Management of patients with musculoskeletal back pain and comorbid anxiety

Musculoskeletal back pain (MSBP) is one of the  most  common  reasons  for seeking  medical  care. A socioeconomic burden  of MSBP is significant, as it leads  to reduced  working capacity of the adult  population.  It is important to consider  that  the MSBP chronicity develops  under the impact of “yellow flags”, i. e. factors that contribute to the central  pain sensitization (pathophysiologically) and pain chronicification  (clinically). The most common factor of pain chronicity is anxiety that underlies  the development  of pain  catastrophization, maladaptive escape  (“pain”)  behaviour,  and  anxiety  disorders.  Anxiety symptoms  can  be expressed not only in the emotional,  but also in the somatic, cognitive and behavioural sphere. Timely detection and management  of anxiety  in patients with  chronic MSBP improves  the  effectiveness of pain  syndrome  treatment. The chronic MSBP treatment requires  a multidisciplinary  approach,  which comprises  kinesiotherapy, cognitive  behavioural therapy, and optimal pharmacotherapy. Evidence-based drugs include  non-steroidal anti-inflammatory drugs, such as dexketoprofen, which can be prescribed  for the treatment of chronic MSBP with a short course and at an average  therapeutic dose. The efficacy and safety of dexketoprofen in the  treatment of pain syndromes, data  from clinical studies  and a systematic  review are discussed. The authors  present their own experience in managing  a patient  with chronic nonspecific MSBP and anxiety. The “yellow flags” that led to the MSBP chronicity in the patient  are provided. The effective  multidisciplinary  approach  to the treatment of a patient with chronic MSBP and anxiety disorder is demonstrated.

1. Karateev A.E. Diseases of the musculoskeletal system in the practice of 2102 doctors of different specialties: the structure of pathology and the opinion of specialists on the effectiveness of NSAIDs (preliminary data of the epidemiological study CORONA-2). Consilium Мedicum. 2013;(9):95–10. (In Russ.) Available at: https://consilium.orscience.ru/2075-1753/article/view/93969.

2. Yаhno N.N., Kukushkin M.L. Сhronic pain: medico-biologic and sotsio-economic aspects. Annals of Russian Academy of Medical Sciences. 2012;(9):54–58. (In Russ.) Available at: https://vestnikramn.spr-journal.ru/jour/article/view/268/ru_RU.

3. Golubev V.L. Pain is an interdisciplinary problem. RMJ. 2008;(3). (In Russ.) Available at: https://www.rmj.ru/articles/bolevoy_sindrom/Boly_meghdisciplinarnaya_problema/?ysclid=lajcy6tkpc167799358.

4. Erdes S.F., Dubinina T.V., Galushko E.A. Frequency and character of low back pain in Moscow outpatients. Report I. Rheumatology Science and Practice. 2007;(2):14–18. (In Russ.)

5. Litwic A., Edwards M., Dennison E., Cooper C. Epidemiology and burden of osteoarthritis. Br Med Bull. 2013;105:185–199. https://doi.org/10.1093/bmb/lds038.

6. Millar N.L., Murrell G.A., McInnes I.B. Alarmins in tendinopathy: unravelling new mechanisms in a common disease. Rheumatology (Oxford). 2013;52(5):769–779. https://doi.org/10.1093/rheumatology/kes409.

7. Parfenov V.A., Yakhno N.N., Davydov O.S., Kukushkin M.L., Churyukanov M.V., Golovacheva V.A. et al. Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics. 2019;(2S):7–16. (In Russ.) https://doi.org/10.14412/2074-2711-2019-2S-7-16.

8. Nieminen L.K., Pyysalo L.M., Kankaanpää M.J. Prognostic factors for pain chronicity in low back pain: a systematic review. Pain Rep. 2021;6(1):e919. https://doi.org/10.1097/PR9.0000000000000919.

9. Oliveira C.B., Maher C.G., Pinto R.Z., Traeger A.C., Lin C.C., Chenot J.F. et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791–2803. https://doi.org/10.1007/s00586-018-5673-2.

10. Sagheer M.A., Khan M.F., Sharif S. Association between chronic low back pain, anxiety and depression in patients at a tertiary care centre. J Pak Med Assoc. 2013;63(6):688–690. Available at: https://pubmed.ncbi.nlm.nih.gov/23901665.

11. Polatin P.B., Kinney R.K., Gatchel R.J., Lillo E., Mayer T.G. Psychiatric illness and chronic low-back pain. The mind and the spine – which goes first? Spine (Phila Pa 1976). 1993;18(1):66–71. https://doi.org/10.1097/00007632-199301000-00011.

12. Ikemoto T., Miki K., Matsubara T., Wakao N. Psychological Treatment Strategy for Chronic Low Back Pain. Spine Surg Relat Res. 2018;3(3):199–206. https://doi.org/10.22603/ssrr.2018-0050.

13. Ströhle A., Gensichen J., Domschke K. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018;155(37):611–620. https://doi.org/10.3238/arztebl.2018.0611.

14. Giacobbe P., Flint A. Diagnosis and Management of Anxiety Disorders. Continuum (Minneap Minn). 2018;24(3, BEHAVIORAL NEUROLOGY AND PSYCHIATRY):893–919. https://doi.org/10.1212/CON.0000000000000607.

15. Janzen K., Peters-Watral B. Treating co-occurring chronic low back pain & generalized anxiety disorder. Nurse Pract. 2016;41(1):12–18. https://doi.org/10.1097/01.NPR.0000475373.08924.04.

16. Golovacheva V.A., Golovacheva A.A., Fateeva T.G. Psychological methods in the treatment of chronic nonspecific low back pain. Neurology, Neuropsychiatry, Psychosomatics. 2019;(2S):25–32. (In Russ.) https://doi.org/10.14412/2074-2711-2019-2S-25-32.

17. Yamada A.S., Simon D., Antunes F.T.T., Say K.G., Souza A.H.D. Psychosocial factors associated with disability in patients with non-specific chronic low back pain: A cross-sectional study. Rehabilitacion (Madr). 2022:S0048-7120(22)00077-9. https://doi.org/10.1016/j.rh.2022.06.002.

18. Parfenov V.A., Yakhno N.N., Kukushkin M.L., Churyukanov M.V., Davydov O.S., Golovacheva V.A. et al. Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics. 2018;(2):4–11. (In Russ.) https://doi.org/10.14412/2074-2711-2018-2-4-11.

19. Kuritzky L., Samraj G.P. Nonsteroidal anti-inflammatory drugs in the treatment of low back pain. J Pain Res. 2012;5:579–590. https://doi.org/10.2147/JPR.S6775.

20. Soloveva E., Karneev A., Fedin A. Vrach. 2007;(3):67–71. (In Russ.) Available at: https://www.elibrary.ru/item.asp?id=12974322.

21. Moore R.A., Barden J. Systematic review of dexketoprofen in acute and chronic pain. BMC Clin Pharmacol. 2008;8:11. https://doi.org/10.1186/1472-6904-8-11.

22. Rainsford K.D. Current status of the therapeutic uses and actions of the preferential cyclo-oxygenase-2 NSAID, nimesulide. Inflammopharmacology. 2006;14(3–4):120–137. https://doi.org/10.1007/s10787-006-1505-9.

23. DePalma M.G. Red flags of low back pain. JAAPA. 2020;33(8):8–11. https://doi.org/10.1097/01.JAA.0000684112.91641.4c.

24. Wippert P.M., Puschmann A.K., Drießlein D., Arampatzis A., Banzer W., Beck H. et al. Development of a risk stratification and prevention index for stratified care in chronic low back pain. Focus: yellow flags (MiSpEx network). Pain Rep. 2017;2(6):e623. https://doi.org/10.1097/PR9.0000000000000623.

25. Glattacker M., Heyduck K., Jakob T. Yellow flags as predictors of rehabilitation outcome in chronic low back pain. Rehabil Psychol. 2018;63(3):408–417. https://doi.org/10.1037/rep0000200.

26. Mescouto K., Olson R.E., Hodges P.W., Setchell J. A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disabil Rehabil. 2022;44(13):3270–3284. https://doi.org/10.1080/09638288.2020.1851783.

27. Corp N., Mansell G., Stynes S., Wynne-Jones G., Morsø L., Hill J.C., van der Windt D.A. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain. 2021;25(2):275–295. https://doi.org/10.1002/ejp.1679.

28. Owen P.J., Miller C.T., Mundell N.L., Verswijveren S.J.J.M., Tagliaferri S.D., Brisby H. et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020;54(21):1279–1287. https://doi.org/10.1136/bjsports-2019-100886.

29. Hayden J.A., Ellis J., Ogilvie R., Malmivaara A., van Tulder M.W. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. https://doi.org/10.1002/14651858.CD009790.pub2.

30. Hajihasani A., Rouhani M., Salavati M., Hedayati R., Kahlaee A.H. The Influence of Cognitive Behavioral Therapy on Pain, Quality of Life, and Depression in Patients Receiving Physical Therapy for Chronic Low Back Pain: A Systematic Review. PM R. 2019;11(2):167–176. https://doi. org/10.1016/j.pmrj.2018.09.029.

31. Pardos-Gascón E.M., Narambuena L., Leal-Costa C., van-der Hofstadt-Román C.J. Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review. Int J Clin Health Psychol. 2021;21(1):100197. https://doi.org/10.1016/j.ijchp.2020.08.001.

32. Knezevic N.N., Candido K.D., Vlaeyen J.W.S., Van Zundert J., Cohen S.P. Low back pain. Lancet. 2021;398(10294):78–92. https://doi.org/10.1016/S0140-6736(21)00733-9.

33. Koes B.W., Backes D., Bindels P.J.E. Pharmacotherapy for chronic non-specific low back pain: current and future options. Expert Opin Pharmacother. 2018;19(6):537–545. https://doi.org/10.1080/14656566.2018.1454430.

34. Onda A., Kimura M. Reduction in anxiety during treatment with exercise and duloxetine is related to improvement of low back pain-related disability in patients with non-specific chronic low back pain. Fukushima J Med Sci. 2020;66(3):148–155. https://doi.org/10.5387/fms.2020-22.

35. Ferreira G.E., McLachlan A.J., Lin C.C., Zadro J.R., Abdel-Shaheed C., O’Keeffe M., Maher C.G. Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ. 2021;372:m4825. https://doi.org/10.1136/bmj.m4825.

36. Karateev A.E., Lila A.M., Dydykina I.S., Kamchatnov P.R., Mazurenko S.O., Naprienko M.V. et al. Personalization of the use of non-steroidal anti-inflammatory drugs for musculoskeletal diseases. Resolution on the results of the Meeting of Experts of December 13, 2017. Meditsinskiy Sovet. 2018;(18):76–84. (In Russ.) https://doi.org/10.21518/2079-701X-2018-18-76-84.

37. Shavlovskaya O.A., Romanov I.D. The use of chondroitin sulfate (Mucosat) for the treatment of chronic back pain and osteoarthritis. Meditsinskiy Sovet. 2020;(2):122–130. (In Russ.) https://doi.org/10.21518/2079-701X-2020-2-122-130.

38. Golovacheva V.A., Golovacheva A.A. B vitamins and nonsteroidal anti-inflammatory drugs: the efficacy of the combination for nonspecific back pain. Neurology, Neuropsychiatry, Psychosomatics. 2020;(5):117–122. (In Russ.) https://doi.org/10.14412/2074-2711-2020-5-117-122.

39. Golovacheva V.A., Golovacheva A.A., Zinovyeva O.E., Golubev V.L. Tolperisone in the treatment of acute and chronic nonspecific back pain. Neurology, Neuropsychiatry, Psychosomatics. 2020;(4):137–142. (In Russ.) https://doi.org/10.14412/2074-2711-2020-4-137-142.

40. Gorenkov R.V., Dadasheva M.N., Zolotovskaya I.A., Kruglov V.A. Comparative efficacy and tolerance of centrally acting muscle relaxants in elderly patients with nonspecific musculoskeletal pain. Neurology, Neuropsychiatry, Psychosomatics. 2020;(1):39–44. (In Russ.) https://doi.org/10.14412/2074-2711-2020-1-39-44.