How I Healed my Lower Back Pain

Back Pain Relief4life

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How does the probability of recovery change with time after the onset of low back pain symptoms

The natural history for recovery after an episode of acute back pain is favorable, with recovery noted in most patients by 6 to 12 weeks. From the onset of symptoms, 50 of patients recover by 2 weeks, 70 recover by 1 month, and 90 recover by 4 months. However, despite the high likelihood of recovery after an episode of acute low back pain, over 50 of patients experience another episode within 1 year. Patients who fail to recover by 4 months frequently progress to long-term chronic disability. Patients with chronic back pain are more difficult to treat than those with acute back pain and require different treatment approaches.

Describe a treatment plan for patients with acute low back pain

The natural history of acute low back pain is improvement over time. Patient reassurance medications (analgesics, NSAIDs, short course of oral steroids, muscle relaxants) and education about back care and exercise are beneficial. Studies suggest that manipulation may decrease pain during the first 3 weeks after onset of symptoms. If pain persists, spinal radiographs should be obtained. Bone scan and or magnetic resonance imaging (MRI) are indicated if serious underlying pathology is suspected.

What is the role of cardiovascular conditioning in low back pain

Cardiovascular deconditioning develops secondary to inactivity in patients with chronic low back pain. Aerobic training to improve cardiovascular endurance is an extremely important part of rehabilitation of the low back. Heart-rate limitations for patients with known or suspected cardiac disease are based on stress testing. Aerobic training (i.e. treadmill, bike, stepper, arm and leg ergometer, walking, jogging, swimming) has multiple beneficial effects

What kinds of nutritional therapy have been used in the treatment of back pain

Joints involved in back pain through improvement of vascular flow. Diets rich in antiinflammatory components have also been recommended based on the principle that pain has an underlying inflammatory component. Such antiinflammatory diets are high in omega-3 and omega-6 fatty acids and linoleic acid and low in saturated fats, processed meats, and sugar. A wide variety of vitamins and minerals has been advocated for treatment of back pain including vitamin A B vitamins (B1, B6, B12) vitamins C, D, E glucosamine methylsulfonylmethane (MSM) S-adenosylmethionine (SAM-e) and D-L phenylalanine (DLPA).

Is severe back pain an indication for spinal surgery

Only in limited specific circumstances. Back pain is a symptom, not a diagnosis. The lifetime prevalence of back pain exceeds 70 . Surgery is not indicated for nonspecific low back pain. However, back pain may be a prominent symptom in patients with neural impingement, spinal instability, or certain spinal deformities. In such situations, appropriate spinal decompression, stabilization, and realignment may improve back pain symptoms related to serious underlying spinal pathology. In select degenerative disorders, spinal fusion is a reasonable option following adequate nonsurgical treatment if a definite nociceptive focus is identified in a patient without negative psychosocial factors. Caution is crucial when the indication for surgery is pain because this complaint is often subjective and personal and surgical results are uniformly poor when issues of secondary gain exist.

The Onset Of Back Pain

We asked more than 500 British patients how their back pain started (Fig. 7.1). There was little difference between patients who saw their family doctor and those who came to a routine hospital clinic, or between men and women. Table 7.1 Onset of work-related backache and Table 7.2 Factors people think are related to the sciatica onset of back pain Table 7.1 Onset of work-related backache and Table 7.2 Factors people think are related to the sciatica onset of back pain start of back pain with back pain Troup and his colleagues made one of the early studies of back pain in an occupational health setting (Troup et al 1981, Lloyd & Troup 1983). They saw nearly 1000 workers when they returned to work after an episode of back pain. In half, the current attack was spontaneous with no question of any kind of injury. In a sixth, the pain began unexpectedly at work with normal activity, most often lifting or handling. One-third described what Troup et al accepted was a true accidental event...

Physical activity and low back pain

Low back pain is pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). About 85 of low back pain cases are non-specific, not attributable to recognizable pathology. The poorly defined pathophysiology and mechanism of pain explain to a large degree the difficulties of prevention and treatment of low back pain. Low back pain is a common disorder, the lifetime incidence being around 60-80 . Most cases are resolved within 2-4 weeks and 90 recover by 12 weeks 48 . However, in a follow-up study nearly one-third of cases had not recovered completely in 1 year 49,50 , and recurrence of low back pain is very frequent with rates of up to 50 in the year following the initial episode. The origin and mechanisms of low back pain are not exactly known, but it seems that the symptoms originate from tissue injury or inflammation and from the resulting irritation, nociception 51 . This in turn causes increased...

Discuss the epidemiology of back pain in children compared with adults

Traditionally, the prevalence of back pain in children is reported as less than in the adult population. In addition, among pediatric patients who seek evaluation for back pain, the likelihood of diagnosis of a definable cause of symptoms is traditionally considered higher than in adult patients. Complaints of back pain are less common before age 10 and increase between 12 and 15 years of age. Recent studies question these traditional beliefs and demonstrate that diagnosis of a definable cause of back pain symptoms is not possible for up to 75 of pediatric patients. The prevalence of idiopathic adolescent spinal pain approaches the reported rate of the adult population by age 18 years. Spinal pain in adolescence is considered to be a risk factor for spinal pain as an adult.

When is a technetium bone scan indicated for evaluation of a child with back pain

If a child with back pain has normal spinal radiographs and does not have a neurologic deficit, a technetium bone scan should be obtained. This test is quite sensitive for diagnosing spinal problems such as infections, tumors, and occult fractures. Single-photon emission computed tomography (SPECT) provides increase sensitivity and specificity compared with a planar bone scan. SPECT is especially helpful in the diagnosis of acute spondylolysis but is less helpful for diagnosis of chronic pars fractures as chronic injuries lack increased bone turnover.

When is an MRI scan indicated for evaluation of a child with back pain

Children presenting with back pain and an abnormal neurologic examination require evaluation with a spinal MRI. MRI is the method of choice for evaluation of the spinal column and neural axis. It is useful for defining abnormalities such as tumor, infection, disc herniation, Arnold Chiari malformation, syrinx, and tethering of the spinal cord. Because it is a noninvasive test, it has largely replaced CT myelography.

What guidelines exist to aid the practitioner in pursuing an effective and systematic approach to the child with back

Diagnostic algorithm for back pain in children. BMT, bone mineral testing (DEXA) CBC, complete blood count CRP, C-reactive protein CT, computed tomography ESR, erythrocyte sedimentation rate HNP, herniated nucleus pulposus MRI, magnetic resonance imaging PE, physical examination Rx, therapy SPeCt, single-photon emission computed tomography Sx, symptoms. (Redrawn from Ecker ML. Back pain. Spine State Art Rev 2000 14 236.) Figure 36-1. Diagnostic algorithm for back pain in children. BMT, bone mineral testing (DEXA) CBC, complete blood count CRP, C-reactive protein CT, computed tomography ESR, erythrocyte sedimentation rate HNP, herniated nucleus pulposus MRI, magnetic resonance imaging PE, physical examination Rx, therapy SPeCt, single-photon emission computed tomography Sx, symptoms. (Redrawn from Ecker ML. Back pain. Spine State Art Rev 2000 14 236.) Nature of symptoms findings Symptoms localized to back pain Nature of symptoms Back pain without systemic or neurologic...

Prevention of future back pain

Back pain is one of the leading causes for morbidity and absenteeism from work during adulthood. To our knowledge, there is only one study investigating the effects of a high level of PA during childhood on the prevalence of back pain in adulthood 28 . The follow-up of former participants of the Trois-Rivieres study showed a significantly lower frequency of back pain in the females who had received 5 hours of physical education per week during grades 1-6 compared with the females who received only 1 hour. There was no effect of additional physical education on future back pain in the males.

Coping with back pain

Most people with back pain, even chronic pain, cope with the pain, adjust, and continue to lead more or less normal liv es. Chronic pain is not synonymous with disability and depression. So how is it that some people cope with the pain successfully while others become disabled What are the different mental strategies they use to cope with the stress (Jensen et al 1991, Main & Spanswick 2000) The most widely used measure of coping is the Coping Strategies Questionnaire (Figure 12.6 Rosenstiel & Keefe 1983). This measures helpful and unhelpful coping strategies, which influence the outcome of treatment. The most harmful or maladaptive coping strategy in patients with back pain is catastrophizing. Catastrophizing is negative and distorted thinking and worrying about the pain and one's inability to cope. We might summarize it as fearing the worst or looking on the dark side. This may be clearer in some examples from the Coping Strategies Questionnaire Widely differing beliefs and...

If you have back pain

Back pain affects nearly everyone at some point in his or her life but is rarely serious. If you have severe pain which gets worse over several weeks instead of better, or if you are unwell with back pain, you should see your doctor. You should see a doctor straightaway if you have But remember that back pain is rarely due to any serious disease. Try to remain at work or get back as soon as possible even if you still have some low back pain. The longer you stay off work the more likely you are to develop chronic pain and disability.

Describe the prevalence and natural history of lumbar disc herniations How do they differ from the prevalence and

The lifetime prevalence of a lumbar disc herniation is approximately 2 . The natural history of sciatica secondary to lumbar disc herniation is spontaneous improvement in the majority of cases. Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10 to 25 (0.5 of the population) experience persistent symptoms. These statistics are in sharp contrast to low back pain, which has a lifetime prevalence of 60 to 80 in the adult population. Although the natural history of acute low back pain is favorable in the majority of patients, successful management of patients with chronic symptoms remains an enigma.

Can I prevent back pain occurring

Injury prevention programmes that focus on reducing employees' exposure to very heavy loads, extreme bending and twisting, excessive whole-body vibration, and falls from a height can help prevent serious back injuries. However, studies show it's almost impossible to prevent the more common acute low back pain because there are many factors involved. But the condition can be managed to help stop it becoming an ongoing problem for you and your employee. The management of low back pain at work is most likely to be successful in a workplace where priority is given to health and safety at all levels of the organisation.

Discuss common nonsurgical treatment options for chronic low back pain due to lumbar DDD

Nonsurgical treatment options for chronic low back pain due to lumbar DDD include Medication Nonsteroidal antiinflammatory medications are effective for short-term relief of symptoms. Muscle relaxants (benzodiazepine and non-benzodiazepine) and anticonvulsant medications are considered second-line medication options. Tricyclic antidepressants are a useful adjunct. Tramadol, a synthetic analgesic, has been shown to significantly reduce pain and improve physical function in chronic low back pain patients. Long-term use of opioids is controversial due to decreasing efficacy over time and high rates of substance abuse. Corticosteroids

Should you employ someone with back pain

Some employers are concerned about taking on people who have had back pain in the past. But low back pain is very common and not usually serious. And whilst many people have more than one episode of pain it is usually short-lived. With good health and safety procedures in your workplace a recurrence, if any, should have a minimal effect. So it makes better sense to employ the best person for the job than to be overly concerned about whether back pain will recur. Is it a claim There can be many factors involved in acute low back pain - it's not always due to injury. The treatment provider must decide if their patient should make a claim by considering all the circumstances surrounding the onset of pain and taking a fair view.

UK health care for back pain

The cost of back pain 413 back pain in 1994 413 We all spend our working lives treating individual patients, and it is difficult to see the broad picture of health care. Let us now try to look at it from a different perspective. What health care services and resources are devoted to back pain Let us look first at the UK, where the National Health Service (NHS) makes it easier to see the whole picture. Remember the background of need (Ch. 5). There are now 55 million people in the UK, but back trouble mainly affects adults, and the number of people aged 16 or over is 44 million. Roughly 27 million are employed 15 million men and 12 million women, although many women only work parttime. Thirty-seven percent of adults have back pain lasting at least 24 hours each year - that is about 16 million people. Three to four percent of those aged 16-44 years, and 5-7 of those aged 45-64 years, say their back trouble is a chronic illness. So, who gets health care for back pain in the UK Who do...

Unspecific low back pain

Low back pain may be caused by a variety of spinal structures, and may be inhibited or reinforced by the human mind 37 . Disorders discriminated by either characteristic history, symptoms, signs or pathophy-siologic features are described above. Clinical techniques developed by chiropractors, manual therapists and osteopaths, and various imaging procedures are widely used, but the diagnostic specificity of these procedures is either low or poorly documented with regard to the asymptomatic population. Furthermore, facet joint injections and discography may be used to discriminate pain elicted from these structures from muscular pain. However, the number of false-positive tests and the modest effectiveness of specific treatments have turned the focus to interaction of the various structures. Experimental studies have demonstrated the existence of neural pathways between various spinal structures and also between the sacro-iliac joint and the spinal and gluteal muscles (Fig. 6.5.1)....

The Cost Of Back Pain

It is difficult to get accurate figures on the cost of back pain in the UK. Different authors give widely varying figures (Coyle & Richardson 1994, Moffett et al 1995, Maniadakis & Gray 2000). There are the problems of estimating health care use for back pain that we have seen throughout this chapter. Costs within the state-funded NHS are somewhat artificial. Most previous calculations of social security costs used the basic benefit rate and did not allow for the actual level of benefit paid. Some authors have confused social security benefits with sickness absence (Ch. 5). Economists have great difficulty deciding how to calculate the employment-related costs of sickness absence. Days lost x average wages is probably an overestimate of lost production. The friction method is probably conservative. Table 19.14 gives my best estimate for the cost of back pain in the UK. Total NHS costs are now about 0.8 billion. Private health care is another 0.3 billion. But these health care...

The State Of Nhs Services For Back Pain In 1994

CSAG (1994) was a major Department of Health report on NHS services for back pain in the UK. We visited eight districts in different parts of the country. At each visit we met GPs and hospital specialists and heard about their experience. We looked at standards of care and compared them with clinical guidelines. Guidelines were new in the UK, but most people at the meetings welcomed them. However, few districts felt that they met these standards in 1994. We heard many common criticisms of services at that time put this into practice because there were no different NHS services for patients with different kinds of back trouble. The main problem was that, in practice, we did not separate patients with serious spinal disease and nerve root problems from those with ordinary backache. Most specialist services were designed to investigate and treat patients with serious spinal disease, nerve root problems, and those who might require surgery. Emergency and urgent referrals of these patients...

US health care for back pain

Back pain and disability in the US 419 Information available on health care 420 Who seeks health care and who do they see 421 The number of visits 421 Conventional medicine 422 Medical vs chiropractic care 423 What happens to them 424 Physical therapy 427 Physician beliefs and patient satisfaction 429 Hospitalization 430 Low back surgery 430 Regional variation 431 Health care for back pain in the US 433 Current trends in the US 433 The health care system in the US is very different from the UK and that affects the treatment Americans receive for back pain. There is no universal, federal health service in the US. Most treatment is provided in a competitive health care market, paid on an item of service basis. Funding is from many sources private health insurance, workers' compensation and government programs, and some from patients themselves. But about 15 of Americans have little or no health insurance. This system produces wide variations in treatment for a problem like back pain...

Health Care For Back Pain In The Us

Let me try to summarize health care for back pain in the US. About 70 million US adults have some low back pain each year and about 24 million have back pain lasting 2 weeks or more. There is no evidence that the prevalence of back pain in the US is changing or much different from that in Europe. Health care for back pain in the US is a curious mixture of dramatic contrasts. It is easy to forget that most Americans still deal with back pain themselves most of the time and get on with their lives more or less normally. Back pain is now the fifth most common reason for visiting a physician in the US and accounts for 2.8 of physician office visits. That is a total of about 16 million visits each year. The number of visits has remained fairly steady over the past decade. Conventional medical care includes two very different patterns. Two-thirds of patients with back pain get their treatment mainly in primary care. But about a third get treatment from medical specialists with a great deal...

Future health care for back pain

The problems with present health care for back pain 440 A new health care system for back pain 441 Principles of services for back pain 441 Key elements for a primary care service for back pain 444 A back pain rehabilitation service 446 Conclusion 448 Change in professional practice 448 Future research and development 451 Conclusion 453 Bibliography 454 This book has tried to chart recent developments and trends. It has presented the argument and the evidence for a new approach to back pain. To conclude, let me gaze in my crystal ball to see the future. This is a very personal view, though I have used ideas and material from many sources. I am particularly grateful to the Clinical Standards Advisory Group (CSAG) report on NHS services for back pain (CSAG 1994). A decade later, it is still one of the few attempts to consider how we should organize health care for back pain. I am well aware this is not the final answer, but simply offer it as a starting point for further research and...

Health care for ordinary backache

These proposals on how to treat back pain are all very well. 1 agree with most of them. But I can't do that. My local physiotherapy department has a 3-month waiting list. The only place I can refer patients with back pain is to the orthopedic I agree we do too many MR1 scans for back pain. But my patients all know about scans and they want to find out what's wrong. They expect to go and see a surgeon, and if I don't refer them they will just go themselves. The surgeons don't want to miss anything and are afraid they might be sued if they do. Then if the scan shows the slightest bulge, both patient and surgeon are hooked. You say that scans don't help the management of ordinary back pain, but how can I stop them I sometimes feel as if these ******* scans drive my whole clinical practice Leave aside the rights or wrongs of these two examples. The common message is that treatment will always be constrained by the services available. As Cherkin et al (1994) showed, who you see is what you...

Principles of services for back pain

Diagnostic triage and decisions about referral occur at the point of first contact in primary care. Primary care clinicians must detect the few patients with specific pathology among the vast majority with ordinary backache. Deyo & Phillips (1996) compared this to searching for the proverbial needle in a haystack. Because of the primary care filter, specialists have a much easier task to search for the needles in a smaller stack of hay. Primary care clinicians must also distinguish between what sometimes seem to be two very different groups of patients with non-specific back pain. Most patients seem to get better no matter what we do, and need little more than reassurance and advice. We need to identify as early as possible the few who are at risk of chronic pain and disability. Most management of non-specific low back pain is, and should be, in primary care (Box 21.2). The main responsibility of specialist services is to investigate and treat patients with serious spinal...

Key elements for a primary care service for back pain

If we are going to manage non-specific low back pain in primary care, we must provide the necessary health care facilities to make this possible (Box 21.3). These support services should be in primary care or provided by direct access to specialists or hospital services. The key issue is that they should be under the direct control and remain the responsibility of the primary health care provider. The exact form of such a service will vary in each health care system, and will depend on local needs and resources, and patient preferences. Box 21.3 A primary care service for back pain A multidisciplinary back pain rehabilitation service The place of radiology is in diagnostic triage and the work-up of patients with possible serious pathology or nerve root problems under consideration of surgery. It has little place in ordinary backache. There should be direct primary care access to plain X-rays and bone scans, provided we are always conscious of the role and limitations of these tests....

A back pain rehabilitation service

Better early management and better primary care services should greatly reduce the number of patients who need further referral. Ideally, we should be able to manage all patients with ordinary backache in primary care. However, no matter how much we improve management and services, there will always be some patients with persistent pain and disability. There is a point at which we must accept that primary care management is failing and that some patients need further help. And because of the enormous number with back pain, even a small proportion of failure will still create a large demand. CSAG (1994) considered how to reorganize these secondary services to best meet the needs of these patients. We got wide support for the idea of a back pain rehabilitation service (Box 21.4). This should be a dedicated service because of the number of patients and the resources it requires. These are Box 21.4 A dedicated, multidisciplinary, back pain rehabilitation service Led by a specialist with...

Understanding And Management Of Back Pain

The symptom of pain in the back is the common link between the ordinary backache that most people have at some time in their life, a number of serious spinal diseases, and low back disability. We should try to keep these different perspectives in mind as we look at the history of back pain. The oldest surviving text about back pain is the Edwin Smith papyrus from about 1500 bc (Fig. 4.1). It is a series of 48 case histories, the last of which is an acute back strain (Breasted 1930) Figure 4.1 The oldest surviving description of back pain. The Edwin Smith papyrus (c. 1500 bc). From Breasted (1930), with permission. Figure 4.1 The oldest surviving description of back pain. The Edwin Smith papyrus (c. 1500 bc). From Breasted (1930), with permission. At this tantalizing point the unknown Egyptian scribe died and the papyrus lay in his tomb for almost 3500 years. This is an early 20th-century translation that reflects thinking at that time, but the accuracy of the clinical description only...

What CAM treatments work best for the treatment of back pain

Popularity or personal testimonials do not prove or disprove treatment efficacy. CAM therapies are most frequently administered in combination with traditional therapeutic interventions for back pain using nonstandardized protocols. The medical evidence to support specific CAM treatments for back pain may be unavailable, insufficient, or conflicting depending on the specific intervention that is evaluated. Nevertheless, standardized reviews and randomized controlled trials have been published supporting CAM treatments, such as spinal manipulation and mobilization, acupuncture, prolotherapy, cognitive-behavioral therapy, and nutritional supplementation. Treatments should be pursued on an individual basis, taking into account the patient's total health picture. 1. Complementary and alternative medicine (CAM) therapies are most frequently administered in combination with traditional therapeutic interventions for back pain. 2. The medical evidence to support specific complementary and...

Changing Attitudes About Back Pain

The back pain revolution begins with changing perceptions about the nature of back pain and its significance. It involves rebutting the idea that back pain typically stems from a discrete injury or disease - or that activity and work are to be feared. This model prescribes a careful but streamlined approach to back pain in clinical settings. It allows the efficient identification of those with serious back problems - and encourages the rest to make a quick and confident return to normal life. It involves using creative psychosocial approaches to identify and overcome barriers to recovery. It recommends a variety of interventions -whatever it takes, really - keep back pain sufferers at work. It also involves tinkering with social welfare and disability systems to ensure that an active life holds greater allure than disability and invalidity. Prevention is a major thrust of this movement prevention of back pain's all too frequent consequences - withdrawal from normal activity, physical...

New Health Care System For Back Pain

How should we change professional practice and the health care system to deliver the new approach It seems logical to start by thinking how we would need to reorganize the health care system to deliver the kind of care recommended in current guidelines. This should let us find common principles of a good back pain service, even if we will always need to adapt the system to suit different circumstances and priorities in each country. Most specialist services for serious spinal pathology and nerve root problems are reasonably satisfactory, if patients are referred and seen without delay. The problem is to provide a better service for the large number of patients with ordinary backache. The aim is to deliver better health care for these patients, but these proposals should also lead to more efficient and cost-effective use of resources. First, let us consider the basic principles for such a service. Then let us apply these principles to the primary care services needed to manage ordinary...

Back pain

Back pain is extremely common, even in athletes. Repetitive, vigorous exercise such as gymnastics or high dives induces considerable spinal torques and stress over the pars interarticularis which may develop into microfractures and subsequently a bone defect. This defect (spondylolysis) may persist and, being painful, limit activity. With SPECT spatial separation of overlapping bony structures is possible improving the diagnostics of the anatomic localization of abnormal findings 44 . scintigraphically active pars interarticularis defect is associated with a healing process which may be causing pain (Fig. 5.1.26), while a normal bone scan in the presence of a radiographically demonstrable pars defect is consistent with an old, healed process, not likely to explain the low back pain 44 .


Backache is common after childbirth, 50 of women suffering at some stage in pregnancy. An anaesthetist is often called to assess patients with backache if they have received an epidural. Certainly, insertion of epidural anaesthesia may contribute to short-term acute back pain if it causes However, long-term backache is not caused by epidural anaesthesia, as has been clearly shown in two prospective studies of over 1000 women giving birth, followed up the day after delivery and 3 months later. The incidence of new-onset backache was of the order of 40-50 , but there was no difference in the incidence of backache at 3 months between those who had received an epidural and those who had not. There was a trend towards a slightly higher chance of back pain on day 1, explained by minor local trauma.

Low back pain

The lifetime, i-year and point prevalence of low back pain in the adult general population is reduced in persons who are physically active for at least 3 h week 23 . Back pain is more common in the general population than in former elite athletes 24 . Weight-lifting is associated with degeneration of the entire spine, and soccer with degeneration in the lower lumbar region. The prevalence of back pain and degeneration is low in runners. The incidence of chronic low back pain varied from 50 to 85 in a Swedish epidemiologic study including soccer and tennis players, wrestlers and gymnasts 25 . In 36-55 of the athletes, the radi-ologic examination was interpreted as abnormal. Low back pain is reported to interfere with sports activity at least once a year in about 30-40 of elite swimmers and more than 60 of elite cross-country skiers. The complaints in cross-country skiing are more related to the double-poling and diagonal stride techniques than to skating techniques 26 . Several...

An Intensive Research Effort

That the approach described in The Back Pain Revolution can succeed is not really in doubt. There have been tantalizing glimpses of the kinds of progress than even modest interventions can produce. A multimedia information campaign in Victoria, Australia - modeled on many of the concepts that Waddell and colleagues developed -produced lasting changes in the attitudes and behavior of health care professionals and the general public (see Buchbinder et al 2001). The on-going 'Working Backs' campaign in Scotland appears to be having a similarly impressive effect (see Burton & Waddell 2004). The concepts described in The Back Pain Revolution can also have a major impact on the culture of disability. The UK recently reported a 42 reduction in new awards of back pain-related disability benefits since the mid-1990s. In human terms, this is a spectacular achievement (see Waddell et al 2002).

Obstacles To Progress

Though the back pain revolution can succeed, it may not. There are cultural and institutional barriers to success. Important stakeholders - from governments to major industries - are still heavily invested in the back pain injury model and the back pain crisis itself. The back pain 'market' is a humming, economic machine that produces billions in revenue annually. Some segments of the medical establishment have been slow to abandon the old ways. Some health care providers fear needlessly that modern approaches to non-specific back pain might erode their influence or limit their options in treating patients with specific spinal diseases.

Blueprint For The Future

So who would benefit from reading The Back Pain Revolution It is essential reading for everyone in the back pain field medical and non-medical The Back Pain Revolution is a 'hands-on' manual for those involved in the provision of clinical back care. But it goes far beyond that it is also a guide to the major social, economic, and political issues affecting the back pain crisis. It is a call to arms and a blueprint for the future.

Differential Diagnosis

Most textbooks give long lists of diseases that cause back pain, but they are all rare. Indeed, some books apologize that these diseases are rare but important. Non-specific low back pain is at the end of the list, almost an afterthought, and diagnosis is by exclusion. Such lists do not reflect the incidence or importance of these conditions. I freely confess that I cannot think of every possible disease in my busy clinic. Also, most patients do not read medical textbooks and their symptoms and signs never quite fit the classic descriptions. In practice, it is almost impossible to match each patient against a long list of half-forgotten thumbnail sketches. So it should be no surprise this approach often results in misleading investigations and bad management. Diagnosis determines management. Whether we make the decision consciously, or do it without thinking, diagnostic triage of back pain is just as vital. It sets the pattern for referral, investigation, and management. It very much...

Is the pain coming from the back

The first step is to be sure that back pain is due to a musculoskeletal problem in the back. This is obvious, but we often take it for granted and sometimes forget other possibilities. We must exclude back pain due to disease elsewhere in the body. Back pain usually dominates the clinical picture of a low back problem and the patient often has other low back symptoms such as stiffness and tenderness. Occasionally, back pain comes from the abdominal or pelvic organs, but these rarely present as back pain alone. There are nearly always some gastrointestinal, urinary, or gynecologic symptoms. Renal lesions may give loin pain with classic radiation. If the history raises suspicion, you should palpate the abdomen and perform a rectal exam, but you do not need to do so in every patient with backache. Back pain may be only one part of a systemic musculoskeletal or rheumatologic problem, but this should be clear from the history. Low back pain often spreads to the buttocks and hips and you...

The role of investigations

Beware of shadows on the wall The more subtle danger is that imaging becomes a lazy substitute for a careful clinical history and exam, and proper clinical decision-making. There is growing concern about the amount of radiation from plain X-rays. A standard set of three lumbosacral views gives 120 times the radiation dose of a chest X-ray. These investigations are also expensive and use health care money that could be spent in better ways for the patient with ordinary backache.

The Major Clinical Problem

One of the most common fears of all health professionals working with back pain is that we will miss the patient with serious pathology. This is understandable, particularly in primary care where such pathology is rare. However, we are all so aware of the danger that with the present approach and reasonable care the risk is very low. We must get triage into perspective. Most back pain is benign and non-specific and all the serious problems put together are probably less than 5 . In the case of serious spinal pathology, it is better to err on the What is the back pain due to Back pain diagnostic triage Possible serious spinal Nerve root problem Simple backache Figure 2.13 Differential diagnosis flow chart diagnostic triage of a patient presenting with low back pain with or without sciatica. GU, genitourinary PH, previous history HIV, human immunodeficiency virus LBP, low back pain SLR, straight leg raising. After CSAG (1994), with permission.

Disability questionnaires

This list contains some sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you today. As you read the list, think of yourself today. When you read a sentence that describes you today, put a tick against it. If the sentence does not describe you, then leave the space blank and go to the next one. Remember, only tick the sentence if you are sure it describes you today. The Roland disability questionnaire (Box 3.1) is simple, quick, and easy to use. It is sensitive to change (Beaton 2000), and gives the best measure of early and acute disability and recovery. Its main disadvantage is that it is less able to measure very severe levels of chronic disability. I believe the Roland disability questionnaire is the best available at present, for most clinical use and research on back pain in primary care. 15. My appetite is not very good because of my back pain. 19. Because of my back pain,...

Classification of chronic pain and disability

Chronic low back pain is not the same as chronic pain-related disability. So it may be better to classify pain and functional outcomes over time. von Korff et al (1992) developed a simple method of grading the severity of chronic back pain and disability. They originally designed this for population studies and tested it on 2389 American Table 3.5 Factors influencing the diagnosis of chronic low back pain

Physical performance measures

Simpler clinical test batteries can also directly observe the patient's capacity to perform everyday activities in a controlled setting. Harding et al (1994) developed such a battery for severely disabled patients with various chronic pain problems. Box 3.2 shows a simplified version they now use in routine clinical practice. They found the tests reliable and sensitive to change after a pain management program. Simmonds' group developed a similar but more comprehensive battery for patients with low back pain (Simmonds et al 1998, Novy et al 2002, Simmonds 2002). They again found it to be simple and easy to use, acceptable to patients, and reliable. On analysis, the tests fell into two groups. The larger and more powerful group assesses speed and coordination. The smaller assesses endurance, strength, and balance. Individual performance tests showed moderate Several studies in back pain have used the shuttle walk test alone (Box 3.3). This is again a general measure of fitness or...

Orthopedic principles

Modern medical treatment for back pain is closely linked to the emergence of the specialty of orthopedics. Early orthopedics was mainly about childhood deformities, and orthopedics first took an interest in sciatica because of sciatic scoliosis. From these roots, orthopedics expanded in the second half of the 19th century to include all musculoskeletal problems. Interest in spinal deformities spread to sciatica and back pain, and focused on the spine. Previously, back pain and sciatica were regarded as separate diseases. From now on, they were linked in the spine. Ever since, failure to distinguish our ideas and treatment of back pain and sciatica has caused much confusion, which continues to this day. There was no precedent for the scale of casualties in World War I. For the first time, medical concern with trauma matched previous concern with disease. It also brought the treatment of fractures within the scope of orthopedics. Between the two world wars orthopedic surgeons struggled...

The epidemiology of back

The South Manchester Study 72 The frequency of back pain 73 Time-course 75 Nerve root pain 76 Comorbidity 76 Low back disability 77 Work loss 78 Sickness benefits 80 Trends over time 81 Pain 81 What is the impact of back pain today There is no doubt it is a common problem, however we judge it. We may look at back pain as a symptom in the general population, as disability, as a reason for health care, or in terms of short- and long-term work loss. By any of these measures, back pain is a major problem. But do we really have an epidemic of low back pain As we saw in Chapter 3, we must consider pain and disability separately. First, we will look at the occurrence of back pain today. Then we will look at the present scale of low back disability. Finally, we will try to see whether back pain and disability are changing.

Trends Over Time Pain

Palmer et al (2000) claimed that there was a dramatic increase in the prevalence of back pain in the UK between 1988 and 1998. However, there were problems to their study that cast doubt on this conclusion. It was based on a single question in two very different surveys. A second question showed no change in disability. Macfarlane et al (2000) looked at two more comparable surveys and found a slight decrease in prevalence between 1991 and 1998. (1994) reported that the prevalence of back pain stayed the same from 1978 to 1992. Preliminary analysis of further data up to 1997 suggests that, if anything, the prevalence may have fallen slightly (P Leino, personal communication). There were three detailed and identical Omnibus surveys on back pain in the UK between 1993 and 1998 (Table 5.10). An unpublished Scottish survey in 2001 gave similar findings. These show no significant change in the prevalence of back pain or disability over the past decade. Both the historic review and modern...

Workrelated back injuries

Table 5.10 Prevalence of back pain in Britain 1993-2001 Scotland only. Slightly different questions. 'Of those with back pain. c0f those with back pain and employed. Based on data from the Omnibus surveys. That trend has reversed from about the late 1980s or early 1990s. US Bureau of Labor statistics ( workcomp 1997-98Data) show that the number of all occupational injuries and illnesses with days off work fell steadily from 2.6 million in 1991 to 1.7 million in 1998. Table 5.11 shows data on back pain from one large workers' compensation provider that covers 10 of the privately insured labor force (Hashemi et al 1998,

Physical demands of work

The study was not designed to assess the relation between overload damage and symptoms, but some data happened to be available. One cohort with overload damage did not have any higher prevalence of back pain. Another cohort with a high prevalence of back pain did not show overload damage. So even mechanical overload damage did not necessarily result in symptoms. Even if modern work does not cause any structural damage, it is still important to ask whether it is a risk factor for back pain. Since the classic study by Magora (1970), there have been hundreds of studies on the relation between physical demands of work and back pain. There are also many good reviews (Burdorf & Sorock 1997, Bigos et al 1996, Hoogendoorn et al 1999, Videman & Battie 1999, Waddell & Burton 2000, Adams et al 2002). The UK Occupational Health Guidelines (Carter & Birrell 2000, Waddell & Burton 2000) tried to summarize the evidence on the complex relationships between physical demands of work and...

Static work postures and sitting

Several early cross-sectional studies suggested that there was an association between sitting and back pain. This was linked to biomechanical theories about raised disk pressure, but we have already seen these findings were suspect. Moreover, this is static loading and any pressure is very low compared with that required to cause experimental damage. We have already discussed the more sophisticated U-shaped model of risk. Despite these theories, there is no actual biomechanical evidence that sitting damages the spine. Hartvigsen et al (2000) reviewed 35 epidemiologic studies on sitting. Only eight had a satisfactory experimental design. Only one showed any significant relation between prolonged sitting at work and low back pain. Seven out of eight showed no effect. They concluded that the extensive evidence now available does not support the popular belief that sitting is a risk factor for back pain. Seating has fluctuated greatly over the centuries in different cultures, from upright...

Driving and exposure to wholebody vibration

Kjellberg et al (1994) and Wickstrom et al (1994) made an extensive review of the health effects of whole-body vibration. They concluded that there was extensive evidence of an association with low back pain. However, at that time there was insufficient evidence to establish the exposure-response relationship. Lings & Leboeuf-Yde (2000) reviewed the more recent epidemiologic evidence. They concluded that there is strong evidence that driving is a risk factor for back pain and limited evidence for disk prolapse. However, there is only weak evidence on a dose-response relationship. The effect size is moderate Burdorf & Sorock (1997) found RR or OR generally ranging from about 1.5 to 3.9. Lings & Leboeuf-Yde (2000) concluded that there is good reason to reduce exposure to whole-body vibration to the lowest practical level. Modern, damped, vehicle seats probably achieve this. There is little evidence of harm occurring on such modern seats. Perhaps being deliberately provocative,...

Leisure activities and sports

Hoogendoorn et al (1999) reviewed 17 studies of sports and physical activity during leisure time. The results were inconsistent. There is no clear evidence that most sports activity or total physical activity during leisure time are risk factors for back pain. Most important, leisure activities such as swimming, walking, running, cycling, golf, or physical exercise do not appear to carry any risk. Overall, the prevalence of back pain is no higher in those who are physically active or take part in general athletic activities. On the contrary, as we saw earlier, improved physical and mental health and physical fitness are likely to be beneficial. There is limited evidence that certain strenuous sports such as weightlifting and gymnastics may carry an increased risk of disk degeneration and vertebral damage (Sward et al 1990,1991 Videman et al 1995). Some high-level and competitive sports may also be associated with an increased prevalence of back pain. That link could, however, involve...

Interactions between physical and psychosocial demands of work

Even more fascinating are possible interactions between physical demands and psychosocial aspects of work. A few years ago, there was an argument about which were more important risk factors in back pain, but that was naive. Both may play a role. So the real question is whether and how they might have an additive or interactive effect. Davis & Heaney (2000) provided one of the most thoughtful reviews of these complex relationships (Fig. 6.5). They suggested three potential links. First, physical demands and psychosocial factors could each contribute independently to the onset or consequences of back pain. These might also have an additive effect. Second, psychosocial factors may modulate the relation between physical demands and back pain. For example, poor psychosocial conditions might reduce ability to cope with physical demands that would otherwise be tolerated. Third, physical demands and psychosocial aspects may co-vary. Many jobs involve both greater physical demands and...

Approaches to prevention and control

Occupational back pain is an enormous problem, and the ideal answer would be to prevent it. Biomechanic and ergonomic approaches aim to reduce back injuries by controlling physical hazards and potential risk factors. This primary prevention may be an unrealistic goal (Burton 1997). Reviews by van Poppel et al (1997) and Linton & van Tulder (2001) could not find good evidence on the effectiveness of primary prevention. Historically, this approach seems to have helped control more extreme physical demands and risks of work in previous generations. But there is little evidence that modern work is damaging to the back. So it is not surprising that there is also little evidence that this approach is effective in reducing the incidence of back trouble. And as back pain is so common, perhaps the goal of primary prevention is unrealistic. Table 6.5 Summary of the evidence on risk factors for back pain of back pain of comfort and enabling workers with back pain to cope (whatever the cause...

What should we tell patients

The review of individual risk factors suggests that most of us are going to get back pain at some time in our lives. It does not make much difference whether we are male or female, young or old, tall and thin, or small and fat. There is not a lot we can do about these personal characteristics in any event, but we do not need to worry about them. We may all be fated to have some back pain, but there is nothing in our genes that dictates it will inevitably lead to chronic pain and disability. This has implications for what we tell patients. Too often, we tell them that they have back pain because they are too tall, too fat, the wrong build, or their legs are of unequal lengths. This is nonsense, and it is a dangerous message because it implies their back pain is inevitable and there is nothing that they or we can do about it. It is good general health advice to stop smoking, avoid excess weight, and be physically fit. This will probably make little difference to the chances of getting...

The Course Of A Clinical Episode

Most people have back symptoms at some time in their lives, and about 40 have back pain each year and each month. Back pain is a recurrent and fluctuating symptom and we must view any clinical episode against that background. Clinical teaching used to be that 75-90 of acute attacks of low back pain recover within about 4-6 weeks. This figure is quite consistent in clinical series over the past 40 years. Vernon (1991) looked closely at a small group of chiropractic patients. He found 25 improvement in pain, disability, and lumbar flexion in 7-10 days 50 improvement took 2-3 weeks 75 improvement varied from 4-6 weeks and 100 improvement took 6-9 weeks or more. Disability and lumbar movement lagged behind improvement in pain. This is a typical picture of a clinical episode, but it is a limited, health care perspective. In contrast, Lloyd & Troup (1983) found that 70 of people still had residual symptoms when they returned to work. Also, when we view back...

Assessment Of Severity

One of the most important measures of any illness is its severity, which helps to determine the impact on patients, the health care system, and society. Patients and their families are most concerned about severity of pain and its interference with their lives. The amount and type of treatment a patient receives depend on severity, particularly in a non-specific condition such as back pain. Fair and consistent rating of permanent impairment or incapacity for work is part of the legal basis for In most chronic disorders with clear pathology -such as osteoarthritis of the hip - assessment of severity is quite straightforward. Clinical assessment is reliable and valid, and different experts will agree. The patient's report of pain, disability, and (in)capacity for work is usually more or less in proportion to the diagnosis and the physical findings. But this is not the case in chronic back pain. Here, we often cannot diagnose any pathology. Clinical examination may not even be able to...

Methods Of Rating Physical Impairment

Even if we agree on the principles of assessing lumbar impairment, it is difficult to put into practice. In the US, there has been constant effort to improve and standardize impairment ratings. The AMA Guides to the Evaluation of Permanent Impairment (AMA 2000) is now the standard for most musculoskeletal conditions. It is in its fifth edition and has been adopted as the official guide in 80 of states. It is also used in Canada and Australia. However, it has been attacked in court for having no scientific basis. It is a consensus document based on clinical experience and agreement about what is reasonable impairment. There is no scientific proof of the reliability or validity of the Guides, but they do give a more consistent rating than relying only on an expert's opinion. When it comes to back pain, however, the Guides are much less satisfactory. It may be worth reviewing the problems of various systems of rating lumbar impairment.

Interpretation of physical impairment

This is a comprehensive group of clinical tests for physical impairment in non-specific low back pain (Table 8.1). It includes spinal movement, SLR, spinal tenderness and strength tests. It has some similarities to the AMA Guides DRE and ROM models, and to Moffroid's scale. In our study, it discriminated patients with back pain from normal subjects and helped to explain low back disability. It provides an objective, clinical check on the patient's own report of disability. To interpret this scale we must look again at the definition of impairment. This is a pragmatic method based entirely on clinical findings. It does not depend on pathologic or clinical diagnosis. Our previous study showed that the only permanent lumbar impairments were structural deformities, fractures, surgical scarring, and neurologic deficits. None of these apply to the patient with non-specific low back pain, and they do not appear in the present scale. This method provides an objective clinical evaluation, but...

Impairment And Disability

Back pain, impairment, and disability go together in clinical practice. The very definitions of impairment and disability relate them to each other. Impairment is that which causes disability disability is that which results from impairment. But it is not a 1 1 relationship (Fig. 8.10). Many other studies have shown similar results. We often see patients with severe pain and disability, in whom we can find little impairment. Other people have severe pain or impairment, yet refuse to admit they have much disability. Disability must depend on other influences, as well as pain and impairment. Before we look at these other influences in the following chapters, we should stop and reflect further on impairment and disability (Fordyce 1995). The limitation is that we cannot assess back pain we can only assess the person with back pain. We cannot separate body and mind. Pain, suffering, and pain behavior all confound our assessment of impairment. Physical defects shape the person's beliefs...

The physical basis of back

A structural basis for back pain 155 So there is no doubt, let me state very clearly back pain is a physical problem. Over the past 25 years, we have focused a lot (perhaps too much at times) on psychosocial issues. Psychosocial factors influence how patients respond to back pain and they are important in low back disability, but they do not cause the pain. Back pain is not a psychological problem. Back pain starts with a physical problem in the back. So, what is the physical basis of non-specific low back pain It is time to look at the basic science. Most books about back pain start with chapters on the anatomy and pathology of the spine. Ian Macnab described this as a form of Brownian movement it seems very busy, but is really mindless and serves no useful purpose. He then went ahead and started that way, anyway You already know I resisted that temptation, deliberately. I firmly believe that we must start with the clinical problem, and only then look for the basic science that helps...

Clinical Characteristics

It is mechanical in the sense that symptoms arise from the Box 9.1 Mechanical low back pain Low back pain is often referred to the buttocks and thighs Table 9.1 Effect of physical activities on back pain in 200 osteopathic patients Table 9.1 Effect of physical activities on back pain in 200 osteopathic patients Fiddler (1980) surveyed the members of the International Society for the Study of the Lumbar Spine (ISSLS). They described a mechanical syndrome for non-specific back pain without nerve root involvement (Box 9.1). Different authors describe these as movement disorders or activity-related spinal disorders. These clinicians focused on what made the pain worse. However, Tables 9.1 and 9.2 show that various activities can make back pain either better or worse. Different activities may have opposite effects in different patients. It would be ideal if we could find patterns that might help to classify different types of back pain, but unfortunately...

The pelvis and sacroiliac joints

There is long-standing dispute about the possible role of the sacroiliac joints in back pain. The closely matched shape of these joints and the strong surrounding ligaments make it very unlikely that they are often damaged. However, the sacroiliac joints do permit a few degrees of movement and protective give in the pelvis. They again contain proprioceptors. So the sacroiliac joints could be subject to abnormal strains and could give rise to pain. They could play a role in the compound function or dysfunction of the lower back.

Clinical Concepts Of Dysfunction

Structure and function are intimately related. The previous section used structure as the starting point to understand disturbed function. Let us now approach the problem from the opposite direction and consider dysfunction per se as a possible explanation for back pain. Once again, let us start from clinical findings and then see if biomechanics and physiology can help to explain them. Alternative medicine has more than a century of astute clinical observation of the musculoskeletal system. It is worth the effort of trying to integrate this into medical and biomechanical research. Osteopathy, chiropractic, and physical therapy each use different terms and emphasize different features, but they share many underlying ideas about back pain. The key concept is of a painful musculoskeletal dysfunction, which may occur in tissues that are structurally normal. It is a primary dysfunction arising in response to abnormal forces imposed on or generated within the musculoskeletal system. Normal...

Altered patterns of movement

Early concepts of vertebrae or disks actually being out of place are now largely discredited. They placed too much emphasis on anatomy and structural pathology for which there is little evidence. Many manual therapists still focus on limitation of movement, but this is also now under question. We saw in Chapter 8 that the range of lumbar flexion is more or less normal in patients with chronic low back pain. Burton et al (1989,1990) questioned the role of simple limitation of movement in back

Abnormal mechanical loading

Figure 9.7 (A) Trophedema due to disturbed autonomic function in a patient with acute low back pain. (B) Normal. From Dr C C Gunn, with thanks. Figure 9.7 (A) Trophedema due to disturbed autonomic function in a patient with acute low back pain. (B) Normal. From Dr C C Gunn, with thanks. Small changes in posture and spinal loading, particularly over time, might generate stress concentrations. Abnormal posture involves changes in the orientation of adjacent vertebrae. Muscle spasm and high forces in antagonistic muscles increase the compressive forces and loading on the spine. Sustained loading causes creep, which may alter anatomic relationships. Loading, posture, and creep may alter the biomechanical properties, and produce high stress concentrations in the disks, facet joints, and ligaments. However, there is little direct evidence these mechanisms are important in back pain.

Disturbed lumbar motion

Marras et al (1999) studied back motion in 335 patients with chronic low back pain and 374 healthy, asymptomatic subjects. They considered symmetric and asymmetric motion in flexion-extension, lateral bending, and rotation. They not only measured range of motion, but also velocity and acceleration. The emphasis was on the performance of tasks. Using complex equations that reflect patterns of movement, they were able to discriminate patients from healthy subjects with up to 94 accuracy. They found greater differences in velocity and acceleration than in range of motion. Performance was reduced more in asymmetric tasks. Most interesting for the present discussion, they found that motion profiles were very different in low back pain of muscular vs structural origin. They then used these measures to track patients over time and against response to treatment. As pain improved, so did velocity and acceleration (but not range of motion). Patients with persistent pain did not show any such...

Disturbed muscle function

Isokinetic and isoinertial studies provide objective, dynamic measurement of trunk strength during movement (Mayer & Gatchel 1988). These measures are reliable and valid (Newton et al 1993). They show clearly that patients with low back pain have reduced strength compared with normal, asymptomatic subjects (Fig. 18.5, Ch. 18). These tests can monitor clinical progress. At least in theory, they can provide information to direct rehabilitation to meet individual needs. There are many studies showing loss of muscle endurance associated with low back pain. Biering-Sorensen (1984) described the most widely used clinical test (Fig. 9.8). Most studies show that it is reliable and it differentiates patients with low back pain and normal, asymptomatic subjects (Latimer et al 1999). Once again, it can monitor clinical progress and rehabilitation. Marras et al (1999) and Adams et al (2002) reviewed the extensive EMG studies in back pain. These show various disturbances in electrical activity...

Ability or performance

We have still not fully resolved the recurring question about physical dysfunction. To what extent is it loss of physical capacity and ability, and how much is it a matter of performance There is no question that there are objective physical changes in the muscles and backs of patients with low back pain (certainly by the chronic stage and probably from a much earlier stage). But much of what we measure clinically and biomechanically is performance. (Loss of) physical ability and physical performance go together and we can never separate them completely. In an award-winning study, Mannion and her colleagues looked at the biomechanical effects of rehabilitation (Mannion et al 1999, 2001a, b, Kaser et al 2001). This was a randomized controlled trial of 148 patients with chronic low back pain. It compared active physiotherapy, muscle reconditioning on training devices, and low-impact aerobics. Pain intensity, frequency, and disability improved after all three treatments and these effects...

History of illness behavior in daily life

These methods of assessing pain, behavioral symptoms and signs, and overt pain behavior are all measures of illness presentation in the context of a clinical history and examination. They provide useful information, but may be peculiar to the health care situation and may be colored by patient-professional communication. We now have several other powerful measures of illness behavior in daily life. These are all illness behaviors in chronic back pain and sciatica. They are of much less significance for a few days in an acute attack. They are obviously not a matter of illness behavior in patients with serious spinal pathology or widespread neurology. This includes use of one or two canes, crutches, or even a wheelchair because of chronic back pain (Fig. 10.13). These patients do not have any gross structural instability or major neurology. There is no physical reason why they are unable to walk. Indeed, when you examine them, they do usually walk more or less normally for a short...

The Concept Of Illness Behavior

Illness behavior is a normal part of human illness, and back pain is no different from any other illness. In most patients, illness behavior is in proportion to their physical problem. In some patients, however, illness behavior gets out of proportion and reflects these psychological and behavioral processes more than the underlying physical disorder. Illness behavior may then aggravate and perpetuate pain and suffering and disability. It becomes counterproductive and is then part of the continuing problem. However, this does not mean that there is normal and abnormal illness behavior. All illness behavior is part of human illness. It is a spectrum, and it does not help to label it normal or abnormal. It is more important to try to understand how each patient is reacting to and dealing with his or her illness.

Increased bodily awareness

Main (1983) explored the concept of somatic awareness. Most patients with back pain are naturally anxious and concerned about their pain. Some describe symptoms of increased sympathetic activity, which are closely allied to anxiety, but few meet the criteria for anxiety neurosis. Many show an understandable focus on their physical problem, but few meet the criteria for hypochondriasis. The common theme seems to be that they are simply more aware of their bodily sensations and function. Main (1983) then developed a Modified Somatic Perception Questionnaire (MSPQ Fig. 11.1). Usually, this is best understood as a normal emotional reaction to illness rather than a psychological disturbance or psychiatric illness.

Psychological questionnaires

Changes in low back pain are increased bodily awareness and depressive symptoms. So we recommend the MSPQ (Fig. 11.1) and the Modified Zung Depression Inventory (Fig. 11.2 Zung 1965, Main & Waddell 1984). These also form the basis of the Distress and Risk Assessment Method (DRAM Main et al 1992). The DRAM is a simple

Chris J Main Gordon Waddell

The nature of beliefs 221 Beliefs about pain and illness 222 Beliefs about damage 222 Fear of hurt and harm 224 Fear-avoidance beliefs 225 Personal responsibility and control 229 Beliefs about treatment 230 Beliefs about work 230 Coping with pain and disability 231 Coping with back pain 232 Beliefs, emotions, and the development of disability 233 Healthcare 234 How beliefs affect health care 234 How health care influences beliefs about back pain 235 Clinical management 236 Conclusion 237 References 237 How people think and feel about back pain is central to what they do about it and how it affects them (Fig. 12.1). In Chapter 11 we looked at feelings and emotions. It is now time to look at how people think about back pain - their beliefs about the pain, about what they should do about it, about health care, about work, and about what it means for their future.

Beliefs about pain and illness

These beliefs provide a framework for us to make sense of illness and how to deal with it. They influence our decisions about health care and sickness absence from work. Every patient brings a set of beliefs to the consulting room. Indeed, the fact that they consult at all shows certain beliefs about health care. Earlier psychological studies focused on general beliefs, and we have only recently begun to appreciate the importance of specific beliefs about back pain. Beliefs play an important role in the

Fear of hurt and harm

There is increasing evidence that fear of pain, and fear of hurt and harm, is a fundamental mechanism in low back pain and disability (Vlaeyen & Linton 2000, 2002). In the first instance, most people's reaction to back pain is instinctive and automatic they try to avoid what seemed to be the cause of the pain. However, fear may then lead to continued attempts to avoid that situation. Up to a point this is reasonable. Unfortunately, depending on circumstances, patients may develop all sorts of misunderstandings about back pain. The intensity of fear depends on the context of the pain, and particular situations will be more likely to cause painful memories and fear (Turk et al 1996). Fear may become associated not only with recurrent injury, but also with pain itself. Such fears may develop into fixed beliefs about hurt and harm. treatment that involves pain, e.g., trying to mobilize. They may even give up treatment or rehabilitation altogether. Inappropriate fears about back pain,...

How beliefs affect health care

Beliefs about back pain determine what we do about it, including the health care we seek and how we respond to treatment. We have rev iewed the spectrum of beliefs and coping strategies that affect health care for back pain. At one end of the spectrum are people with back pain who are not unduly concerned about it. At the other end of the spectrum are patients to whom back pain is a serious problem that takes over their attention and their lives. Fear dominates their approach. They are convinced it is due to some serious disease, which no one has yet been able to identify. They are pessimistic about the future, believing they will continue to have back pain permanently and that sooner or later it will disable them. They feel it is all out of their control, and there is nothing they can do about it. It is up to health professionals to find out what is wrong and to cure them. Their beliefs are fixed and difficult to change. They do not accept reassurance easily, and may seek repeated...

Other biopsychosocial material

Linton & Andersson (2000) in Sweden carried out an RCT of three forms of information. Their aim was to prevent long-term disability in patients with acute or subacute low back pain. The main intervention was a cognitive-behavioral program (Ch. 18) of six 2-hour group sessions. The goals were to reassure and activate patients, correct dysfunctional beliefs, and promote coping. Patients in the two control groups received either a Swedish translation of the Symonds leaflet, or a package of more conventional biomedical material. All patients received usual care. All three groups showed improvement in pain, fear avoidance, and catastrophizing. The cognitive-behavioral group had a ninefold reduction in the risk of > 30 days' sickness absence in the next 6 months. They also used less health care. Clearly, the cognitive-behavioral intervention was by far the most effective. However, suitable pamphlets might be a cheap and cost-effective alternative for some patients at lower risk. There...

Low backs can be a pain

Acute low back pain is very common and causes significant costs in terms of suffering, lost work time and profitability, treatment and compensation. But the latest findings from around the world show that acute low back pain can be effectively managed. And one of the most important key players is you - the employer. This guide brings you up to date information, and outlines strategies you can use in your workplace to minimise the impact on both your business and your employees. You might find some of it quite surprising - ideas on how to manage acute low back pain have undergone a radical reversal. We have focused entirely on the management of acute low back pain - rather than covering prevention. Why Quite simply because, unlike with serious injuries, acute low back pain is common and it's almost impossible to prevent. And unfortunately it often results in lost work time - even when the pain didn't start at work.

Watch for those who need extra support

There are some people who find it harder to get back to work. They may have had back pain before, think work will harm their back, do heavy work or not always enjoy their job. It's important to keep a special eye out for these people - and it may help to call in a treatment provider early if you think the person needs extra support.

How can the treatment provider help

Unfortunately there is no quick fix for acute low back pain. The treatment provider can provide reassurance and encouragement to continue normal activities. And they can advise on pain relief, treatment, appropriate exercise and modifying activities (your functional job description will help them make decisions about suitable work tasks). They'll also check for any serious problems.

What if the pain recurs

Many people have more than one episode of acute low back pain. This doesn't mean that it's serious, although the pain may be severe and limit activity. There is strong evidence that the symptoms will pass quickly and that staying in work, with modified tasks if necessary, is the best treatment.

If your employee is off work

Has the Return to work plan in the Patient Guide to Acute Low Back Pain Management been completed Low back pain evidence-based recommendations Take back pain seriously whatever its cause it is the largest reported reason for sickness absence but it need not be. Help the back pain sufferer to stay at work. Consider temporarily adapting job demands if necessary. If sickness absence occurs, keep in touch and discuss how you can help the worker r with back pain return to work as soon as possible. Encourage early reporting of back pain and monitor sickness absences to he p Talk with the worker with back pain and those providing treatment to discuss how you can help. Involve your employees and their health and safety representatives to help you develop better plans to manage back pain and reduce its effect in the workplace. Consider initiatives to identify workplace factors and devise and review strategies for return to work.

Gordon Waddell Paul J Watson

Rehabilitation is now flavor of the month, and everyone wants to jump on the bandwagon. But what exactly is rehabilitation Despite what many doctors and therapists assume, it is not just health care. Nor better health care. Nor even earlier and more efficient delivery of health care. There is a strong argument for better, more timely, and more effective health care for back pain, but that is a separate issue. Health care and rehabilitation share some common goals, but there are differences in emphasis and in the means of reaching these goals (Table 18.1). At the simplest level, the goal of health care is to make people better the goal of rehabilitation is to enable them to return to normal activities. These goals overlap. Most patients with back pain do get better and return to their normal activities and work. So we can argue that routine clinical care does rehabilitate many patients, especially those who get better quickly. But the link is weak, especially for those who do not...

Obstacles To Recovery

The first requirement is that the physical capacity of the worker must match the physical demands of his or her job. However, this often leads to negative thinking about limitations and restrictions and incapacity. A few patients with back pain have severe physical restrictions and a few jobs have very heavy physical demands. But most people with back pain do not have any absolute physical limitation for most jobs in modern society. For many patients, that way of thinking may actually create an obstacle to return to work. Do you remember the discussion about ability and performance in Chapter 9 It may be more helpful to think about the patient's current activity level compared with the physical requirements of the job. We might overcome any imbalance either by improving the patient's activity level or reducing the demands by modified work, or sometimes both. But for most patients this should not be an insurmountable obstacle. This may be a much more positive approach that leads...

Exercise vs rehabilitation

Painkillers should be working soon, and that won't stop you walking. These therapists concentrate on getting her walking again. And, if she survives, this gives her the best chance of getting mobile, independent, and back to her own home. What a contrast with back pain Our argument is simply that therapists should apply the same rehabilitation principles and professional skills to back pain that they use in every other musculoskeletal condition (Fig. 18.2). People with back pain require a rationale for returning to activity a safe environment to engage in physical exercise to restore confidence in movement and the opportunity and encouragement to return to normal physical activity. It is the latter, where treatment becomes rehabilitation, that is the key to why physical exercise works. When patients ask What are the best exercises for back pain the answer is The one(s) that you actually do It's not what you do that matters, it's the fact that you do it.

Occupational Interventions

However, doctors and therapists must be careful with the idea of modified work. These trials showed that when the employer provides the opportunity for modified work, that facilitates return to work. We must always remember this is a workplace intervention, and depends on the employer. Doctors or therapists are often tempted to recommend return to light duties, but we often do this just to play safe. The trap is that many employers do not provide modified work. Our recommendation may then become a prescription only to return to light duties and actually be an obstacle to return to regular work (Hall et al 1994). Imposing restrictions may continue to medicalize the problem. It may create an adversarial situation with some employers. We must also be realistic. Most workers return quickly to their usual job and do not need modified work, so there is no need to raise the question. Employers can only provide a limited number of modified posts, and usually only for a limited period. We...

Functional Restoration

Mayer developed the first functional restoration program for chronic back pain in Dallas (Mayer et al 1985,1987, Mayer & Gatchel 1988). The focus was no longer on diagnosis or treatment but on promoting and maximizing functional abilities in the face of on-going pain (Teasell & Harth 1996). The general view is that these programs essentially ignore the complaint of pain, though Mayer argues that is not entirely true. Improved function often leads to less pain. In contrast, subjective expressions of pain usually do not improve unless there is improved function. Despite that argument, any impact on pain is clearly secondary. range of movement, strength, endurance, and aerobic capacity. The most novel element, however, was dynamic measurement of trunk strength using the new iso-machines (Fig. 18.5). This showed the importance of deconditioning. It also gave a tool to monitor progress and provide very graphic feedback to the patient. There have been two main claims about these...

The National Health Service

An appointment to see a family doctor. It takes weeks or even months to see a therapist. It takes months - sometimes many months - to see a specialist. You can wait weeks or months for a scan. You then join another waiting list for surgery and in some places that will take more than a year. Despite many political attempts at reform over the past 20 years, waiting lists are still a major problem. On the whole, the NHS is quite good at seeing urgent and emergency cases. The problem is how to provide an adequate service for the large numbers of routine patients - and most back pain is regarded as routine. Access to NHS service is through your family doctor or general practitioner (GP). Everyone in the UK has a GP and many people stay with the same GP for years. In principle, and often in practice, GPs know their patients. They know their medical histories and their social and family background. The GP is the gate keeper who controls referral to a specialist and the choice of specialist,...

Health care statistics

Population surveys depend on patients' memory of the health care they receive. The answers are subjective and there is no cross-check. The answers vary with the exact wording of the questions. The questions usually define a time period, often of 1 year, but the longer the period, the less accurate the answers. If a patient has had a lot of trouble, he or she is more likely to answer yes, even if that treatment was actually before the time period of the question. Many questions simply ask Have you seen 7 or Have you had but perhaps back pain was not the main reason for consulting. Patient and doctor may have different ideas of what the consultation was about. The patient may indeed have back pain, but the doctor may not think that was the main reason for consulting. For all these reasons, population surveys probably overestimate health care for back pain. Or they may overestimate serious health problems but underestimate minor problems because people forget. but this does not always...

Hospital outpatient clinics

In the UK, NHS patients see medical specialists in hospital outpatient clinics. Various sets of data suggest that about 1.6 million people attend an NHS specialist with back pain each year. Back pain is the reason for about 57 of all new outpatient visits in all adult specialties in NHS hospitals. The South Manchester Study gave the most detailed information, and there is no evidence this has changed. They found that the four back pain specialties were orthopedics, rheumatology, pain clinics, and neurosurgery. Every patient whose back pain was due to a spinal problem or a mechanical problem in his or her back went to one of these departments. Small numbers of patients going to other specialties had back pain at least in part the reason for referral. In all of these patients, however, the symptom of back pain was a minor part of some other condition. GP triage between primary back disorders and other non-spinal disease does seem to be reasonably accurate. Of the four back pain...

Total Health Care

Benn & Wood (1975) made one of the first attempts to estimate the size of the problem of back pain in the UK, using data from the 1950s and 1960s. At that time they found that about 2.7 of people consulted their GP with back disorders each year. Of these, 1 in 2.3 would see a hospital specialist, 1 in 4 would get a spinal support, 1 in 30 would be admitted to hospital, and 1 in 200 would have a disk operation. They pointed out that this pattern of health care looks very different to people with Figure 19.3 Estimated health care for back pain in the UK in 1985. From OHE (1985), with permission. Figure 19.3 Estimated health care for back pain in the UK in 1985. From OHE (1985), with permission. Figure 19.4 Estimated NHS care for back pain in the UK in 1993. Based on CSAG (1994). Figure 19.4 Estimated NHS care for back pain in the UK in 1993. Based on CSAG (1994). back pain and to health professionals. Few people with back pain in the UK received any specialist treatment, but the...

Recent Advances 19942003

There has been such a radical shift in thinking about back pain, that it is difficult to remember Table 19.15 UK initiatives on clinical management and health services for back pain Table 19.15 UK initiatives on clinical management and health services for back pain the Management of Low Back Pain Audit toolkit for acute back pain Back In work managing back pain National Back Pain Collaborative NHS. National Health Services LBP, Low back pain. NHS. National Health Services LBP, Low back pain. The question is, how much has changed in practice Most countries now have clinical guidelines and agree how back pain should be managed. Yet most have put much less effort into implementing the guidelines or looking at the implications for health care delivery. That is where the UK may differ (Waddell 2002). Table 19.15 lists the main UK initiatives since 1994. Little et al (1996) had doubts about whether family doctors' management at that time matched guidelines. Two surveys in 1996-1997...

Information Available On Health Care

Deyo et al (1994) reviewed official sources of data on US health care for back pain. The National Center for Health Statistics (NCHS) now provides more information online at nchs. Examination Surveys (NHANES) obtain health histories and include physical examinations. The National Health Interview Surveys ask questions about health status and health care use but do not include any examinations. The National Ambulatory Medical Care Surveys give record-based data on visits to office-based physicians. The National Hospital Discharge Surveys give record-based data on hospital discharges. Health insurance data such as workers' compensation, Medicare and Medicaid cover selected groups of patients. By their nature, all of these surveys collect general information about all conditions, so they give limited information about back pain. What they do is set back pain in the broader health care picture. The problem is finding your way through this labyrinth. In the past few years, more...

Who Seeks Health Care And Who Do They

We must always remember that there are two separate systems of health care for back pain in the US. Conventional medicine and alternative medicine are completely independent and competing. Conventional medicine offers a wide range of specialties. But alternative medicine also offers a wide range of choices, of which chiropractic is simply the largest and most powerful. There are fundamental differences in philosophy and practice between the different health care systems, even though they share some therapies in common.

Conventional medicine

The pattern of medical care for back pain seems to have stayed constant over many years (Cypress 1983, Deyo & Tsui-Wu 1987, Hart et al 1995, Shekelle et al 1995a, b). About two-thirds of medical care for back pain is in the primary care specialties of family practice, osteopathic medicine, and general internal Table 20.4 Specialty market share and workload of back pain in 1989-1990 Specialty Percentage market Back pain as a share of all back percentage of pain visits specialty office low back pain Table 20.4 shows the specialty market share of back pain visits and the proportion that back pain forms of each specialty's caseload. Most patients go directly to family doctors, DOs, and internists. Some patients are then referred to a specialist. But in the US, unlike in the UK, many patients go directly to a specialist of their choice without any screening. That applies to 55 of those who go to orthopedic surgeons, 27 to neurosurgeons, and 26 to neurologists. Table 20.5 shows back pain...

Physician beliefs and patient satisfaction

Bush et al (1993) found that primary care physicians in the late 1980s had little confidence in their ability to treat back pain. I lack the diagnostic tools or knowledge to effectively assess patients with back pain. There is little I can do to prevent patients with acute back pain from developing chronic back pain. I am very uncomfortable treating patients with low back pain. Chiropractors at that time were much more confident about their training and their ability to help patients with back pain (Cherkin et al 1988). They were more comfortable and less frustrated by spinal pain, which is just as well as it is two-thirds of their practice Despite the philosophic basis of chiropractic medicine, the chiropractors in this study firmly believed that back pain depends on physical factors that they can and should diagnose. Family doctors (MDs) were less certain about the physical basis of back pain and their ability to assess it. Medical doctors and physical therapists placed more...

Current Trends In The Us

What has happened to health care for back pain in the US since AHCPR (1994) This would seem to be one of the most important questions about back pain today, but we have no clear answer. We have data on trends of health care visits, hospitalizations, and operations. But there is a lack of up-to-date information on current professional practice and the care patients with back pain receive. I suspect there has been little change in the overall pattern of US health care for back pain since 1994 and the same trends continue. There is certainly no evidence of any major shift. It is more a question of continuing expansion in the types Evidence-based medicine suffered a major setback in the US with the political defeat of AHCPR (Waddell 2002). There is no strong guideline movement in the US, comparable to the UK and Europe. Despite that, or perhaps instead, most health care organizations are making some effort at managed care. Most have some kind of informal guideline, many of which are...

Back Pain Revealed

Back Pain Revealed

Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.

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