What does CBP (Chronic Back Pain) stand for?

CBP: Chronic Back Pain

CBP stands for Chronic Back Pain, which is defined as pain in the back that persists for more than 3 months. 1, 2

Understanding Chronic Back Pain

Chronic back pain (CBP) is a significant health issue that:

• Persists beyond normal tissue healing time (>3 months) 1
• Is a leading cause of disability worldwide 2
• Represents the second leading cause of disability globally 2
• Has increased in prevalence by more than 100% in the last decade 2
• Affects both men and women across all ethnic groups 2

Clinical Presentation and Classification

Chronic back pain can be categorized into:

1. Primary CBP: Approximately 85% of cases where a specific peripheral etiology cannot be identified 3

   • Maintenance factors include fear, avoidance, and beliefs that pain indicates injury

2. Specific CBP: Cases where pain can be attributed to a specific pain generator 2

   • Radicular pain
   • Facet joint pain
   • Sacro-iliac pain
   • Pain related to lumbar stenosis
   • Discogenic pain

Pathophysiological Mechanisms

The pathogenesis of chronic back pain involves multiple mechanisms:

• Peripheral mechanisms: 4

  • Inflammatory pathways in lumbar components (intervertebral discs, facet joints, muscles)
  • Nerve damage and pathologic innervation
  • Compression of nerve roots

• Central mechanisms: 4

  • Altered sensory processing in the brain
  • Malfunction of descending pain modulatory systems
  • Abnormalities in brain biochemical metabolism
  • Activation of glial cells and subsequent inflammation

Diagnostic Approach

According to clinical practice guidelines, diagnostic evaluation should include:

• History and physical examination to categorize patients into: 1

  1. Nonspecific low back pain
  2. Back pain potentially associated with radiculopathy or spinal stenosis
  3. Back pain potentially associated with another specific spinal cause

• Assessment of psychosocial risk factors which predict risk for chronic disabling back pain 1

• Imaging considerations: 1

  • Not routinely recommended for uncomplicated CBP
  • Consider imaging after 6 weeks of unsuccessful medical management and physical therapy
  • Immediate imaging indicated for patients with "red flags" (cauda equina syndrome, malignancy, fracture, infection)

Treatment Approaches

Non-pharmacological Interventions

1. Pain Reprocessing Therapy (PRT): 3

   • Aims to help patients reconceptualize pain as due to nondangerous brain activity rather than tissue injury
   • Shows significant effectiveness with 66% of participants becoming pain-free or nearly pain-free post-treatment
   • Effects maintained at 1-year follow-up

2. Physical Therapy: 5

   • Active physical therapy and supervised exercise strongly recommended over passive therapy
   • Land-based physical therapy conditionally recommended over aquatic therapy

Pharmacological Management

For chronic back pain, guidelines recommend: 1, 5

• NSAIDs/COXIBs at maximum approved dosage for 2-4 weeks
• Consider NSAID rotation if insufficient response after 2-4 weeks
• Re-evaluate treatment response at regular intervals
• Short courses of oral prednisolone may be considered in severe cases

Interventional Procedures

For specific types of CBP, interventional procedures may be considered: 5

• Facet joint interventions for confirmed facet-mediated pain
• Diagnostic blocks before proceeding with rhizotomy
• Clear documentation of failed conservative management required

Surgical Intervention

Surgical intervention should be considered only after failure of conservative management, with immediate surgical consultation necessary if: 5

• Signs of myelopathy develop
• Progressive neurological deficits occur
• Spinal cord compression is evident on imaging

Prevention of Unnecessary Interventions

Guidelines emphasize avoiding: 5

• Premature imaging for acute back pain without red flags
• Repeated spinal radiographs more frequently than every 2 years unless clinically indicated

Key Considerations for Management

When treating chronic back pain, clinicians should:

1. Identify the specific pain generator when possible
2. Address both physical and psychological aspects of pain
3. Recognize that inflammation plays an important role in both peripheral and central sensitization
4. Consider the impact of CBP on functional capacity and quality of life

By understanding the abbreviation CBP as Chronic Back Pain and recognizing its complex pathophysiology and management approaches, clinicians can provide more effective care for this common and disabling condition.