Chronic Low Back Pain-Affecting the adults & the elderly - Q & A session with an expert.
(Focus - Singapore)
We present our discussion on chronic low back pain with Dr. Rajeesh George, a renowned orthopedic spine surgeon from Singapore.
Low back pain is one of the most common problems affecting adults and the elderly. The severity of the pain is often underestimated. As the pain goes away, people avoid visiting physicians. Consequently, it will transition to chronic pain. Dr. George suggests that observing the red flag signs and consulting a doctor during the initial days of pain is the correct way to deal with this condition.
Dr. Rajeesh George is an orthopedic spine surgeon currently serving in Ng Teng Fong General Hospital, Singapore.
Patients who are obese and have low back pain have a higher chance of it becoming chronic. People who smoke have a bigger chance of acute back pain being converted to a chronic one. Back pain associated with leg pain, like radiculopathy, is also more likely to become chronic.
At some point in life, everyone experiences low back pain, but they seldom take it seriously. When should someone experiencing LBP be worried and consult a doctor?
Dr. Rajeesh: Everyone experiences back pain, and it is quite common. In Singapore, 80% of the population experience back pain at some point in their life but do not visit the doctor because the pain is usually mechanical, and it usually resolves. Some of the back pain may not resolve and persist and you should look for certain warning symptoms. In doctor's language, we call it red flag signs.
When we call red flag signs, you need to be more concerned.
For example, if you have a fever associated with back pain, the indicator might be an infection like tuberculosis or various other bacterial infections. The other red flag to look for is when you have numbness or weakness in your arms or legs. it could be indicative a disc prolapse. If you are experiencing pain radiating down the arms or legs, you must visit a doctor to further investigate.
The other red flag is unexplained weight loss; for example, you have no appetite, cannot sleep, and have rest pain, which means pain even when you lie down. It can also indicate something like cancer or infection. In those cases, the patient must go to a doctor and get it checked also
We understand that once Lower Back Pain becomes chronic, it is problematic to manage. How do you manage acute pain patients to prevent transitioning to chronic LBP? 
Dr. Rajeesh: Previously, low back pain used to settle with some medications. There were no fixed workflows to manage this kind of back pain; everyone used to do their own thing. Recent evidence says there is a problem with treating acute low back pain. Specific indicators can provide evidence that certain treatment strategy itself can result in chronic low back pain. One of those studies, published in JAMA in 2020, found evidence that clinical factors associated with acute back pain becoming chronic.
Number one is patients with obesity. Patients who are obese and have low back pain have a higher chance of it becoming chronic. People who smoke have a bigger chance of acute back pain being converted to a chronic one. Back pain associated with leg pain, like radiculopathy, is also more likely to become chronic.
Another interesting aspect is the impact of insurance coverage. For people with insurance coverage, there are high chances of their acute pain transitioning to chronic pain. These are the general factors, but the other things that primary care physicians, tertiary care doctors, and even specialists should take care is about the guideline discordant care practices. Concordant means what is established; specific guidelines have been given. Discordant or Non-concordant refers to practices that are not conforming to those guidelines. There are mainly three non-concordant practices:
1. Not following conservative management practices of routine back pain
What was given by a doctor in the first prescription is critical. For example, if you are seeing a GP or a primary care physician and if they prescribe benzodiazepines, corticosteroids, steroids, or even opioids, in the first instance (let us say that they do not follow the WHO guidelines) instead of starting with something like paracetamol or NSAIDs, or ibuprofen, or diclofenac or a COX 2 inhibitor, then the physician might not helping those patients, he might help them in the short run, but in the long term, it can convert their pain to chronic back pain.
2. Not avoiding early imaging tests in cases without red flags
You do not need an X-ray in the first phase, or at least in the first 4-6 weeks if you do not have any red flag signs. Interestingly, they have found that ordering an X-ray or even a CT or MRI for acute back pain can convert to chronic back pain.
3. Patient referrals to other specialists upfront
The third one that I want to mention of this non-concordant practice is referring to medical subspecialty. If a GP refer acute back pain patients to an orthopedic surgeon, neurologist or neurosurgeon, or a pain specialist, it can contribute to that patient's becoming chronic. You can refer to a specialist if the conservative treatment fails or when there are red flags signs.
So, you need to take a step back, look at our practice, and think, are we helping or contributing to the problem?!
You mentioned that around 80% of people in Singapore experience back pain. So, how common is chronic low back pain in Singapore?
Dr. Rajeesh: If you look at Southeast Asian countries, there was a recent epidemiological study done in Indonesia, Malaysia, Philippines, and Vietnam, on work-related low back pain disability adjusted life years. After considering socio-economic situations even in other countries, it was found to be higher than in other parts of the world. So, you might be surprised. One reason is that even if you do a racial analysis, Caucasians have a better tolerance for back pain, whereas when you come to Asia, we have a very low tolerance. Hence, it is becoming a chronic problem. Singapore is no different. It contains 80% of the population having acute back pain, mainly adults between 30 to 50 years old. And 75% of them have presented with recurring back pain. We do not have a specific number, but 75% of that 80% is quite a significant number.
Are there any challenges related to treating and managing chronic low back pain in Singapore?
Dr. Rajeesh: Singapore has a specific number of challenges. You may have heard that Singapore has quite a healthy population; they exercise, and obesity was not a huge problem. But now obesity is becoming a challenge, primarily because of the pandemic, people have been working from home. A study done in 2019-2020 mentioned that the obesity level now is almost the same as the obesity level in 2010. I think the pattern has pushed us back a decade regarding obesity. And obesity is also a contributor to chronic low back pain.
The main challenge that we face is a non-concordant practice. Many low back pain patients get referred to specialists, especially by general practitioners. When it comes to a specialist, they do MRI or CT, and even the patient requests a detailed investigation. So, a lot of people get MRIs done. Research is already showing that you are contributing to chronic low back pain when referring low back pain patients to a specialist or getting an investigation done.
Opioids are not a big problem in Singapore because they are very well controlled.
When you look at chronic pain, we know that relief of chronic pain has a profound effect on a person's quality of life, and a lot is associated with substantial health care costs and productivity. So, all these studies are quite early, especially with fasinumab and NGF inhibitors. NGF inhibitors have the potential to provide pain relief, and this mechanism is quite distinct from the commonly used NSAIDs or even opioids, thus avoiding the side effects of NSAIDs, like cardiovascular side effects, GI side effects, drowsiness, and depression with opioids.
You mentioned no challenge lies with opioid pain treatment in Singapore. What about opioid drug dependence?
Dr. Rajeesh: It is a problem that contributes to chronicity of back pain, but not a huge problem. We do have our small share though.
In your opinion, what can be done to prevent/overcome drug dependence in patients with CLBP?
Dr. Rajeesh: It is not a huge problem because most general practitioners or specialists do not prescribe opioids in the first instance usually. So, they have a protocol in place, but we have patients who can become dependent on opioids once it is prescribed. The key is to identify those patients who might become dependent. We need to look for specific behaviors:
a. Like borrowing and stealing drugs and people who repeatedly seek medications in the clinic.
b. The other one is non-compliance. You tell them to do physiotherapy or other therapy, but they
do not comply. They show up only for some medication appointments and ask for medications.
In Singapore, heroin, cocaine, and methamphetamine use is almost nil because here, the trafficking or possession of drugs over a certain amount invites capital punishment and they are strict on it. So, we do not have that much of a problem with illicit drugs.
c. Deterioration in function at work and family.
these are the people we need to look out for who might be having problems with the drug dependence.
Opioids are currently one of the leading causes of treatment for chronic pain. So, we have our set of standards of how we treat; for example, when you prescribe opioids, especially if you are looking at long-term treatment, it should not be prescribed as a first-line treatment.
If you are starting a strong opioid, then, especially when patients have multiple presentations, you do it in a multidisciplinary pain management team, rather than one person just ordering it with the help of a pain specialist. We must look for these risk factors, including assessing whether a patient can become drug dependent. There are some patients out there who are dependent, but not all of them. We need to follow specific parameters and review these kinds of prescriptions every three months to see that they do not have dependence.
Singapore is a very small country, and we have well-connected systems; all the medical, except private most of the public hospitals can view the electronic medical reports. So, we can prescribe and see what drug this patient was prescribed and avoid duplicating prescriptions.
A recent study showed fasinumab as a possible new treatment option for patients with CLBP with inadequate pain control or who are intolerant to or have a contraindication for existing therapies.  What are your thoughts on the use of NGF inhibitors for CLBP patients?
Dr. Rajeesh: When you look at chronic pain, we know that relief of chronic pain has a profound effect on a person's quality of life, and a lot is associated with substantial health care costs and productivity. So, all these studies are quite early, especially with fasinumab and NGF inhibitors. NGF inhibitors have the potential to provide pain relief, and this mechanism is quite distinct from the commonly used NSAIDs or even opioids, thus avoiding the side effects of NSAIDs, like cardiovascular side effects, GI side effects, drowsiness, and depression with opioids.
The treatment with NGF inhibitors has been associated with pain relief but on a higher dose. So, there are different dosages they have tried, but NGF inhibitors with higher doses are found to have some pain relief, especially with chronic back pain. Still, it comes with a caveat, i.e., there is a dose-dependent risk of joint damage especially the peripheral joints. As far as Iam aware, these studies have not been approved in Singapore, so we don't use this now because it's still in the preliminary stages. But there are promising data. Other developments, like denosumab and different monoclonal antibodies also help to reduce chronic low back pain.
I have heard about the spinal cord stimulation for CLBP. So, could you please comment on its benefit and usage in Singapore?
Dr. Rajeesh: I do not personally do it. Still, it's early data about spinal cord stimulation, and we are also looking out for research. They have come out with chemonucleolysis using chymopapain as an intradiscal injection. We do give discography and discal therapies. New evidence is coming out on collagenase and matrix metalloproteinases injected into the disk. There are also intravenous glial cell-derived neurotrophic growth factors, which are being trialed. There have been trials on platelet-rich plasma, stem cells, or gene therapy to alter how low back pain is perceived. I do not have my personal experience with spinal cord stimulators. It is early to say about the benefits of it, but we do refer to a pain specialist for these kinds of treatments.
The COVID-19 pandemic and the extended lockdown are associated with numerous changes in behavior and lifestyles, especially with most working from home.   Do you see an increase in CLBP cases during the COVID-19 pandemic?
Dr. Rajeesh: I am sure you would have experienced back pain working from home. This pandemic is affecting the whole world, so there has been an increase in back pain incidence. And we do see patients who are coming back with increasing back pain. When you look at chronic back pain, it has got two components, one is physical, and one is psychological. So, your stress also can exacerbate your chronic back pain. My advice is lifestyle modification; you need to adapt to changing conditions.
So, my first advice is if you are working and sitting down, don't slouch. It takes away the whole biomechanics of the spine, and slouching reduces the space for your lungs. If you sit slouched, you can see that the room for your lungs to breathe in is reduced; also, it gives you very little space for your intestine, and you end up being fatigued very early. Now, how do you prevent it? There are five easy steps that we tell:
Always be conscious of your posture. Just keep a reminder on your phone or any smart device for a 30-minute break. You take a coffee break, toilet break, no matter what break it is, but take a break.
You can stand up, stretch, and then sit down.
When you sit, you should have your head on top of your shoulder, which means your ears should be in line with your shoulder.
The fourth thing is to sit back in your chair and have good support for your mid and lower back.
Bend your knees at the right angle, keep them at the same height or a bit lower than your hips, and place your foot flat on the floor. That is how a good sitting posture is.
And then you can do some desk exercises. It affects your neck as well. For example, bring the screen to the same level. One of the common things we find is what we call tech neck, which is technology-associated neck problems.
So, one is to take phone breaks from your smartphone. And when you use a smartphone, don't bend your neck down; bring your smartphone up to your eye level. Now, you can't keep that for a long time. So, if you use a smartphone, sit down someplace, and then keep it on the same eye level.
Apart from all these, my other advice is to do core-building exercises. Too many pounds around your belly adds stress to your back. So, it would help if you built a solid muscle to support your spine. Core muscles are your tummy, back, buttock, and thigh muscles. So, core exercises include doing your planks, and you can start with stretching exercises.
There are a lot of videos out there you can use as guidance. These are the things that you need to do. Do not be a slouch; take breaks, have a good posture when you sit, be aware of your posture, and do your core exercises to build your back.
Thank you for the tips and suggestions, doctor. To conclude, what is your key takeaway message to CLBP patients?
Dr. Rajeesh: You will never end up talking about it. I will say prevention is the key. People say, "Oh, I have already got it. What do I do? I cannot prevent it anymore. It has already happened to me" then I would say that prevention of aggravation of their back pain is equally important.
So, my first advice is activity modification and physical therapy. There is umpteen number of research coming out. We do not have anything concrete yet, but what is being proven is activity modification and physical therapy. Under that, I would say exercise regularly and use ergonomically designed furniture at work or home. Switch sitting positions and periodically walk around the office or gently stretch your muscles to relieve tension.
Do not try to lift objects that are too heavy or lift from your knees; pull the stomach muscles and then keep the head down and align with a straight back. It means lifting things correctly, sitting down properly, and having a good posture. Even in the office, please wear comfortable, low-heeled shoes, if it conforms to the industry standard. A high heel is not suitable for your back. Even I have switched to sneakers at work, which worked wonders for me. Sleeping on one side or with knees drawn up towards your chest helps; putting a pillow under your knee helps.
The second most important for CLBP is reducing dependency on drugs and painkillers. That will not get you anywhere; it will cause you problems, but sometimes you need it, so take advice from your doctor.
And my third point is to do your daily core exercises, the one I have already mentioned. Number four is diet, maintaining a healthy weight, and eating a nutritious diet. Losing weight helps. Imagine you're sitting down; all the upper body weight is falling on the last segments in the lumbar spine, L5-S1 and L4-L5. So, by losing weight, you’ve already taken a great leap forward. And to people who smoke, quit smoking! Smoking kills your back too. Smoking reduces blood flow to the lower spine, accelerates disc degeneration, osteoporosis, impedes healing, and a lot of other health issues.
Psychological factors play a significant role in chronic back pain. Chronic back pain is draining both physically and emotionally. To manage the frustration in our daily work, irritability, and depression, people are turning to meditation, yoga, tai chi etc. So, know your alternative treatments. In Singapore, we have acupuncture, biofeedback therapy, and laser therapy. You can talk to your doctor about what are the other alternative treatments. Alternative treatments are coming up and are also available for the latest research on chronic back pain.
Thank you so much. It was an insightful discussion, doctor; I hope our readers will find it helpful too.