Chronic low back pain

Peter HTG Heuts, rehabilitation medicine, Hoensbroek, The Netherlands

Back pain is very common. Incidence and life time prevalence are high. The suffering due to back pain varies greatly. Costs due to health care and sick leave related to back pain and disability are rising. To reach a better understanding of back pain problems it’s important to differentiate between back pain and back disability.

In this review course an overview will be given on diagnosis and treatment of chronic low back pain problems. Emphasis will be on the rehabilitation perspective in chronic disability. Assessment and management of function and pain disability will be adressed from a biopsychosocial point of view.

The presentation and this abstract consists of four parts :

  1. What evidence is available on management in chronic low back pain ?
  2. What is the “new clinical model of low back pain and disability” as described and advocated by Waddell ?
  3. Overview of assesment in chronic low back pain problems.
  4. Treatment modalities in rehabilitation settings.

Evidence on management of low back pain

Recently, van Tulder and collegues have published a series of reviews on evidence about effectiveness of conservative treatments in acute and chronic low back pain (1999). The systematic reviews were performed according to high methodological standards. Many different treatment modalities are studied. To summarise, in persisting back pain problems (duration longer than 6 weeks) an activating approach is useful, e.g. with exercise. Prevention of chronicity is the most important treatment goal in this phase. In longlasting, chronic back pain disability the use of multidisciplinary programmes can be helpful.

A new clinical model of low back pain and disability

In 1987 Waddell described a new clinical model for the treatment of low back pain. This model is also well presented in the book “The Back Pain Revolution”. Starting from the disease model other important elements is the development of chronic disablity are described and incorporated in a more comprehensive biopsychosocial model. This gives more insight in the links between psychological and physiological and environmental events. It also offers a more dynamic model of low back pain and disability with opportunities for treatments.


In the assessment prior to rehabilitation several questions need to be answered. These questions can be summarised in four groups :

  1. Check of the medical and somatic status.
  2. Are there problems that could hamper a rehabilitative approach ? (addictions, specific psychopathology, etc).
  3. What is the social context (is the partner or e.g. work environment stimulating or else ?).
  4. What are the specific goals for treatment (in terms of the patient himself/herself).

Treatment modalities

In a rehabilitation period a multidisciplinary team works in close cooperation with the patient. The treatment modalities can be divided in “general” and “specific” components. In our setting general components are used in every pain programme ; the more specific parts are individually indicated and tailored to the needs of the patient.


• Information on low back pain
• Information on biopsychosocial approach
• Baseline measurements of functional level
• Goal setting
• Graded activity on a time-contingent basis
• Partner instruction
• Generalisation or extrapolation phase (learning how to use the gains and maintain the in everyday life
• Relapse prevention

Specific components

• In conditoned muscular hyperreactivity : individual relaxation/ biofeedback
• Depression : medication, cognitive therapy
• Specific fear of movement/(re)injury (“ kinesiophobia”) : graded exposure in vivo
• Subassertiviness : social skills-training
• Low control in pain : cognitive coping skills

In summary

In the case of chronic low back pain disability a comprehensive assessment is needed using a biopsychosocial frame of reference. Treatment programs must incorporate physical, psychological and environmental components. This has to be tailored to the specific needs of the chronically disabled low back pain patients.


Fordyce W., Back pain in the workplace : management of disability in non-specific conditions. Task Force Report, Seattle, 1995.
Goossens MEJB, Silvia M A A.Evers , Johan W S Vlaeyen, Maureen P M H Rutten-van Molken, Sjef M J P van der Linden, Principles of economic evaluation for interventions of chronic musculoskeletal pain, European Journal of Pain, 3 (1999) 343-353.
Heuts P H T G & Vlaeyen J W S, Chronische pijnproblemen : samenwerking tussen eerstelijns-gezondheidszorg en revalidatiegeneeskunde.
In : Dekker JB den, Aufdemkampe G, Ham I van, Smits-Engelsman BCM, Vaes P (Ed.), Jaarboek Fysiotherapie Kinesitherapie 1999, Bohn Stafleu Van Loghum, Houten, 1999, pp. 52-65.
Kendall NAS, Linton SJ., Main CJ, Guide to assessing psychosocial yellow flags in acute low back pain : risk factors for long-term disability and work loss, Wellington, NZ, 1997.
Koes BW, Tulder .MW van, Het beleid bij lage-rugpijn : een vergelijking van nationale richtlijnen uit vier landen, Huisarts en Wetenschap, 41 (1998) 57-61.
Mayer TG, Polatin P., Smith B, Smith C, Gatchel R, Herring S, Hall H, Donaldson R, Dickey J & English W., Spine rehabilitation : Secondary and tertiary nonoperative care, Spine, 20 (1995) 2060-2066.
Morley S, Eccleston C, Williams A, Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour and behaviour therapy for chronic pain in adults, excluding headache, Pain, 80 (1999) 1-13.
Nachemson, A.L., Newest knowledge of low back pain. A critical look., Clin Orthopaed Related Res, 279 (1992) 8-20.
Tulder van MW, Koes BW, Bouter L M, A cost-of-illness study of low back pain in the Netherlands, Pain, 62 (1995) 233-240.
Tulder van MW, Koes .B, Assendelft WJJ & Bouter LM, The effectiveness of conservative treatment of acute and chronic low back pain, EMGO Institute, Amsterdam, 1999.
Turk, D., Efficacy of multidisciplinary pain centers in the treatment of chronic pain. In : C.J.e. Cohen MJM (Ed.), Pain treatment centers at a crossroads : A practical and conceptual reappraisal., 1996.
Turk D C & Gatchel RJ, Psychological Approaches to Pain Management ; A Practitioner's Handbook, The Guilford Press, New York, London, 1996.
Vlaeyen J.W.S., A.M.J.Kole-Snijders, P.H.T.G. Heuts, H. van Eek, Behavioral analysis, fear of movement/ (re)injury and behavioral
rehabilitation in chronic low back pain. In : M. Vleeming, Dorman, Snijders and Stoeckart (Ed.), Movement, Stability & Low Back Pain., Churchill Livingstone, 1997.
Vlaeyen J.W.S. & Heuts P.H.T.G., eds. Gedragsgeorienteerde behandelingsstrategieen bij rugpijn. Utrecht, Cure&Care, 2000.
Waddell G. A new clinical model for the treatment of low back pain. Spine 12 : 632-644.
Waddell G. The back pain revolution, Churchill Livingstone, Edinburgh London New York Philadelphia Sydney Toronto, 1998.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 69 - 71.