Causes of pain

What is Fibromyalgia?

Fibromyalgia (FM) affects approximately 10–20 million individuals in the U.S. FM is a chronic condition associated with widespread pain and tenderness along with other symptoms such as problems with sleep, memory, mood, and fatigue. Women tend to be more susceptible to fibromyalgia, usually in middle age (20 years–50 years), and there is some evidence to suggest that it may run in families. If you have fibromyalgia, the pain and fatigue can affect many areas of your life including work, daily activities, enjoyment of hobbies, and taking care of your family. Currently there is no known cure for fibromyalgia, but the symptoms of FM can be managed successfully.

Symptoms

• Pain and tenderness: The most common symptoms of FM are widespread pain and tenderness. These symptoms tend to be highly variable with some days being better than others. The location of pain may also change over time - people often describe FM as "whole body pain" since the pain and tenderness of FM is not confined to a single location within the body.
• Fatigue: The fatigue of FM is described as both physical fatigue and mental fatigue. Both types of fatigue are described as being more profound than "general tiredness". People with FM are more easily fatigable and when fatigued, slower to recover. People with FM fatigue often consider the fatigue to be as problematic as the pain.
• Sleep Problems: Some individuals with FM may have difficulty falling asleep or staying asleep. Others may sleep through the night but upon wakening, feel unrefreshed as though they were unable to sleep at all.
• Cognitive and Memory Problems: Problems with thinking (also referred to as "Fibro-Fog") can take many forms including: difficulty concentrating, difficulty remembering, difficulty finding the right words for objects or people, mental cloudiness, difficulty navigating, and sensing that thinking is slower than usual.
• Depression and Anxiety: While FM used to be misdiagnosed as a variant of depression, depression and anxiety often co-exist with FM. When present, anxiety and depression can make FM symptoms worse. The depressive symptoms and anxiety do not need to be at the level of a diagnosable disorder to influence pain perception. Simply experiencing the symptoms of FM will likely have a negative impact on mood which in turn can make other FM symptoms worse.
• Sensory Sensitivity: In addition to pain, individuals with FM tend to experience hypersensitivity to light, sound, touch, taste, odors, and medications. This means that for people with FM, sensations will become unpleasant at intensities that do not bother other people. For example, individuals with FM may feel chilled or overly warm at temperatures that seem normal to others, movies or concerts may seem uncomfortably loud, or common perfumes may seem noxious.
• Stiffness: Stiffness upon wakening is common for individuals with FM. Stiffness can also occur after sitting or standing or when there are changes in barometric pressure.
• Dryness of Eyes or Mouth: Some individuals with FM report excessively dry eyes and/or mouth even when tear production or saliva is normal.
• Chronic Overlapping Pain Conditions (COPCs): If you have FM, you may also have one or more of the other COPCs found on this page. It is thought that these conditions may share common underlying causes.

What Causes FM?

About half of people with FM can identify some triggering event that they suspect led to the onset of FM. Others however report that FM started spontaneously - for no apparent reason.

Normally we experience pain when there is some injury (e.g., a broken bone, cut, or fall). This represents the body's pain processing mechanism working adaptively to protect us from harm.

FM is an example of a disorder where sensory information (both normal and threatening) gets amplified by the brain. Thus in the case of FM, the problem is not necessarily an injury but a problem in how the brain processes nociceptive information and produces pain. The underlying problem in FM is thought to be nociplastic pain or centrally augmented pain, a disorder of pain processing.

It should be noted that pain experienced in response to an injury is indistinguishable from pain associated with central augmentation. Both are "real" forms of pain and both can result in comparable levels of suffering. Many factors can contribute to central pain augmentation including genetics, infections, hormonal abnormalities, physical and/or psychological trauma, repetitive injuries, and sustained physical/psychological stress.

Diagnosis of FM

Currently there are no reliable laboratory tests, x-rays, or other objective tests for diagnosing FM (even though there are some tests that purport to do so). In part this is because the problem is not the result of an injury or disease, but how the brain produces the experience of pain. Often individuals with FM will have seen many doctors before receiving a diagnosis of FM because FM can mimic many other illnesses. It is important to note however that you can have FM in addition to having other illnesses.

In the U.S., a doctor familiar with FM will typically take a careful medical history, and then utilize the diagnostic criteria from the American College of Rheumatology (ACR) to make the diagnosis of FM. These criteria take into account the following elements:

• The areas of your body in which you feel pain and its duration (e.g., pain wide-spreadedness)
• The presence of additional symptoms (e.g., fatigue, sleep problems, cognitive problems)

Who treats FM?

FM is often treated by family doctors, rheumatologists, or internists. While these doctors often coordinate the care, optimal care often requires a team approach. This team might include the following specialists:

• Rheumatologist – physicians specializing in arthritis and other diseases of the bones, joints, and muscles
• Nurse educators – specialists who can educate about the condition and help develop or refine a personalized treatment plan
• Physical therapists – specialists trained in mobilizing muscles, bones, and joints through exercise, hands-on care, and patient education
• Occupational therapists – specialists trained in teaching ways to protect joints, conserve energy, engage more fully in activities of daily living, and patient education.
• Psychologists or social workers – specialists who can help initiate and maintain self-care approaches to pain management and who can help address social challenges associated with dealing with chronic pain
• Dietitians - specialists who teach about optimal diets and maintaining a healthy weight
• Acupuncturists - specialists who may influence pain perception, promote healing, and improve functional status by stimulating specific points on the body often by inserting needles into the skin

Most importantly however YOU need to be a member of the team. Much of FM management can be done at home, by you, and does not require seeing a doctor. The parts that you can do may require some changes in how you live your life. You will need to stick to this plan for better pain control.

It is likely that you and your doctor will need to team up to identify the best combination of professional and self-care approaches that work for you. This plan will need to be reviewed and potentially revised over time as your needs shift.

Treatment of FM

The treatment/management of FM can take many forms. We identify the various approaches below. You can follow the links to learn more about each treatment/management strategy.

• Self-Care – There are many changes in your lifestyle that can help you to improve the symptoms of FM. What you choose to focus on needs to be personalized to your specific situation. The link above will take you to a description of the many self-management approaches others have found helpful. You may want to talk with your doctor to identify the self-care approaches that would be best for you at the present time.
• Professional Care – Combining self-care with professionally lead care can create an optimal approach to successful management of FM. The link above will take you to a description of the many professionally lead approaches to chronic pain management. For FM, the most common approaches include medications (e.g., anti-depressant, and anti-seizure), cognitive-behavioral therapy, and aerobic exercise.

Additional Resources

• American College of Rheumatology
• National Institute of Arthritis and Musculoskeletal and Skin Diseases, (NIH)
• National Fibromyalgia Association (NFA)
• National Fibromyalgia Partnership, Inc.
• Chronic Pain Research Alliance
• Chronic Pain and Fatigue Research Center (CPFRC)

Some Additional Reading

• Dr. Daniel Clauw provides a mechanistic review of FM and its treatment.
• Overview of non-pharmacological interventions for FM
• Using the Internet to deliver pain interventions.

What is Irritable Bowel Syndrome?

Irritable bowel syndrome (IBS) has a worldwide prevalence of 11%. It is characterized by chronic and recurrent abdominal pain associated with alterations in stool form and/or frequency. It is one of the most common gastrointestinal (GI) conditions diagnosed in both primary care and specialty practice. IBS occurs in the context of a grossly and histologically normal GI tract, and thus, it has been referred to as a "functional" GI disorder. However, growing scientific evidence supports that IBS is a disorder of brain-gut interactions resulting in physiologic disturbances at the peripheral (gut-based) and central (brain, spinal cord) levels. It occurs in children and adults and is generally more common in women than men. Symptoms can fluctuate over time; there can be periods when symptoms flare up as well as periods of remission when they diminish or disappear. In some women, symptoms increase just prior to menses. IBS can affect many areas of a person's life including work, school, daily activities and relationships. Although there is currently no known cure for IBS, the symptoms of IBS can be managed effectively.

Symptoms

• Abdominal Pain and Discomfort: The hallmark symptom of IBS is chronic or recurrent abdominal pain. This tends to be highly variable, with some days being better than others. The location of pain is typically in the lower abdomen but can occur in any part of the abdomen. It is associated with a change in bowel habits, such as diarrhea and/or constipation. The pain is usually relieved, but also can worsen, after having a bowel movement.

• Diarrhea and/or constipation: A change in bowel habits occurs and presents as diarrhea and/or constipation. Individuals with IBS may either have mostly diarrhea, mostly constipation, or both diarrhea and constipation (mixed pattern). The main bowel habit can change over time. For example, some individuals who suffer mainly from constipation (or diarrhea) may later experience a change to constipation alternating with diarrhea.

• Bloating (a sensation of fullness in the belly) is a common symptom in IBS. It is more commonly experienced in individuals with constipation or constipation alternating with diarrhea.

• Urgency (the need to use a restroom in a hurry) is a bothersome symptom generally associated with diarrhea or loose stools.

• Fatigue: Fatigue or tiredness can occur in some people with IBS. This may be associated with sleep difficulties or experienced during times of more severe abdominal pain or diarrhea.

• Sleep Problems: Some individuals with IBS may have difficulty falling asleep or staying asleep. Poor sleep has been associated with more bothersome GI symptoms.

• Anxiety and Depression: IBS can co-exist with anxiety and/or depression but more often in individuals with more severe symptoms. The depressive symptoms and anxiety do not need to be at the level of a diagnosable disorder to influence pain perception. Simply experiencing the symptoms of IBS will likely have a negative impact on mood which in turn can make other IBS symptoms worse.

• Chronic Overlapping Pain Conditions (COPCs): If you have IBS, you may also have one or more of the other COPCs. It is thought that these conditions may share common underlying causes. The COPCs are listed below and detailed descriptions of each can be found by following the link.

  • Fibromyalgia
  • Low back pain
  • Temporomandibular disorder
  • Urinary chronic pelvic pain syndrome
  • Migraine and tension headache
  • Endometriosis
  • Vulvodynia
  • Myalgic Encephalopathy / Chronic Fatigue Syndrome

What Causes IBS?

IBS is thought to be due to a disturbance in the communication between the brain and gut, which is known as the "brain-gut axis." There is not a consensus on the underlying cause of this altered brain-gut axis, but IBS likely represents a combination of factors involving different mechanisms. These mechanisms include increased gut sensitivity and altered GI motility (contractions of the bowel), immune function, gut microbiome (bacteria in the gut), and central nervous system (brain and spinal cord) processing of gut sensations. These disturbances are thought to result in the symptoms of IBS.

Risk factors include a family history of IBS, prior GI infection, and stressful life events. Individuals who develop IBS symptoms following a prior gastroenteritis are considered to have post-infection IBS. Younger age, female gender, a more severe diarrhea illness, and having anxiety, depression or stressful life events at the time of the infection increases the risk of getting post-infection IBS.

A history of adverse life events experienced in childhood and adulthood (e.g., abuse, mental illness in the family) is associated with an increased risk of having IBS and more severe symptoms. Confiding in others at the time of the traumatic event can lower the risk of IBS. IBS symptoms can fluctuate over time. Symptom flares can be triggered by certain foods and stressors.

Diagnosis of IBS

Currently there are no reliable laboratory tests, x-rays, or other objective tests for diagnosing IBS (even though there are some tests that make such claims). Often individuals with IBS will have seen many doctors before receiving a diagnosis of IBS because IBS can mimic other conditions, such as celiac disease and inflammatory bowel disease (IBD). It is important to note however that you can have IBS in addition to having other medical conditions.

The diagnosis of IBS is based on symptoms. The key symptom of IBS is chronic or recurrent abdominal pain associated with altered bowel habits. The current criteria for diagnosis of IBS are the Rome IV criteria, which is a collection of the most common symptoms that typify this condition. This includes abdominal pain at least 1 day per week for three months that is associated with two of the following: 1) the pain is related to defecation, 2) the pain is associated with an increase or decrease in stool frequency, and/or 3) the pain is associated with the stools becoming harder or softer in form. The symptoms should have started at least 6 months ago. The next important step is to look for signs and symptoms that are suggestive of a condition other than IBS, such as IBD (i.e., Crohn's disease or ulcerative colitis) or celiac disease. These signs and symptoms have been referred to as "alarm signs" or "red flags." They include anemia and other abnormal blood tests, bloody stools, unexplained weight loss, fever, new onset of symptoms at the age of 50 or older, and family history of IBD, colon cancer or celiac disease. While the presence of these red flags may warrant a more comprehensive diagnostic evaluation, it often does not identify another condition that explains the symptoms of IBS.

Supportive symptoms that are not used for diagnosis include: abnormal stool frequency (> 3 bowel movements/day or < 3 bowel movements/week), abnormal stool form, excessive straining or urgency during defecation, feelings of incomplete evacuation, and mucus with bowel movements. IBS is sub-grouped by predominant bowel habit. Because stool form is the best predictor of predominant bowel habit in IBS, stool form determines whether a person has IBS with predominantly diarrhea (IBS-D; >25% of bowel movements are loose or watery and < 25% are hard and lumpy), IBS with predominantly constipation (IBS-C; >25% are hard and lumpy and <25% are loose or watery), IBS with mixed bowel habit pattern (IBS-M; >25% loose or watery stools and >25% hard and lumpy), or IBS unclassified (IBS-U; <25% loose or watery stools and <25% hard and lumpy stools).

Who treats IBS?

IBS is often treated by primary care doctors (family practice, internists) and gastroenterologists. While these doctors often coordinate the care, optimal care often requires a team approach. This team might include the following specialists:

• Gastroenterologists – physicians specializing in GI conditions
• Advanced practice providers (nurse practitioners, physician assistants) who specialize in GI conditions and often work with gastroenterologists
• Nurse educators – specialists who can educate about the condition and help develop or refine a personalized treatment plan
• GI health psychologists– specialists who can help initiate and maintain behavioral and self-care approaches to manage symptoms and who can help address psychosocial challenges associated with dealing with chronic abdominal pain, diarrhea and/or constipation and other symptoms
• GI dietitians - specialists who educate and provide guidance on diets that are effective in managing IBS symptoms and optimizing nutritional status
• Integrative health practitioners - specialists who use mindfulness and other positive behavioral approaches to improve IBS symptoms, promote healing, and improve functional status and overall well-being

These healthcare providers work with patients with IBS to improve symptoms, overall well-being and quality of life. It is likely that you and your doctor will need to work together to identify the best combination of professional and self-care approaches that works for you. This plan will need to be reviewed and potentially revised over time as your needs shift.

Treatment of IBS

The treatment/management of IBS can take many forms. We identify the various approaches below. You can follow the link to learn more details about each treatment/management strategy.

• Self-Care – There are many changes in your lifestyle that can help you to improve the symptoms of IBS. What you choose to focus on needs to be personalized to your specific situation. The link above will take you to a description of the many self-management approaches others have found helpful. You may want to talk with your healthcare provider so as to identify the self-care approaches that would be best for you at the present time.
• Professional Care – Combining self-care with professionally led care can create an optimal approach to successful management of IBS. The link above will take you to a description of the many professionally lead approaches to chronic pain management. For IBS, the cornerstone of treatment is education, reassurance, and a therapeutic provider-patient relationship. Dietary management, e.g. low FODMAP (fermentable oligo-, di-, mono-saccharides and polyols) diet, exercise and lifestyle changes can help reduce symptoms of IBS. Treatment is generally focused on the most bothersome or predominant symptoms. Medications approved to treat IBS-D include rifaximin (antibiotic), eluxadoline, and alosetron. Medications to treat IBS-C include lubiprostone, linaclotide, plecanatide, and tegaserod. However, over-the-counter remedies can relieve milder symptoms and include anti-diarrheal medication for IBS-D and laxatives for IBS-C. However, they may not relieve abdominal pain as the FDA approved medications for IBS do. Abdominal pain in IBS can also be relieved by antispasmodics and neuromodulators (e.g. antidepressants or neuromodulators). Behavioral approaches such as cognitive behavioral therapy, hypnotherapy, and mindfulness-based stress reduction have been shown to improve IBS symptoms.

ADDITIONAL RESOURCES

American Gastroenterological Association

American College of Gastroenterology

National Institute of Diabetes and Digestive and Kidney Diseases

International Foundation for Functional Gastrointestinal Disorders

Rome Foundation

American Neurogastroenterology and Motility Society

What is Low Back Pain?

If you have low back pain, you are not alone. Close to 80% of all adults experience low back pain at some point in their lifetime. It is the most common cause of job-related disability and a leading contributor to missed work. Studies have reported that more than a quarter of adults reported experiencing low back pain during the past 3 months. Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache to a sudden, sharp sensation that leaves the person debilitated. Pain can begin quickly as a result of an injury or it can develop over time from a variety of age-related changes to the spine. Sedentary lifestyles can also set the stage for low back pain. Most low back pain is acute, or short term, and lasts a few days to a few weeks. It usually resolves on its own with self-care and there is no continued loss of function. The majority of acute low back pain is mechanical in nature, meaning that there is a disturbance in the way the components of the back (the spine, muscles, intervertebral discs, and nerves) fit together and move.

Subacute low back pain is defined as pain that lasts between 4 and 12 weeks.

Chronic low back pain (CLBP) is defined as pain that persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20% of people with acute low back pain develop chronic low back pain with persistent symptoms at one year. In some cases, treatments can successfully relieve chronic low back pain, but in other cases pain persists despite medical and surgical treatment. The scale of the burden from low back pain has grown worse in recent years.

Symptoms

• Pain in the lower back or buttocks area that can be described as aching, shooting, or stabbing

• Limited flexibility and range of motion

• Inability to stand up straight

• Possible pain in the lower extremities

• Possible neurologic problems in the lower extremities including: painful tingling, numbness, or weakness

• Chronic Overlapping Pain Conditions (COPCs): If you have CLBP, you may also have one or more of the other COPCs. It is thought that these conditions may share common underlying causes. The COPCs are listed below and detailed descriptions of each one can be found by following the link.

  • Fibromyalgia (FM)
  • Irritable Bowel Syndrome (IBS)
  • Temporomandibular Joint Disorder (TMD)
  • Migraine Headache (MI)
  • Tension Type Headache (TTH)
  • Urologic Chronic Pelvic Pain Syndrome (e.g., Interstitial Cystitis) (UCPPS)
  • Endometriosis (ENDO)
  • Vulvodynia (VVD)
  • Chronic Fatigue Syndrome (CFS) (also sometimes called Myalgic Encephalomyelitis)

What Causes CLBP?

The vast majority of low back pain is mechanical in nature. In many cases, low back pain is associated with spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older. Some examples of mechanical causes of low back pain include:

• Sprains and strains account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something that is too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
• Intervertebral disc degeneration is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
• Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain and possibly lower extremity pain.
• Radiculopathy is a condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
• Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place causing misalignment and can pinch the nerves exiting the spinal column.
• A traumatic injury, such as from motor vehicle accidents or playing sports, can injure tendons, ligaments or muscle resulting in low back pain.
• Spinal stenosis is a narrowing of the central spinal column that can put pressure on the spinal cord and nerves and result in pain or numbness with walking and over time leads to leg weakness and sensory loss.
• Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.

Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention. Serious underlying conditions include:

• Infections are not a common cause of back pain. However, infections can cause pain when they involve the vertebrae (osteomyelitis) or the intervertebral discs (discitis).
• Tumors are a relatively rare cause of back pain. Occasionally, tumors originate from low back, but more often they appear a result of cancer that has spread from elsewhere in the body.
• Cauda equina syndrome is a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control. Permanent neurological damage may result if this syndrome is untreated.
• Abdominal aortic aneurysms occur when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is becoming larger and that the risk of rupture should be assessed.
• Kidney stones can cause sharp pain in the lower back, usually on one side.

Other underlying conditions that predispose people to low back pain include:

• Inflammatory diseases of the joints such as arthritis, including osteoarthritis and rheumatoid arthritis.
• Osteoporosis is a bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae.
• Fibromyalgia, a chronic pain syndrome involving widespread muscle pain and fatigue.

Risk Factors for CLBP

Beyond underlying diseases listed above, other risk factors may increase the risk for chronic low back pain, including:

• Age
• Fitness level
• Pregnancy
• Weight gain
• Genetics
• Occupational risk factors
• Mental health factors

Diagnosis of CLBP

A complete medical history and physical exam can usually identify any serious conditions that may be causing the pain. During the exam, a healthcare provider will ask about the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. Along with a thorough back examination, neurologic tests are conducted to determine the cause of pain and appropriate treatment. The cause of chronic lower back pain is often difficult to determine even after a thorough examination. Imaging and blood tests are not warranted in most cases. Under certain circumstances, however, imaging may be ordered to rule out specific causes of pain, including tumors and spinal stenosis.

Who treats CLBP?

CLBP is often treated by family doctors, internal medicine doctors, physical medicine & rehabilitation (PM&R) doctors, pain management doctors, neurologists, and orthopedic or neurosurgical surgeons. While these doctors often coordinate the care, optimal care often requires a team approach when low back pain becomes chronic. This team might include the following specialists:

• Pain Medicine specialists – Fellowship-trained practitioners (often with original training in anesthesiology, PM&R, or neurology) who are familiar with the anatomy of the spine and mechanisms of pain processing who can provide non-pharmacologic, pharmacologic, and interventional options for treatment of CLBP
• Spine surgeons – physicians specializing in the surgical treatment of spine conditions
• Nurse educators – specialists who can educate about the condition and help develop or refine a personalized treatment plan
• Physical therapists – specialists trained in mobilizing muscles, bones, and joints through exercise, hands-on care, and patient education
• Psychologists or social workers – specialists who can help initiate and maintain self-care approaches to pain management and who can help address social challenges associated with dealing with chronic pain
• Dietitians - specialists who teach about optimal diets and maintaining a healthy weight
• Acupuncturists - specialists who influence pain perception, promote healing, and improve functional status by stimulating specific points on the body often by inserting needles into the skin

Most importantly however YOU need to be a member of the team. Much of CLBP management can be done at home, by you, and does not require seeing a doctor. The parts that you can do may require some changes in how you live your life. You will need to stick to this plan for better pain control.

It is likely that you and your doctor will need to team up to identify the best combination of professional and self-care approaches that works for you. This plan will need to be reviewed and potentially revised over time as your needs shift.

Treatment of CLBP

Treatment for low back pain generally depends on whether the pain is acute or chronic. In general, surgery is recommended only if there is evidence of worsening nerve damage and when diagnostic tests indicate structural changes for which corrective surgical procedures have been developed.

Conventionally used treatments:

• Hot or cold packs
• Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain.
• Strengthening exercises: may be an effective way to speed recovery from chronic or subacute low back pain. Healthcare providers can provide a list of beneficial exercises that will help improve coordination and develop proper posture and muscle balance. Evidence supports short- and long-term benefits of yoga to ease chronic low back pain.
• Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combinations with other interventions.
• Acupuncture is moderately effective for chronic low back pain. It involves the insertion of thin needles into precise points throughout the body. Some practitioners believe this process helps clear away blockages in the body's life force known as Qi.
• Biofeedback involves the attachment of electrodes to the skin and the use of an electromyography machine that allows people to become aware of and self-regulate their breathing, muscle tension, heart rate, and skin temperature.
• Nerve block therapies aim to relieve chronic pain by blocking nerve conduction from specific areas of the body. Nerve block approaches range from injections of local anesthetics, botulinum toxin, or steroids into affected soft tissues or joints to more complex nerve root blocks and spinal cord stimulation. The success of a nerve block approach depends on the ability of a practitioner to locate and inject precisely the correct nerve. Chronic use of steroid injections may lead to increased functional impairment.
• Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device with special electrode pads placed on the skin over the painful area that generate electrical impulses designed to block incoming pain signals from the peripheral nerves.

A wide range of medications are used to treat chronic low back pain. Some are available over the counter (OTC); others require a physician's prescription. Certain drugs, even those available OTC, may be unsafe during pregnancy, may interact with other medications, cause side effects, or lead to serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. Consultation with a healthcare provider is advised before use. The following are the main types of medications used for chronic low back pain:

• Analgesic medications are those specifically designed to relieve pain. They include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), as well as prescription opioids. Opioids should only be used for a short period of time and under a physician's supervision as they have significant side effects including constipation, cognitive dysfunction, tolerance, dependence, addiction and the possibility for overdose and death due to significant respiratory depression.
• Anticonvulsants such as gabapentin and pregabalin are drugs primarily used to treat seizures. They may be useful in treating people with radiculopathy and radicular pain.
• Antidepressants such as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain.
• Topical therapies such as creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain.

Surgery

When other therapies fail, surgery may be considered an option to relieve pain caused by serious musculoskeletal injuries or nerve compression. It may be months following surgery before the patient is fully healed and recovered, and he or she may suffer permanent loss of flexibility. Surgical procedures are not always successful, and there is little evidence to show which surgical procedures work best for their particular indications. Patients considering surgical approaches should be fully informed of all related risks.

Self-Care

There are many changes one can make to improve the symptoms of CLBP.

• Stretch before exercise or other strenuous physical activity.
• Have good posture when standing or sitting.
• Sit in a chair with good lumbar support and proper position and height for the tasks (such as work).
• Wear comfortable, low-heeled, and supportive shoes.
• Don't try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
• Have proper nutrition and a healthy diet to reduce and prevent excessive weight gain.
• Quit smoking. Smoking decreases blood flow to the spine, which can facilitate spinal disc degeneration.
• Pacing activities, improving sleep, changing how you think about pain, acupressure, and meditation can all help with pain management. Consult the self-management section of PainGuide to identify lifestyle changes that you and your doctor think would be beneficial.

ADDITIONAL RESOURCES

American Society of Anesthesiology (ASA)

American Society of Regional Anesthesia and Pain Medicine (ASRA)

National Institute of Arthritis, Musculoskeletal, and Skin Diseases (NIAMS – NIH)

National Institute of Neurologic Disorders and Stroke (NINDS – NIH)

National Institute of Complimentary and Integrative Health (NCCIH – NIH)

Chronic Pain Research Alliance

Chronic Pain and Fatigue Research Center (CPFRC)