title: Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms.
abstract: Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.
  
  
  
  Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.
  
  
  
  This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.
authors.affiliation: a Schmerz- und Palliativzentrum , Göppingen , Germany.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Müller-Schwefe
authors.affiliation: b University Hospitals Leuven , Belgium.
authors.forename: Bart
authors.initials: B
authors.lastname: Morlion
authors.affiliation: c Capio St Görans Hospital , Stockholm , Sweden.
authors.forename: Karsten
authors.initials: K
authors.lastname: Ahlbeck
authors.affiliation: d Universitätsspital Zurich , Zurich , Switzerland.
authors.forename: Eli
authors.initials: E
authors.lastname: Alon
authors.affiliation: e Santa Maria General Hospital , Terni , Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Coaccioli
authors.affiliation: f Department of Medical and Surgical Sciences and Biotechnologies , Sapienza University of Rome , Italy.
authors.forename: Flaminia
authors.initials: F
authors.lastname: Coluzzi
authors.affiliation: g University Hospital , Rotterdam , The Netherlands.
authors.forename: Frank
authors.initials: F
authors.lastname: Huygen
authors.affiliation: h Wilhelminenspital der Stadt Wien , Austria.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Jaksch
authors.affiliation: i Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki, and Helsinki University Hospital , Finland.
authors.forename: Eija
authors.initials: E
authors.lastname: Kalso
authors.affiliation: j Department of Pain Research and Treatment , Collegium Medicum Jagiellonian University , Kraków , Poland.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Kocot-Kępska
authors.affiliation: k Department of Special Anaesthesia and Pain Therapy , Medizinische Universität/AKH Wien , Vienna , Austria.
authors.forename: Hans-Georg
authors.initials: HG
authors.lastname: Kress
authors.affiliation: l Hospital de Santo André , Leiria , Portugal.
authors.forename: Ana Cristina
authors.initials: AC
authors.lastname: Mangas
authors.affiliation: m Hospital General Universitario de Alicante , Spain.
authors.forename: Cesar
authors.initials: C
authors.lastname: Margarit Ferri
authors.affiliation: n Clinique Cecil , Lausanne , Switzerland.
authors.forename: Philippe
authors.initials: P
authors.lastname: Mavrocordatos
authors.affiliation: o St. Georges Hospital , London , UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Nicolaou
authors.affiliation: p Hospital Universitario de la Princesa , Madrid , Spain.
authors.forename: Concepción Pérez
authors.initials: CP
authors.lastname: Hernández
authors.affiliation: q Naples Anesthesia and Pain Associates , Naples , FL , USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Pergolizzi
authors.affiliation: r Department of Anaesthesiology and Intensive Care Medicine , Charité University Berlin, Campus Virchow Klinikum , Berlin , Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Schäfer
authors.affiliation: s Hôpitaux de Saint-Denis , Paris , France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Sichère
mesh_terms: D000700:Analgesics / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use; D059350:Chronic Pain / Q000188:drug therapy / Q000628:therapy*; D003131:Combined Modality Therapy; D052246:Cyclooxygenase 2 Inhibitors / Q000627:therapeutic use; D006801:Humans; D017116:Low Back Pain / Q000188:drug therapy / Q000628:therapy*
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000927:Anticonvulsants; D052246:Cyclooxygenase 2 Inhibitors
keywords: Biopsychosocial; Chronic low back pain; Multifactorial; Multimodal treatment; Neuropathic; Nociceptive; Synergistic analgesia