What's the next step for a patient with persistent severe back pain when twisting and turning despite 8 weeks of physical therapy (physiotherapy) after a fall?

Management of Persistent Severe Back Pain After 8 Weeks of Physiotherapy

For a patient with persistent severe back pain when twisting and turning after 8 weeks of physiotherapy with only partial improvement, you should immediately assess their risk stratification using the STarT Back tool and refer high-risk patients for comprehensive biopsychosocial assessment with review no later than 12 weeks from pain onset. 1

Immediate Assessment and Risk Stratification

• Apply the STarT Back tool now to determine if this patient is at medium or high risk for developing chronic disabling pain, as the British Pain Society guidelines recommend this assessment at 2 weeks but it remains critical at 8 weeks for directing appropriate resources. 1

• High-risk patients demonstrate psychosocial factors including anxiety, depression, catastrophizing, fear-avoidance beliefs, or significant functional impairment that limits daily activities. 2

• The severe pain with specific movements (twisting and turning) combined with incomplete response to 8 weeks of physiotherapy suggests either inadequate treatment intensity or presence of psychosocial barriers to recovery. 1

Management Pathway Based on Risk Level

For High-Risk Patients (Most Likely Scenario)

• Refer immediately for biopsychosocial assessment performed in the context of a multidisciplinary team, as the British Pain Society pathway specifies this for patients not improving after standard physiotherapy. 1

• Review no later than 12 weeks from initial pain onset - if no improvement at that point, consider referral to a specialist pain center or specialist spinal center. 1

• Consider whether this patient meets criteria for comprehensive pain rehabilitation, particularly if they demonstrate significant functional impairment with avoidance behaviors that severely restrict daily functioning. 3

For Medium-Risk Patients

• Continue with physiotherapy but ensure it includes a comprehensive biopsychosocial approach rather than purely biomechanical treatment. 1

• Develop a patient-centered management plan that addresses both physical and psychosocial factors. 1

Specific Treatment Considerations at This Stage

Psychological interventions should now be integrated, as the British Pain Society identifies two levels: low-intensity psychological therapy provided by a single professional following a treatment manual, or high-intensity cognitive behavioral therapy as part of multidisciplinary care. 1

Medication optimization may be warranted:

• Ensure adequate trial of NSAIDs if not contraindicated. 2
• Consider tramadol or duloxetine as second-line options if NSAIDs insufficient. 2
• Avoid long-term opioids given considerable risks and lack of evidence for chronic pain. 1

Workplace considerations are critical:

• Use fit notes (statements of fitness for work) to facilitate modified return to work or workplace accommodations. 1
• The British Pain Society emphasizes that work is the area of people's lives most disrupted by pain, and managing return to work is essential. 1

Red Flags Requiring Immediate Specialist Referral

Before proceeding with the above pathway, exclude serious pathology:

• Progressive neurological deficits (worsening weakness, numbness, or bowel/bladder dysfunction) require immediate MRI and specialist consultation. 2, 4

• Severe unrelenting pain that worsens at night, unexplained weight loss, or history of cancer suggests possible serious underlying condition. 2, 4

• If any red flags present, obtain immediate MRI (preferred over CT as it avoids radiation and better visualizes soft tissue) and arrange urgent specialist consultation. 2

Imaging Considerations at 8 Weeks

• Plain radiography may be considered if not previously performed and patient has risk factors for vertebral compression fracture or if symptoms suggest specific structural pathology. 2

• The American College of Physicians recommends against routine imaging for nonspecific low back pain, but at 8 weeks with persistent severe pain, imaging becomes more reasonable to guide further management. 2, 4

• MRI should be considered if symptoms of radiculopathy persist or if considering interventional procedures. 2

When to Consider Specialist Pain Center Referral

Refer to specialist pain center if:

• No improvement by 12 weeks despite biopsychosocial assessment and appropriate multidisciplinary management. 1

• Patient demonstrates chronic pain syndrome with central sensitization (suggested by intractable nature despite multiple interventions). 3

• Significant functional impairment with pain limiting prolonged sitting, walking, exercise, and physical activity with avoidance behaviors. 3

Comprehensive Pain Rehabilitation Programs

For patients with severe functional impairment who fail the above interventions, intensive interdisciplinary pain rehabilitation becomes medically necessary:

• The Mayo Clinic model recommends a 3-week intensive outpatient program including physical and occupational therapy for physical reconditioning, concurrent management of functional and behavioral morbidities, and potential tapering of pain medications including opioids. 3

• These programs have demonstrated effectiveness in improving physical and emotional functioning with sustained long-term benefits, including patients transitioning from wheelchair-bound status to active lifestyles. 3

Common Pitfalls to Avoid

• Do not continue passive physiotherapy indefinitely - the British Pain Society consensus states that "physical therapy for all" is not working, and stratified care based on risk is essential. 1

• Do not delay psychological assessment - psychosocial factors are critical in generating disability from back pain, and addressing them early prevents chronicity. 1

• Do not prescribe prolonged bed rest - maintaining activity within pain limits is superior to rest for outcomes. 2

• Avoid overreliance on opioid medications - they carry considerable risks, addictive potential, and are not considered a treatment option for chronic back pain. 1

• Do not delay referral to comprehensive pain rehabilitation for patients with intractable pain despite multiple interventions, as further delay is inappropriate. 3