Pain Experience in Individuals With Chronic Low Back Pain
Pain Experience in Individuals With Chronic Low Back Pain
Low back pain is a very common musculoskeletal condition that affects many people each year
 regardless of age, gender, and ethnicity. Most people get better however, some continue
 suffering from painful episodes despite treatment.

 Self-management strategies for the management of chronic low back pain are very important to
 patients as they help them develop skills to manage their pain more effectively. However,
 self-management strategies are not always effective as expected. It is possible that the
 brain has become very sensitive to signals coming from peripheral parts of the body (e.g. low
 back) affecting the ability of patients to self-manage their condition.

 The aim of this study is to establish whether central sensitisation (sensitivity of the brain
 to peripheral signals) predicts how effective self-management approaches will be.

 On three different occasions, scheduled sessions will include a clinical assessment session
 and completion of a questionnaire booklet. The clinical assessment will measure three
 features of central sensitisation: 1) sensitivity to blunt pressure on the forearm, 2)
 changes in pain, felt during repeated light pricking of the forearm skin, and 3) reduction in
 pain that accompanies inflation of a blood pressure cuff on the opposite arm. Participant
 involvement at each session is expected to last for 70 minutes.

 Individuals over 18, diagnosed with chronic low back pain and enlisted to follow a pain
 management program are eligible to participate. The clinical assessments, questionnaire
 completion and subsequent statistical analysis are expected to be completed within 18 months
 of study commencement.

 Based on our findings, future research may use similar clinical assessment to identify people
 who might be helped to self-manage by using treatment that reduces central sensitisation.
Low Back Pain (LBP) is considered a common condition consisting of a set of complains (pain,
 muscle tension, or stiffness), manifesting primarily to the lower back region (below the
 costal margin and above the inferior gluteal folds). LBP may or may not include radiating
 pain to the lower limb and can be caused by a number of underlying pathologies with varying
 levels of severity [1]. The condition can be the result of complex interactions between
 multiple physical and psychological factors including osteoarthritis (OA), degenerated discs,
 disc herniation, muscle dysfunction, obesity, poor posture, mental illness, negative affect
 (stress, anxiety, depression) [2].

 LBP lifespan incidence appears to be 58-84% while it is estimated that 11% of males and 16%
 of females suffer from chronic LBP at any point in time [3]. It is expected that 40-50% of
 individuals suffering from acute LBP will continue to experience pain at three months and
 will demonstrate little or none further improvement, while 60-70% of those who improve will
 relapse within a year [4]. The global prevalence of LBP demonstrates continuously growing
 trends with a 17.3% increase in the last 10 years [5].

 Self-management (SM) support is a portfolio of techniques and tools to help patients choose
 healthy behaviours as well as a fundamental transformation of the patient-caregiver
 relationship into a collaborative partnership [6]. Self-management support has to incorporate
 in its approach elements that aim to increase patients' self-efficacy, develop
 problem-solving, decision-making and goal-setting skills as well as to promote partner-like
 behaviour between patients and health professionals [7]. SM interventions pose as ideal
 rehabilitation strategies for chronic low back pain (CLBP) as they aim to address biological
 (neurophysiological, deconditioning, lifestyle) and psychosocial (self-efficacy, maladaptive
 beliefs, anxiety/depression) factors that have been identified as risk factors for poor
 outcome [8, 9] and are negatively affected by central sensitisation (CS) [10]. SM
 interventions are designed to be cost-effective by reducing health care utilisation
 associated with LBP [11].

 Self-management programs (SMP) for CLBP demonstrate only small to moderate effects for
 long-term improvements in pain and disability. Currently, it is not known what factors
 predict effective self-management. Evidence of CS varies between individuals with chronic
 pain, and may contribute to the relatively poor efficacy of SMPs.

 CS is a marker of widespread and centrally augmented pain that refers to those
 neurophysiological processes that can occur throughout the central nervous system (CNS)
 distribution, leading to changes in the spinal cord as well as in the brain [12]. The
 presence of CS increases the complexity of the clinical picture [13] and negatively affects a
 range of outcomes (e.g. pain, disability, negative affect, quality of life) following
 treatment [14]. CS is not present within all patients with chronic pain [15] rendering
 identification of those patients and decision-making for the right management approach even
 harder [16]. Patients with potential development of CS should receive treatment that address
 the full biopsychosocial clinical spectrum consisting of cognitive behavioural therapy (CBT)
 as well as therapeutic pain neuroscience education [17]. Changes in pain mechanisms may
 explain the moderate levels of evidence for the effectiveness of self-management (SM)
 interventions in LBP populations [7] as CS has been shown to negatively affect the perception
 of back pain, pain-related disability and lead to poor physical and mental health-related
 quality of life as well as to greater levels of depression and anxiety [10].

 Quantitative Sensory Testing (QST) is a reliable [18] and valid [19] method to assess for the
 presence of CS and demonstrates predictive capacity in relation to musculoskeletal (MSK)
 treatment outcomes [20]. The testing consists of pressure pain threshold (PPT), punctate
 thresholds, temperature sensitivity, temporal summation (TS) and conditioned pain modulation
 (CPM) used to quantify noxious or innocuous stimuli within healthy individuals and patients
 alike [21]. QST has been used, among others, as a screening and assessment tool for sensory
 abnormalities in patients with pain disorders [21], as well as to assist in the
 stratification of patients [22] and evaluate the clinical aspects of peripheral and CS [23].

 The STarT Back screening tool [24] was developed for individuals of LBP with the aim to
 identify prognostic indicators that could potentially assist decision making concerning
 initial treatment options in primary care [25]. Start Back has been formally validated,
 displaying satisfactory reliability, and has demonstrated that a stratified management
 approach displays higher health gains for patients with LBP than a non-stratified one [26].
 Nevertheless, the tool's predictive performance has not been examined when other biomarkers
 (CS) are included as prognostic indicators.

 Findings from this research will have an impact on differential diagnosis of chronic pain and
 CS identification as potential prognostic indicators for self-management. The results will
 assist effective patient subgrouping (stratification) based on CS measurements, aid
 appropriate self-management approaches in CLBP and potentially other chronic musculoskeletal
 pain states.
Inclusion Criteria:

 -  have the ability to give informed consent.

 -  be 18 years old or over

 -  be diagnosed with chronic LBP

 -  be enlisted for participation in a self-management program

 -  be able to speak and understand English as all questionnaires are validated in the
 English language.

 Exclusion Criteria:

 -  Inability to give informed consent due to cognitive impairment or otherwise

 -  Inability to understand key aspects of the study due to cognitive impairment or
 otherwise

 -  Patients giving history of additional co-morbidities such as cancer, diabetic
 neuropathies, fractures or other conditions causing greater disability than their back
 pain.

 -  Pregnancy