1	Chronic Back Pain An Integrative Approach James T. Prado, D.C. Pomperaug Chiropractic & Holistic Center Southbury, CT 203-264-3583
2	Chronic Back Pain Defined Back pain lasting more than 12 weeks Chronic recurrence of “acute” episodes Back Pain Prevalence¹ 28% Pt. prevalence of LBP 11% Pt. prevalence disabling LBP 84% Lifetime prevalence of LBP
3	CAM Therapies for Back Pain Back Pain #1 reason for CAM use 48% of adults w/ back pain used CAM, 30% saw CAM provider¹ Back pain #1 reason for visit to Chiropractors (45%), acupuncturists, massage therapists ²
4	Misconceptions Most chronic and chronic, recurrent back pain is due to serious underlying conditions.
5	Facts 1.4%⁽¹⁾ - 2%⁽²⁾of all back pain patients have a serious underlying pathology. Only 1 out of 100 back pain cases benefit from surgery.⁽²⁾
6	1.4 – 2% of Back Pain Cases Red Flags: Cancer – Primary or metastatic Other tumors, Infection, Fracture Cauda Equina Syndrome Progressive Neuro. Deficit
7	More Misconceptions… Most back pain is caused by: Degenerative, bulging or herniated discs Spinal stenosis Spondylolisthesis Transitionial Lumbar Vertebra
8	More Facts… High incidence of “pathology” in the asymptomatic population: Degenerative, Bulging, Herniated discs ^{1 - 5} Spinal Stenosis ^{1, 2, 3, 5} Spondylolisthesis < grade III ¹ Transitional Lumbar Vertebra ^{6, 7}
9	Symptomatic Discs Far less common than previously thought 76% asymptomatic Vs. 96% symptomatic have HNP ⁽¹⁾ 25% asymptomatic “high intensity zones” on MRI ⁽²⁾ Predictors of symptomatic discs: Disc extrusions w/ neural compromise⁽¹⁾ Neural compromise w/ psychosocial factors⁽¹⁾ Aggressive Immune/Inflammatory response⁽³⁾
10	Causes of Chronic Back Pain Psychosocial Risk Factors – “Yellow Flags” Increase chance of long term disability ^{(1, 2, 3)} Psychological distress doubles later risk of LBP ⁽²⁾
11	Psychosocial More Important “Psychosocial features are more important risk factors for chronicity than biomedical symptoms and signs.”^1-5
12	Psychological Factors Psychological Attitudes and beliefs about back pain Fear - Avoidance Beliefs Personal responsibility for pain & rehab. Psychological Distress & Depressive Symptoms Illness behavior
13	Social Factors Social Family Attitudes & beliefs about back pain Reinforcement of disability behaviors Work Physical job demands Job satisfaction Other health/non-health issues causing time off or job loss
14	Mechanism of Chronic Pain
15	Biopsychosocial Treatment of Chronic Back Pain Education Manipulation Meditation Aerobic Exercise Psychotherapy
16	Education Education^{1 - 3} Reduces anxiety & Fear – Avoidance Promotes early return to activity Empowers the patient
17	Chiropractic Manipulation Manipulation – “adjustment” Attenuates sympathetic hyperactivity^{1 - 3} Attenuates alpha motor neuron response^{4, 5} Restoration of joint play (motion) Reduced pain and muscle tension/spasm
18	Neurophysiology
19	Safety of Chiropractic Cauda Equina Syndrome 1 : 1 million – 1: 100 million ⁽¹⁾ Vertebral Basilar Stroke/Death 1 : 1.3 million ⁽²⁾ – 1 : 3 million ⁽³⁾ NSAID’s Risk of serious injury 400 x’s >; risk of death 160 x’s > than with manipulation ⁽⁴⁾
20	Chiropractic Efficacy 43 RCT’s of Spinal Manipulation for LBP 30 favored manipulation 13 found manipulation = to comparable Tx
21	Meditation Meditation or “Relaxation Response” Reduces pain, anxiety, muscle tension^{1, 3} Attenuates sympathetic hyperactivity ²
22	Exercise Aerobic activity better than lumbar flexion exercises¹ Specific back exercises not effective² Just stay active!³
23	Psychotherapy Anxiety & Depression Suppressed Emotion⁽¹⁾ Fear, worry Resentment, anger, rage PTSD ⁽²⁾
24	Chronic Back Pain Personality ? Highly conscientious “Do-gooder” Takes on excessive responsibilities Puts hart & soul into all they do Subconsciously resentful of those who do less Tendency toward anxiety
25	Holistic Interpretation Facilitates Life Change Spirituality – The way we live our lives Back pain as “barometer” for how we live our lives Live a life of balance Reminds us to stay active Avoid suppressing emotions Avoid anxiety - Live in the Present!