AdobeStock
Chronic low back pain is one of the most prevalent and disabling medical conditions worldwide. Chronic low back pain can interfere with work, family life, and overall wellbeing. Despite advances in medicine, managing CLBP remains a complex challenge due to its multifactorial origins.
A common condition with an enormous impact
Low back pain is the single leading cause of disability worldwide, according to the World Health Organization. A U.S. National Health Interview Survey found that chronic low back pain, defined as low back pain persisting for more than 12 weeks, affects approximately 8.2% of American adults. In the U.S. alone, CLBP accounts for a significant proportion of total outpatient visits, diagnostic imaging, and physical therapy referrals.
The economic implications are also substantial. CLBP contributes to billions of dollars in healthcare spending and lost productivity each year. Beyond the financial burden, the condition can take a significant toll on patients’ quality of life.
Etiology: Often multifactorial
The causes of chronic low back pain are varied and often interrelated. Unlike acute pain, which typically has a clear and identifiable source such as a muscle strain or herniated disc, chronic pain may not always be linked to obvious structural damage.
Mechanical issues are a common cause of CLBP and include conditions such as lumbar disc degeneration, facet joint osteoarthritis, spinal stenosis, and sacroiliac joint dysfunction.
These issues may arise from degenerative changes from wear and tear, aging, repetitive strain, or traumatic injury. However, imaging studies often reveal degenerative changes in asymptomatic individuals as well, making it difficult to establish direct causality in many cases.
Neuropathic pain can also contribute, especially when nerve root irritation or compression is involved. This type of pain often presents with radiating pain, numbness, tingling, or weakness in the lower extremities.
Psychosocial factors can also be a factor. Patients with depression, anxiety, or a history of trauma are more likely to develop and sustain chronic pain. The biopsychosocial model of pain — which integrates biological, psychological, and social dimensions — has become the prevailing framework for understanding CLBP.
Lifestyle factors such as obesity, physical inactivity, smoking, and poor ergonomics are also significant contributors. Inactivity can weaken core musculature, compromising spinal support and increasing the risk of injury. Poor posture can further exacerbate strain on the lumbar spine.
Ross M. Jenson
Treatment: A multidisciplinary approach
Optimally treating CLBP involves a personalized, multimodal strategy. There is no one-size-fits-all solution, and effective care often involves a combination of therapies tailored to the individual’s specific symptoms and underlying causes.
Non-pharmacological treatments can be an important tool for treating CLBP. Physical therapy is a first-line intervention that focuses on improving flexibility, strengthening the core muscles, and correcting posture.
Modalities such as heat therapy, massage, and spinal manipulation can also offer symptomatic relief. Patients are encouraged to stay active, as prolonged inactivity can lead to deconditioning and worsened pain.
Medications may also be part of a multimodal treatment strategy. Nonsteroidal anti-inflammatory drugs have some evidence for efficacy. Muscle relaxants, antidepressants and anticonvulsants may be considered in certain cases.
Opioids are generally avoided for long-term use due to their limited long-term efficacy as well as risk of serious adverse events. Interventional procedures may be helpful for patients with pain stemming from specific anatomical sources of pain.
For example, epidural steroid injections may be beneficial for patients with pain involving the low back and lower extremities due to irritation of the spinal nerves in the lumbar spine. Facet joint diagnostic blocks and radiofrequency ablations can be utilized for patients whose pain stems from facet joint arthritis in the low back.
Other procedures, such as minimally invasive lumbar decompression, interspinous spacer placement, or basivertebral nerve ablation can potentially also be considered. These procedures are typically considered when conservative measures fail to provide adequate relief.
Cognitive-behavioral therapy and other forms of psychological support can be beneficial for patients whose pain is influenced by emotional or psychological factors.
CBT can help reframe negative thought patterns, reduce fear-avoidance behaviors, and improve pain coping skills.
Surgical intervention is a complex topic beyond the scope of this overview and is usually reserved for cases with structural abnormalities, such as nerve compression with neurological deficits, that have not responded to non-invasive treatments.
Moving forward
Understanding that chronic low back pain is a complex condition, often without a single, identifiable cause — can help shape expectations and reduce frustration. Current research and evidence support a multimodal treatment approach. While chronic low back pain may not always be curable, it’s often able to be managed and improved.