Published: Journal of Orthopaedic & Sports Physical Therapy, 2017 Volume:47 Issue:9 Pages:593–615 DOI: 10.2519/jospt.2017.7117

Study Design

Systematic review with meta-analysis.

Objectives

To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component.

Background

Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown.

Methods

A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes.

Results

Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0–50]: mean difference, −9.26; 95% confidence interval [CI]: −14.50, −4.01; P<.001) and pain (intensity [0–10]: mean difference, −1.78; 95% CI: −2.55, −1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, −1.89; 95% CI: −3.14, −0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia.

Conclusion

This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time.

Ref: https://www.jospt.org/doi/abs/10.2519/jospt.2017.7117

Yu-Hsuan Cheng, Chih-Yang Hsu, Yen-Nung Lin First Published August 28, 2019 Research

Article

https://doi.org/10.1177/0269215519872528

            Abstract

Objective:

To evaluate the effectiveness of traction in improving low back pain, functional outcome, and disk morphology in patients with herniated intervertebral disks.

Data Source:

PubMed, Scopus, Embase, and the Cochrane Library were searched from the earliest record to July 2019.

Review methods:

We included randomized control trials which (1) involved adult patients with low back pain associated with herniated disk confirmed by magnetic resonance imaging or computed tomography, (2) compared lumbar traction to sham or no traction, and (3) provided quantitative measurements of pain and function before and after intervention. Methodological quality was assessed using the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias assessment.

Results:

Initial searches for literature yielded 3015 non-duplicated records. After exclusion based on the title, abstract, and full-text review, 7 articles involving 403 participants were included for quantitative analysis. Compared with the control group, the participants in the traction group showed significantly greater improvements in pain and function in the short term, with standard mean differences of 0.44 (95% confidence interval (CI): 0.11–0.77) and 0.42 (95% CI: 0.08–0.76), respectively. The standard mean differences were not significant to support the long-term effects on pain and function, nor the effects on herniated disk size.

Conclusion:

Compared with sham or no traction, lumbar traction exhibited significantly more pain reduction and functional improvements in the short term, but not in the long term. There is insufficient evidence to support the effect of lumbar traction on herniated disk size reduction.

Despite being the most common form of physiotherapy treatment for patients there is a lack of evidence to support its use.

Any benefit over no treatment/minimal treatment can be attributed to the general exercise effect.

Core stability should not be used in patients with chronic LBP and a more general, functional,exercise regime used instead, as proposed by Klaber Moffet and Frost #SPR

What exactly is ‘core stability’? Well it means many different things to different people, but within the world of physiotherapy the term has come to symbolise a series of exercises that asks you to brace and pull in your deep abdominal muscles as you perform different movements. These are commonly prescribed by many physios to those with longstanding back pain, but, do they help, do they make a difference, and what’s the evidence for using them?

To try and answer these questions I’m delighted to welcome Ben Smith to ‘The Sports Physio’. Ben is an MSK Physiotherapist working in the NHS in Derby. He’s currently completing a Masters at Nottingham University and is working towards a PhD application in relation to PFJS. His specialist interest is integrating evidence into practice, particularly with spines and knees, and can be followed on Twitter @benedsmith Ben has very kindly written an extremely well researched and evidenced based piece looking at the use of core stability exercises for chronic low back pain.

Now before we get started, this is a subject I’ve touched on before in my rants and ravings online and those who know me will already know my own strong, cynical and sceptical views on this subject, that being I have very little time or patience with core stability exercises within physiotherapy and that I find the practice of asking those with back pain to brace and clench things tight and rigid, absurd and complete nonsense, so to avoid the screams, accusations and shouts of bias and unfairness I will extend an invitation to anyone willing or wanting to defend the role of core stability exercises the chance to write a reply article in response to Ben’s, just leave a comment below with your request and I will be in touch!

So without further ado lets get into it and I’ll hand over to Ben as we delve into the role of ‘Core stability and chronic low back pain’

Introduction

Physiotherapy treatments for LBP range from spinal manipulations, mobilisation, advice, general exercises and specifically tailored exercises (Liddle et al., 2009). Despite doubts raised about its effectiveness compared with other forms of treatment (May et al., 2008), the most frequently given exercise by physiotherapists is core stability (Liddle et al., 2009). The exercise has become the unquestioned treatment of choice for physiotherapist.

This blog will examine relevant evidence surrounding the effectiveness and the underpinning physiological effects of core stability exercises for chronic LBP.

Background

It has been suggested that in normal people the muscle transversus abdominis (TrA) activates prior to limb movement in an anticipatory feed forward mechanism, and further suggested that this activation is delayed in patients with chronic LBP (Hodges et al., 1996, 1999; Richardson et al., 1999). It was therefore hypothesised that addressing this delayed feed forward mechanism through therapeutic exercise would have a positive effect on patients with chronic lower back pain, furthermore that people without current symptoms, but a history of symptoms, would be at a reduced risk of re-injury by following this treatment protocol (Hodges et al., 1999). An exercise regime aimed at isolating TrA was then developed, designed to retrain motor skills and ‘reset’ the delayed feed forward mechanisms (Richardson et al., 1999).

Underpinning physiological effects

The hypothesis that TrA training can have a positive impact on patients with chronic LBP is based upon two premises. Firstly, that TrA is the key component to spinal stability, and secondly that training can ‘reset’ the delayed timing issue.

The first premise, that TrA is the key component to spinal stability, is a huge assumption, and a theory that fails when tested. It centres upon the biomedical model of causation, as described by Bradford Hill (1965). It is a model of causation whereby biological changes are used to describe states of illness. It makes assumptions based upon the considered ‘normal’ state in which a body should be (Tyreman, 2006), with any variations from this ‘normal’ state being considered abnormal, and ultimately leading to illness. What we know is that this model is extremely simplistic, and fails to take into account psychological and social factors (Tyreman, 2006).

More recent studies have shown that the onset timing of TrA does not have an ideal pattern in pain free subjects, and that variance is ‘normal’ (Mannion et al., 2008; O Vasseljen et al., 2009). Furthermore, any delayed timing in chronic LBP patients has not yet been consistently found in subsequent research. Gubler et al. (2010) carried out a cross section study using ultrasound to time the onset of TrA during shoulder flexion in 48 patients with chronic LBP and 48 pain free patients. It was high quality, with little to no bias and suitable control and group allocation. They concluded that no difference exists between chronic LBP patients and pain free subject for TrA activation timing during shoulder flexion.

The second premise, that TrA training can improve delayed timing, also fails when testing. Ottar Vasseljen et al. (2012) carried out an eight week RCT (N=109) looking at one on-one core stability training versus one-on one sling exercises and group general exercises. Outcome measures were pain and disability, but also onset timing of TrA during shoulder flexion. They found that after 8 weeks of training there was no difference between groups on pain, disability and most importantly TrA onset timing with shoulder flexion. Generally it was a methodologically robust study with suitable power calculation, intention to treat analysis, low attrition and appropriate allocation. Unfortunately bias could have entered the study (in either direction, depending on the assessor’s preference), since the assessor was not blinded to group allocation during TrA timing analysis.

It can be concluded that; there is no consistent evidence chronic LBP patients have a delayed onset of TrA activation, any delay is not important to the causation of their LBP, and TrA training does not improve any timing issues.

Clinical Effectiveness

There have been many published research articles looking into the effect of core stability exercises in patients with chronic LBP, some higher quality than others. However, no randomised control trial has shown that core stability is more effective over general exercises for pain, function or disability in patients with chronic LBP. A 2008 systematic review which, included trials up to 2006, concluded that core stability exercises are unlikely to produce betters outcomes over other form of exercise (May et al., 2008).

 

Petrofsky et al. (2008) and Pensri & Janwantanakul (2012) state that core stability exercises reduced pain in chronic LBP patients, but with no comparison with general exercise, outcomes only taken on discharge and no subject allocation information, the results are inadequate to enable generalisations.

Ferreira et al. (2007) state that the short term effect of core stability is greater than general exercise for chronic LBP. They undertook a pragmatic RCT with 240 participants with chronic LBP of three or more months’ duration. They compared three different treatment protocols lasting eight weeks; general exercise, manipulation and core stability exercise. The general exercise group was a class based group involving general exercises based on the ‘Back to Fitness’ program by Klaber Moffet and Frost (Klaber Moffett et al., 2000). The core stability group received 12 individual treatment sessions over eight weeks based on Richardson et al. (1999), with the use of an ultrasound machine to aid in muscle recruitment and biofeedback.

At 8 weeks the core stability group had significantly better function, as measured by Patient-Specific Functional Scale (Westaway et al., 1998). However, pain and disability at eight weeks were the same in all groups. Furthermore, all outcomes at 6 and 12 months were similar in all groups. Pain was measured on a visual analogue scale, where 0 represents no pain and 10 worst pain imaginable, and disability by the Roland Morris Disability Questionnaire (RMDQ). This is an extremely reliable and valid outcome measure for pain, function and disability in chronic LBP (Beurskens et al., 1995; Roland et al., 1983).

The internal validity of Ferreira et al. (2007) is low. Intention to treat and sensitivity analysis were avoided. Coupled with a high, un-even, drop out rate, (9% for general exercise compared with 19% for core stability) this omittance lowers the robustness of the results and usefulness to the practitioner as it biases the results in favour of core stability. If core stability patients not having benefit from treatment drop out more frequently than the general exercise group their exclusion from the analysis would lead to an exaggeration of the effect of core stability.

Ferreira et al.’s (2007) short term results are contradicted by Koumantakis et al. (2005) study. Short term outcome measures at eight weeks showed core stability had significantly worse fear avoidance scores compared with general exercise on the Roland Morris Disability Questionnaire (RMDQ).

Koumantakis et al. (2005) had a slightly different methodology to Ferreira et al., (2007), comparing general exercises with general exercises plus core stability over eight weeks, and the general exercises were not based on the ‘Back to Fitness’ program by Klaber Moffet and Frost, (2000), but were non specific mat exercises.

Koumantakis et al. (2005) adjusted the total class time according to time of muscle activation, and as a result total class time for the core stability group was almost double that of the general exercise group (99 minutes v 180 minutes), biasing results in favour of the core stability group.

Koumantakis et al. (2005) had a larger attrition rate than Ferreira et al. (2007), however they carried out a sensitivity analysis, with intention to treat producing similar results to per protocol analysis, improving internal validity of results since this adjusts for the uneven drop out rates in their analysis.

Comparison and generalisation between these two studies may not be possible; the majority of patients for Ferreira et al. (2007) were unemployed, from low socio-economic groups whereas all patients for Koumantakis et al. (2005) were employed. It has been shown that people from low socio-economic groups are at a far greater risk of developing chronic LBP, and may have worse results with therapy (Katz, 2006). In addition, all patients for Koumantakis et al. (2005) must have had a x-ray or MRI to be included. It has been shown that patients who have x-rays or MRIs may have better short term satisfaction, but long term fear avoidance is generally worsened (Chou et al., 2007). Therefore, comparison of improvements in RMDQ scores between studies is of limited value.

Despite being unable to compare results directly, the higher internal and external validity ofKoumantakis et al. (2005) means we can trust the result more, and make generalisations better, which is further discussed in the conclusion.

Cairns et al. (2006) was another pragmatic, multi-centred, RCT comparing core stability exercises with conventional physiotherapy for chronic LBP. Both groups received 12 weeks of physiotherapy on a one to one basis, for up to 12 sessions. Both groups were allowed, if the physiotherapist felt warranted, manual therapy and electrotherapy. It was a comparatively high quality RCT, with power calculation, sensitivity analysis and a robust methodology. Attrition rates were high at 30%, but were comparable with Koumantakis et al. (2005), potentially indicative of patients with chronic LBP.

External validity of Cairns et al. (2006) as a stand alone RCT is low, since ‘distressed patients’ were excluded from the study, and it is known that many patients that present with chronic LBP are classified as distressed (MC Cairns et al., 2003). However, Cairns et al. (2006) included the RMDQ as an outcome measure, and in agreement with Koumantakis et al. (2005) and Ferreira et al. (2007) found no significant between group difference at 6 months and 12 months. Furthermore, they found short term outcomes were the same for both groups.

Although not statistically significant, the general exercise group had an improvement in 57% of patients, compared with 48% in the core stability group, and had a lower average number of treatment sessions. Cost was not calculated nor compared, but this finding is corroborated by Critchley et al. (2007) who did calculate cost in a comparison of traditional physiotherapy, with core stability and group pain management. Critchley et al. (2007) looked at the Roland Disability Questionnaire in 212 patients up to 18 months after discharged and found no difference between pain and disability in the three groups. However, cost was significantly lower for group rehab and traditional physiotherapy when compared with core stability.

These four trials are further strengthened by Lewis et al. (2005), Gladwell et al. (2006), Norris & Matthews (2008), Rasmussen-barr et al. (2009) and Muthukrishnan et al. (2010) who found that core stability training compared with control groups had no improvement in outcomes measures. Control groups being; group rehab, no treatment, information leaflet, daily walks and general physiotherapy respectively.

It can be concluded; there is some agreement that core stability offers no additional benefit in long term outcomes of pain, function and disability over general exercises, plus or minus other forms of physiotherapy treatment. It is likely to be more costly, and there is some evidence to suggest that fear avoidance in the short term may be worse.

Conclusion

This blog has questioned the relevant evidence surrounding the effectiveness and the underpinning physiological effects of core stability exercises for chronic LBP.

Despite being the most common form of physiotherapy treatment for patients there is a lack of evidence to support its use.

Any benefit over no treatment/minimal treatment can be attributed to the general exercise effect.

Core stability should not be used in patients with chronic LBP and a more general, functional,exercise regime used instead, as proposed by Klaber Moffet and Frost (Klaber Moffett et al., 2000).

References

Beurskens, A., De Vet, H., Van der Heijden, G., & Knipschild, P. Measuring the functional status of patients with low back pain: assessment of the quality of four disease-specific questionnaires. Spine 1995; 20: 1017–1028.

Bradford Hill, A. The Environment and Disease: Association or Causation? Proceedings of the Royal Society of Medicine 1965; 58: 295–300.

Cairns, M, Foster, N., & Wright, C. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine 2006; 31(19): E670–81. doi:10.1097/01.brs.0000232787.71938.5d

Cairns, MC, Foster, N., Wright, C., & Pennington, D. Level of distress in a recurrent low back pain population referred for physical therapy. Spine 2003; 28(9): 53–9.

Chou, R., Qaseem, A., Snow, V., et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007; 147(7): 478–491.

Critchley, D., Ratcliffe, J., Noonan, S., Jones, R., & Hurley, M. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine 2007; 15(32): 1474–81.

Ferreira, M. L., Ferreira, P. H., Latimer, J., et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131(1-2): 31–7. doi:10.1016/j.pain.2006.12.008

Gladwell, V., Head, S., Haggar, M., & Beneke, R. Does a Program of Pilates Improve Chronic Non-Specifi c Low Back Pain ? J Sport Rehabil 2006; 15(4): 338–350.

Gubler, D., Mannion, A., Schenk, P., et al. Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain. Spine 2010; 15(35): 1506–13. doi:10.1097/BRS.0b013e3181c3ed41

Hodges, & Richardson. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 1996; 21(22): 2640–2650.

Hodges, & Richardson. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Archives of physical medicine and rehabilitation 1999; 80(9): 1005–12. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10489000

Katz, J. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. The Journal of Bone and Joint Surgery 2006; 88(2): 21–24.

Klaber Moffett, J., & Frost, H. Back to Fitness Programme: The manual for physiotherapists to set up the classes. Physiotherapy 2000; 86(6): 295–305.

Koumantakis, G. A., Watson, P. J., & Oldham, J. A. Supplementation of general endurance exercise with stabilisation training versus general exercise only. Physiological and functional outcomes of a randomised controlled trial of patients with recurrent low back pain. Clinical biomechanics (Bristol, Avon) 2005; 20(5): 474–82. doi:10.1016/j.clinbiomech.2004.12.006

Lewis, J., Hewitt, J., Billington, L., et al. A randomized clinical trial comparing two physiotherapy interventions for chronic low back pain. Spine 2005; 30(7): 711–21.

Liddle, S. D., David Baxter, G., & Gracey, J. H. Physiotherapists’ use of advice and exercise for the management of chronic low back pain: a national survey. Manual therapy 2009; 14(2): 189–96. doi:10.1016/j.math.2008.01.012

Mannion, A., Pulkovski, N., Schenk, P., et al. A new method for the noninvasive determination of abdominal muscle feedforward activity based on tissue velocity information from tissue Doppler imaging. J Appl Physiol 2008; 104(4): 1192–201. doi:10.1152/japplphysiol.00794.2007

May, S., & Johnson, R. Stabilisation exercises for low back pain: a systematic review. Physiotherapy 2008; 94(3): 179–189. doi:10.1016/j.physio.2007.08.010

Muthukrishnan, R., Shenoy, S. D., Jaspal, S. S., Nellikunja, S., & Fernandes, S. The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain. Sports medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT 2010; 2: 13. doi:10.1186/1758-2555-2-13

Norris, C., & Matthews, M. The role of an integrated back stability program in patients with chronic low back pain. Complementary therapies in clinical practice 2008; 14(4): 255–63. doi:10.1016/j.ctcp.2008.06.001

Pensri, P., & Janwantanakul, P. Effectiveness of Brief Education Combined with a Home-Based Exercise Program on Pain and Disability of Office Workers with Chronic Low Back Pain: a Pilot Study. Journal of Physical Therapy Science 2012; 24(2): 217–222. doi:10.1589/jpts.24.217

Petrofsky, J. S., Batt, J., Brown, J., et al. Improving the Outcomes after Back Injury by a Core Muscle Strengthening Program. Journal of Applied Reliabiltiy 2008; 8(1): 62.

Rasmussen-barr, E., Bjorn, A., Arvidsson, I., & Nilsson-wikmar, L. Graded Exercise for Recurrent Low-Back Pain. Spine 2009; 34(3): 221–228.

Richardson, Jull, Hodges, & Hides. Therapeutic Exercise for Spinal Segmental Stabilization: In Lower Back Pain 1999. Edinburgh: Churchill Livingstone.

Rivero-Arias, O., Gray, A., Frost, H., Lamb, S. E., & Stewart-Brown, S. Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine 2006; 31(12): 1381–1387.

Roland, M., & Morris, R. A study of the natural history of back pain, part I: the development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141–144.

Tyreman, S. Causes of illness in clinical practice: a conceptual exploration. Medicine, health care, and philosophy 2006; 9(3): 285–91. doi:10.1007/s11019-006-9006-6

Vasseljen, O, Fladmark, A., Westad, C., & HG, T. Onset in abdominal muscles recorded simultaneously by ultrasound imaging and intramuscular electromyography. J Electromyogr Kinesiol. 2009; 19(2): 23–31.

Vasseljen, Ottar, Unsgaard-Tøndel, M., Westad, C., & Mork, P. J. Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: a randomized controlled trial. Spine 2012; 37(13): 1101–8. doi:10.1097/BRS.0b013e318241377c

Westaway, M. D., Stratford, P. W., & Binkley, J. M. The patient-specific functional scale: validation of its use in persons with neck dysfunction. The Journal of orthopaedic and sports physical therapy 1998; 27(5): 331–338. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9580892

Credit ~ Ben Smith via thesports.physio.

Yu-Lun Huang, PhD*, Jaehun Jung, PhD, Colin M.S. Mulligan,

First Published August 30, 2019 

Abstract

Background:

Anterior cruciate ligament (ACL) injury prevention programs (IPPs) are generally accepted as being valuable for reducing injury risk. However, significant methodological limitations of previous meta-analyses raise questions about the efficacy of these programs and the extent to which meeting current best-practice ACL IPP recommendations influences the protective effect of these programs.

Purpose:

To (1) estimate the protective effect of ACL IPPs while controlling for common methodological limitations of previous meta-analyses and (2) systematically categorize IPP components and factors related to IPP delivery to assess the validity of current best-practice IPP recommendations.

Study Design:

Systematic review with meta-analysis.

Methods:

A systematic search of 5 electronic scientific databases was conducted to identify studies testing the efficacy of ACL IPPs. Studies were included if (1) the intervention aimed to prevent ACL injury, (2) the incidence rate (IR) or other outcome data that made it possible to calculate the IR for both the intervention and control groups were reported, and (3) the study design was a prospective randomized controlled trial (RCT) or cluster-RCT.

Results:

Of the 2219 studies screened, 8 studies were included in the quantitative synthesis, and their analysis revealed a significant reduction in ACL IR when athletes received IPPs (IR ratio = 0.47; 95% CI, 0.30-0.73; P < .001). The majority of included IPPs tended to meet minimum best-practice recommendations and incorporated plyometric, strengthening, and agility exercises along with feedback on proper landing technique. However, the specific exercises included in each IPP and key factors related to IPP delivery were highly variable.

Conclusion:

Despite limiting the analysis to only high-quality studies and controlling for time at risk and potential clustering effects, the study showed that ACL IPPs had a significant protective effect and reduced injury rates by 53%. However, significant variability in the specific exercises and the manner of program delivery suggests that ACL IPPs may be able to be designed within an overarching best-practice framework. This may allow practitioners the flexibility to develop IPPs that meet the specific characteristics of the target population and potentially increase the likelihood that these programs will be widely adopted and implemented.

Shaquir Salduker¹, Eugene Allers², Sudha Bechan³, R Eric Hodgson⁴, Fanie Meyer⁵, Helgard Meyer^6,7, Johan Smuts⁸, Eileen Vuong⁹, David Webb<sup>10

1</sup>Durban Pain Clinic, St Augustine Hospital, Durban, South Africa; ²Glynview Multiprofessional Practice, Gauteng, South Africa; ³Department of Anaesthesiology, Head Clinical Unit, Inkosi Albert Luthuli Central Hospital, Nelson R Mandela School of Medicine, Durban, South Africa; ⁴Inkosi Albert Luthuli Central Hospital, Nelson R Mandela School of Medicine, Durban, South Africa; ⁵Optima Psychiatric Hospital, Bloemfontein, South Africa; ⁶Department of Family Medicine, University of Pretoria, Pretoria, South Africa; ⁷Wilgers MR & Medical Centre, Pretoria, South Africa; ⁸Faculty of Medicine, University of Pretoria, Pretoria, South Africa; ⁹South African Research Chairs Initiative (SARChI), PTSD Program, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa; ¹⁰Houghton House Group, Gauteng, South Africa

Correspondence: Shaquir Salduker
Durban Pain Clinic, St Augustines Hospital, Chelmsford 1, Durban, South Africa
Email shaquir@shrink.co.za

Abstract: Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.