yield, even within an �active treatment�. Psychologists can readily address these issues with their patients and help them become advocates of their own treatment success.

Emotional Concomitants of Pain

An often challenging aspect of the management of chronic pain is the unequivocally high prevalence of comorbid emotional distress. Research has demonstrated that depression and anxiety disorders are upward to three times more prevalent among chronic pain patients than among the general population.[52,53] Frequently, pain patients with psychiatric comorbidities are labeled �difficult patients� by healthcare providers, possibly diminishing the quality of care they will receive. Patients with depression have poorer outcomes for both depression and pain treatments, compared with patients with single diagnoses of pain or depression.[54,55] Psychologists are remarkably suited to address most of the psychiatric comorbidities typically encountered in chronic pain populations and thus improve pain treatment outcomes and decrease the emotional suffering of patients. Psychologists can address key symptoms (eg, anhedonia, low motivation, problem-solving barriers) of depression that readily interfere with treatment participation and emotional distress. Moreover, irrespective of a psychiatric comorbidity, psychologists can help chronic pain patients process important role transitions they may undergo (eg, loss of job, disability), interpersonal difficulties they may be encountering (eg, sense of isolation brought about by pain), and emotional suffering (eg, anxiety, anger, sadness, disappointment) implicated in their experience. Thus, psychologists can positively impact the treatment course by reducing the influence of emotional concomitants that are addressed as part of therapy.

Conclusion

Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain are abundant. These include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress-improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, a psychologist can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives. Additional benefits of an integrated and holistic approach to the management of chronic pain may include increased rates of return to work, reductions in health care costs, and increased health-related quality of life for millions of patients throughout the world.

Image of a trainer providing training advice to a patient.

Footnotes

Disclosure: No conflicts of interest were declared in relation to this paper.

In conclusion, psychological interventions can be effectively used to help relieve symptoms of chronic pain along with the use of other treatment modalities, such as chiropractic care. Furthermore, the research study above demonstrated how specific psychological interventions can improve the outcome measures of chronic pain management. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

blog picture of cartoon paperboy big news

The Injury & Trauma Rehabilitation Specialists

PUSHasRx® Trauma Rehabilitation Center

Health, Wellness & Nutrition Specialists

Occupational Health Guidelines for the Management of Low Back Pain: an International Comparison

Abstract

Dr. Alex Jimenez’s Insight

Main Messages

Methods

Policy Implications

Results

Selection of Studies

Appraisal of the Quality of the Guidelines

Development of the Guidelines

Patient Population and Diagnostic Recommendations

Summary of Recommendations for the Assessment of LBP

Recommendations Regarding Information and Advice, Treatment, and Return to Work Strategies

Summary of Recommendations Regarding Information, Advice, Return to Work Measures, and Treatment in Workers with LBP

Discussion

Quality Aspects and Development Process of the Guidelines

Assessment and Management of LBP

Development of Future Guidelines in Occupational Health Care

Acknowledgements

Additional Topics: Back Pain

Blank

References

Close Accordion

An Updated Overview of Clinical Guidelines for the Management of Non-Specific Low Back Pain in Primary Care

Abstract

Dr. Alex Jimenez’s Insight

Introduction

Methods

Results

Patient Population

Diagnostic Recommendations

Therapeutic Recommendations

Discussion

Use of Available Evidence

Differences in Recommendations

Few Changes in Management Recommendations Over Time

Implementation

Future Developments in Research and Guideline Development

Open Access

Footnotes

Additional Topics: Back Pain

Blank

References

Close Accordion

Chiropractic Care For Lower Back Pain

Chiropractic Clinic Extra: Non-Surgical Options

Is Chiropractic Care Safe During Pregnancy?

Benefits Of Chiropractic Care During Pregnancy

Why You Should Have Chiropractic Care During Pregnancy

Chiropractic Clinic Extra: Stress Management Care & Treatments

Chiropractic Clinic Extra: Back Pain Care & Treatments

Back Clinic News Extra: Migraine Pain Treatment With Chiropractic

The Role of Psychological Interventions in the Management of Patients with Chronic Pain

Abstract

Dr. Alex Jimenez’s Insight

Introduction

Pain Management

Psychophysiological Techniques

Biofeedback

Behavioral Approaches

Relaxation Training

Operant Behavior Therapy

Cognitive-Behavioral Approaches

Acceptance-Based Approaches

Expectations

Emotional Concomitants of Pain

Conclusion

Footnotes

Additional Topics: Back Pain

Blank

References

Close Accordion

Online Booking & Appointments 24/7*

COMPLETE ONLINE HISTORY 24/7*

Clinic Locations

Additional Areas Of Care Offered

EVENTS CALENDAR: LIVE EVENTS & WEBINARS