Treatment of Lower Back Pain-The Gap between Guideline-Based Treatment and Medical Care Reality
SOURCE: Healthcare (Basel) 2016 (Jul 15); 4 (3): 44 ~ FULL TEXT
Andreas Werber and Marcus Schiltenwolf
Department of Orthopedics and Orthopedic Surgery,
University Hospital Giessen,
Klinikstr. 33, 35392
Despite the fact that unspecific low back pain is of important impact in general health care, this pain condition is often treated insufficiently. Poor efficiency has led to the necessity of guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). We present some statements of the German medical care reality. Self-responsible action of the patient should be supported while invasive methods in particular should be avoided due to lacking evidence in outcome efficiency. However, it has to be stated that no effective implementation strategy has been established yet. Especially, studies on the economic impact of different implementation strategies are lacking.
A lack of awareness of common available guidelines and an uneven distribution of existing knowledge throughout the population can be stated: persons with higher risk suffering from LBP by higher professional demands and lower educational level are not skilled in advised management of LBP. Both diagnostic imaging and invasive treatment methods increased dramatically leading to increased costs and doctor workload without being associated with improved patient functioning, severity of pain or overall health status due to the absence of a functioning primary care gate keeping system for patient selection.
Opioids are prescribed on a grand scale and over a long period. Moreover, opioid prescription is not indicated properly, when predominantly persons with psychological distress like somatoform disorders are treated with opioids.
Keywords: guideline-based treatment; low back pain; somatisation.
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The onset of chronic lower back pain (cLBP) is based upon various factors. A former history of LBP is the most consistent risk factor for transition from a baseline of a pain-free state.  LBP is marked as chronic if the pain occurs on more than half of the days of the last half-year. In a broader sense, cLBP is defined as the final point of a chronification process including the following characteristics: generalization of pain, changing areas of pain, other complaints that cannot be explained merely somatically (buzzing in one’s ears, digestive disorders, insomnia). Furthermore, changes in behaviour are concomitant, for instance increasing consumption of medication, alternating presentation of different symptoms, avoidance of exercises and social withdrawal. 
The risk of suffering from LBP differs significantly within the general population. Especially psychological distress in terms of dysfunctional behaviour plays a decisive role in the development process.  In less than 10% of the cases LBP can solely be explained somatically. In fact, LBP is often an alternative expression of physical stress symptoms of which the patients are seldom aware. LBP is rather a medical condition than a complete medical entity. In combination with other symptoms like depression or anxiety disorders, cLBP is an expression of distress. 
Several countries developed guidelines in order to provide a systematic approach for treatment of cLBP with similar procedures both for diagnosis and treatment. [4, 5] However, both patients and physicians are seldom aware of how to deal properly with LBP according to recommendations of common available guidelines.  Monomodal therapy often leads to insufficient therapeutic response, hence it is important to identify the distinct factors of causing pain and treat them properly in terms of a multidisciplinary (=multimodal) therapeutic approach.