Chronic Back Pain Treatment: Why Integrated Care Is Needed

Many patients with chronic back pain (CBP) undergo treatment with analgesics, physical therapy, acupuncture, and other conservative approaches without achieving lasting relief. According to Sabine Alfter, MD, chief physician at the Day Clinic for Conservative Orthopedics at Gesundheitscampus Loreley GmbH in Oberwesel, Germany, the challenge often lies not in the effectiveness of individual therapies but in their delivery. Speaking with Medscape’s German edition, Alfter explained that routine outpatient care often relies on individual treatment rather than an integrated approach.The problem isn’t that the individual treatments are ineffective,” Alfter said. “The problem is that, in routine outpatient care, they are often used in isolation.”Individualized CareCBP requires a personalized multimodal approach that combines a range of therapeutic strategies. This approach is also recommended in the National Care Guideline on “Nonspecific Low Back Pain,” which is on the basis of biopsychosocial model of pain. The guideline considers physical, psychological, and social factors and recommends combining multiple therapeutic interventions.There is no one-size-fits-all approach. “It’s important to work with the patient to develop a personalized treatment plan,” Alfter said. The most appropriate interventions depend on the patient’s clinical presentation, as well as their needs and preferences.Therefore, a broad range of treatment options is essential. For example, some patients have liver disease or kidney dysfunction, which limits the use of certain analgesics. Other patients are reluctant to receive injections. However, others need effective pain relief before they can become active again and participate in physical therapy. “You need a wide range of treatment options to decide, together with the patient, which measures are right for them,” Alfter said.Care begins with a thorough medical history and physical examination. “First, you have to take the time to conduct a thorough medical history and physical examination and address the patient’s specific clinical picture. Only then can you decide what will actually help the patient.” However, routine outpatient practice often leaves little time for such a comprehensive evaluation, as Alfter noted.Access to conservative treatment remains a challenge. “When a family doctor or orthopedist prescribes physical therapy, patients often have no way at all to fill the prescription promptly, or they’re only given one appointment in a week,” Alfter said.For CBP, one session in a week is usually insufficient. In contrast, patients enrolled in semi-inpatient multimodal pain programs receive physical therapy every day. “That’s, of course, completely different from someone being treated once a week,” she said.Insurance requirements also create another obstacle. In many cases, health insurers require patients to exhaust individual conservative treatments before approving multimodal pain therapies.“We actually know that multimodal treatment is necessary. Nevertheless, all the individual measures must be tried first before the health insurance company says, ‘Now we’ll pay for the multimodal therapy,’” Alfter said.“We actually know that multimodal treatment is necessary. Nevertheless, all the individual measures must be tried first before the health insurance company says, ‘Now we’ll pay for the multimodal therapy,’” Alfter said.Primary care physicians and orthopedists can make an important difference by educating patients. “Patients need to understand what condition they have and why it causes pain,” Alfter said. This means not only explaining the diagnosis but also helping patients understand the mechanisms behind chronic pain. Many patients feel powerless or believe that every flare-up signals additional damage.Psychoeducation is, therefore, a key part of treatment. Patients need to understand that CBP is often linked to pain memory and that it can influence their own symptoms. “The key term here is self-efficacy,” Alfter said. The goal is to help patients put pain flare-ups into perspective rather than respond with fear.Effective care also means providing patients with practical strategies for managing recurrent pain. These may include an individualized home exercise program with regular follow-up or relaxation techniques such as progressive muscle relaxation. “When patients realize that they themselves can influence their pain, they no longer feel so at the mercy of it,” Alfter said.Taking patients seriously and reassuring them that their symptoms are real and that there are effective ways to manage them can be an important first step. “You have to take patients seriously,” Alfter said. “And reassure them: Yes, the pain is there, but there are ways to get through it.”

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