Commentary on NIH Guidelines for research on chronic low back pain.

NIH GUIDELINES FOR CHRONIC LOW BACK PAIN RESEARCH

The NIH Guidelines for research for chronic low back pain papers were produced by a panel of experts specifically chosen for the task. The panel included neurosurgeons, orthopedic surgeons, internists, rheumatologists, practitioners of manual therapies, and physical therapists. It also included experts in psychological testing as well as pain specialists who focus on the diagnosis and treatment of chronic pain disorders.

In general, the authors made their recommendations using the principles of an evidence-based approach. They covered a wide range of conditions ranging from degenerative disease to those patients with no spinal pathology. This excluded systemic diseases (e.g. cancer and inflammation). They did not assume, however, that patients with no identifiable pathology had psychosomatic or somatoform pain. They stratified chronic back pain according to its impact rather than the demonstrated pathology. This required using a minimal uniform dataset that included both biomedical and psychosocial variables as well as specific populations (e.g. those in surgical trials and older populations). They also noted that research standards should evolve as further suggestions from the Research Task Force become available over time.

Their recommendations defined the chronicity of low back pain (LBP) and stratified LBP according to its impact on the patient. They utilized a minimum dataset that included workers’ compensation/work status, physical function, catastrophizing, etc., The also used the PROMIS[116] measures which are short forms patients can fill out, new research to improve prognostic stratification, and dissemination of recommendations.

The Published Product

The published NIH Guidelines serve as an excellent template for research on the difficult and extensive medical/surgical problems encountered in the management of chronic LBP. However, the current product is a work in progress and, as such, they expect further changes to be forthcoming. Nevertheless, that statement is made noting significant omissions. Although the bio-psychosocial model of chronic pain is noted throughout the final document, there are no psychologists on the panel who are primarily engaged in the diagnosis and treatment of patients with chronic back pain problems. Consequently, structured psychological examinations and their role in the diagnosis and treatment of chronic LBP syndromes are missing from the final recommendations.

Need for multidisciplinary team to manage patients with chronic lbp

Having served both as a spinal surgeon and the Medical Director of a major comprehensive, multidisciplinary pain treatment center for 30 years, I can well attest to the necessity of comprehensive psychological, psychosocial, and physical examinations by members of a comprehensive pain management team. Evaluations of patients with chronic pain must include personality testing.[12345678910111213141517] This helps distinguish between a chronic low back problem that is related to a primary nociceptive process (e.g. chronic nerve root entrapment due to an unstable lumbar segment) versus a chronic low back complaint related to psychological factors with superimposed secondary gain.

Secondary gain confounds diagnosis/treatment of patients with chronic back pain syndromes

Patients with chronic back pain but whose neurological/radiological investigations fail to document an adequate organic cause for their complaints may be seeking secondary gain. How a patient gains rewards and handles onerous situations is the result of their personality formation. For these patients, this may arise from factors related to their upbringing (e.g. how they develop interpersonal relations which are integrally related to their behavior in adverse circumstances). Such phenomena are only appropriately diagnosed and properly treated by psychiatrists, psychologists, and psychiatric social workers (e.g. others) utilizing structured psychological examinations, in concert with the other practitioners in a multidisciplinary program. Research on any chronic LBP problem, must, of necessity, take the psychological/psychosocial aspect of the disorder into account or it will be fraught with significant error.

Otherwise, the recommendations from the NIH Guidelines regarding the diagnosis/management of chronic LBP are quite readable and complete at this time.