Management of patients with subacute back pain: how to effectively prevent chronicity

A clinical observation of a patient with subacute nonspecific lower back pain and comorbid panic disorder is presented; it illustrates a modern approach to the management of this type of patients. Subacute back pain is the transition from acute to chronic pain. Clinically, the pain becomes constant, exhausting the patient and reducing his quality of life, and pathophysiologically, the pain transforms from nociceptive to dysfunctional. Chronicity of musculoskeletal pain does not occur in conditions of mental and social well-being, the patient necessarily has the so-called “yellow flags” – factors that contribute to central sensitization and chronic pain. In the presented clinical case, the most common “yellow flags” were identified – anxiety, misunderstanding about the causes of back pain, pain catastrophizing, restrictive “pain” behavior. These factors are often found among patients with subacute back pain. It is important to identify “yellow flags” timely and treat patient taking into account their correction. For the treatment of this category of patients, the prescription of pain therapy alone is not enough, an interdisciplinary approach is needed, which will include rational pharmacotherapy, psychological methods and kinesiotherapy.
The patient underwent interdisciplinary treatment, including non-drug and drug therapies and in accordance with Russian and foreign clinical guidelines for the treatment of subacute nonspecific lower back pain and panic disorder. Non-drug treatment consisted of educational talks, recommendations for daily activities, cognitive behavioral therapy, and kinesiotherapy. These methods were aimed at forming the patient's correct ideas about his condition, at reducing the catastrophizing of pain and anxiety, and at increasing the patient's physical and social activity. It is known that many patients with pain syndromes have insufficient adherence to treatment and adherence to medical recommendations. Patient adherence to non-drug treatments was maintained through educational conversations and cognitive-behavioral therapy. Taking into account the previous multiple intake of non-steroidal anti-inflammatory drugs and in order to avoid the risk of side effects, drugs of this group were not included in the present pharmacotherapy plan. The patient was prescribed Alflutop as a pharmacotherapy. After 10 days of treatment, a marked relief of pain was observed, and after 3 weeks of treatment, back pain regressed, and anxiety significantly decreased. The patient has formed correct ideas about his condition, about his lifestyle. Follow-up of the patient for 12 months showed that there were no repeated episodes of back pain and panic attacks. The patient continued to regularly engage in kinesiotherapy and maintain an active lifestyle.

1. Koes BW, van Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010 Dec;19(12):2075-94. doi:10.1007/s00586-010-1502-y. Epub 2010 Jul 3. 2. Подчуфарова ЕВ, Яхно НН. Боль в спине. Москва: ГЭОТАР-Медиа; 2010. 368 c.

2. Podchufarova EV, Yakhno NN. Bol' v spine [Back pain]. Moscow: GEOTAR-Media; 2010. 368 p. (In Russ.)

3. Parfenov VA, Yakhno NN, Davydov OS, et al. Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(Suppl. 2):7-16. doi:10.14412/2074-2711-2019-2S-7-16 (In Russ.)

4. Parfenov VA, Yakhno NN, Kukushkin ML, et al. Acute nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2018;10(2):4-11. doi:10.14412/2074-2711-2018-2-4-11 (In Russ.)

5. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791-803. doi:10.1007/s00586-018-5673-2. Epub 2018 Jul 3.

6. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-30. doi:10.7326/M16-2367. Epub 2017 Feb 14.

7. Monticone M, Ambrosini E, Portoghese I, Rocca B. Multidisciplinary program based on early management of psychological factors reduces disability of patients with subacute low back pain: one-year results of a randomized controlled study. Eur J Phys Rehabil Med. 2021 Dec;57(6):959-67. doi:10.23736/S1973-9087.21.06696-X. Epub 2021 May 5.

8. World Health Organization. International statistical classification of disease and relation health problems. 10<i>th</i> ed. Geneva, Switz: World Health Organization; 1992. Available from: https://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf

9. Medvedev VE. Anxiety and depression in COVID-19: treatment options. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(2):111-6. doi:10.14412/2074-2711-2021-2-111-116 (In Russ.)

10. Pappa S, Ntella V, Giannakas T, et al. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020 Aug;88:901-7. doi:10.1016/j.bbi.2020.05.026. Epub 2020 May 8. Erratum in: Brain Behav Immun. 2021 Feb;92:247.

11. Li Y, Qin Q, Sun Q, et al. Insomnia and psychological reactions during the COVID-19 outbreak in China. J Clin Sleep Med. 2020 Aug 15;16(8):1417-8. doi:10.5664/jcsm.8524

12. Cenat JM, Blais-Rochette C, Kokou-Kpolou CK, et al. Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry Res. 2021 Jan;295:113599. doi:10.1016/j.psychres.2020.113599. Epub 2020 Nov 26.

13. Golovacheva VA, Golovacheva AA, Fateeva TG. Psychological methods in the treatment of chronic nonspecific low back pain. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(Suppl. 2):25-32. doi:10.14412/2074-2711-2019-2S-25-32 (In Russ.)

14. Parfenov VA, Isaiykin AI. Bol' v nizhneiy chasti spiny: mify i real'nost [Pain in the lower back: myths and reality]. Moscow: IMA-PRESS; 2016. 104 p. (In Russ.)

15. Parfenov VA, Golovacheva VA. Khronicheskaya bol' i yeye lecheniye v nevrologii [Chronic pain and its treatment in neurology]. Moscow: GEOTAR-Media; 2018. 288 p. (In Russ.)

16. Zhivolupov SA, Samartcev IN, Ponomarev VV. Quantative evaluation and analysis of the central mechanisms involved in analgesic effect of Alflutop in patients with chronic lower back pain. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2021;121(10):38-44. doi:10.17116/jnevro202112110138 (In Russ.)

17. Samartsev IN, Zhivolupov SA, Barantsevich ER, Danilov AB. The evaluation of the efficacy of Alflutop in the complex treatment of patients with chronic lower back pain (the observational study ZEITNOT). Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2021;121(2):24-30. doi:10.17116/jnevro202112102124 (In Russ.)

18. Gao Y, Bai L, Zhou W, et al. PARP-1-regulated TNF-α expression in the dorsal root ganglia and spinal dorsal horn contributes to the pathogenesis of neuropathic pain in rats. Brain Behav Immun. 2020;88:482-96. doi:10.1016/j.bbi.2020.04.019

19. Zhou R, Xu T, Liu X, et al. Activation of spinal dorsal horn P2Y13 receptors can promote the expression of IL-1β and IL-6 in rats with diabetic neuropathic pain. J Pain Res. 2018;11:615-28. doi:10.2147/JPR.S154437

20. Levin OS, Olyunin DYu, Golubeva LV. Alflutop efficacy in chronic vertebrogenous lumbar ischialgia. A double blind placebo controlled study. Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice. 2004;42(4):80-4. doi:10.14412/1995-4484-2004-809 (In Russ.)