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...

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...

Assessment Of Physical Impairment

There are problems associated with all of the methods described above, so we tried to develop a new method of assessing lumbar impairment, starting from basic principles (Waddell et al 1992). Our study had three aims 1. to investigate physical impairment in patients with chronic low back pain 2. to develop a method of clinical evaluation suitable for routine use 3. to study the correlation between pain, disability, and physical impairment. Our study was on patients with chronic low back pain,...

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....

Social security benefits

Everyone must now be aware of the dramatic rise in social security benefits for back pain in all Days p a. per 1000 population at risk Days p a. per 1000 population at risk Figure 5.6 Male and female sickness and invalidity benefits for back incapacities in the UK, expressed as the rate per 1000 members of the eligible population. Based on statistics from the Department of Social Security. Figure 5.6 Male and female sickness and invalidity benefits for back incapacities in the UK, expressed as...

The interpretation of leg pain

One of the most common mistakes is to assume that all leg pain is sciatica, and must be due to a disk prolapse pressing on a nerve. That is false logic. Leg pain may be nerve root pain due to a disk prolapse pressing on a root, but more often it is not. Most leg pain is not nerve root pain, and has nothing to do with a disk prolapse. There is so much confusion about the term sciatica that it is better not to use it. Sciatica is pain in the distribution of the sciatic nerve, but different...

References

AAOS 2000 The Dartmouth atlas of musculoskeletal health care. American Academy of Orthopedic Surgeons, Rosemont, IL AHCPR 1994 Clinical practice guideline number 14. Acute low back problems in adults. Agency for Health Care Policy and Research, US Department of Health and Human Services, Rockville, MD Baldwin M L, Cote P, Frank J W, Johnson W G 2001 Cost-effectiveness studies of medical and chiropractic care for occupational low back pain a critical review of the literature. Spine Journal 1...

Deconditioning

Health and fitness depend on continued use use it or lose it. Normal musculoskeletal function depends on movement, physical activity, and regular exercise. These are essential for the development, maintenance, and continued function of the musculoskeletal system throughout life. They stimulate and maintain bone and muscle mass and strength, aid nutrition, help to maintain articular Abnormal patterns of movement Abnormal patterns of muscle activity Abnormal patterns of neurophysiology activity...

Sciatica

The word sciatica has been in use from Greek times, and is derived from ischias or pain around, or coming from, the hip and thigh. It was only with modern ideas of pathology that it came to mean pain in the distribution of the sciatic nerve. Hippocrates (460-370 bc) noted that ischiatic pain mainly affected men aged 40-60 years. In younger men it usually lasted 40 days. Contrary to modern ideas, radiation of pain to the foot had a good prognosis but pain that stayed in the hip was dreaded....

Major spinal deformity and widespread neurologic disorders

Major spinal deformity and widespread neurologic disorders are rare but should be obvious - again, provided you are aware. You should not miss a major deformity such as a kyphosis or structural scoliosis providing you get the patient to undress. This may seem obvious, but one recent survey found that more than 50 of patients with back pain said their doctor had never examined them. In backache the common deformity is a list (Fig. 2.2). Muscle spasm pulls the spine to one side when the patient...

Nonorganic or behavioral signs

In the same way, we have standardized a group of non-organic signs or, more accurately, behavioral responses to examination (Waddell et al 1980). We often assume that physical signs on clinical examination are objective. They are objective in the sense that they are assessed by an independent observer, but that does not necessarily mean they Table 10.1 The spectrum of clinical symptoms and signs Table 10.1 The spectrum of clinical symptoms and signs are purely physical and independent of the...

The back book

We wrote The Back Book (Roland et al 1996) to accompany the UK RCGP (1996) guidelines. At the time, it was innovative and challenged traditional teaching and advice about how to deal with back pain. We had difficulty getting any publisher to produce it, and released it with some trepidation. It is now the established market leader and has been translated into many languages. Building on that success, in the second edition (Roland et al 2002) we have been more confident about some of the...

The problem

Back pain was a 20th-century medical disaster and the legacy reverberates into the new millennium. Medicine has made great advances over the past two centuries and especially since World War II. We have developed powerful tools to treat disease. Medical technology and resources reached a peak in solving the mystery of life itself in DNA, in our ability to replace hip joints and even transplant hearts. We now have cures that past generations would literally have thought were miracles. We have...

Appendix 10a A Response To Critics

You might want to skip this section first time round. I have added it to this edition by popular demand, but by its nature you may find it heavier-going. It is not essential to the line of my main argument. It is almost 25 years since I first wrote up the non-organic signs (Waddell et al 1980), and none of my research has caused so much controversy. It continues to this day. So let me say straight out that I still stand by the non-organic signs, provided we are careful to define what they are...

Principles Of Rehabilitation

Can we pull this all together and extract some basic principles (Staal et al 2002) A biopsychosocial framework lets us relate the components of a rehab program to the obstacles to recovery they aim to overcome (Table 18.9). We must never forget the fundamental importance of good clinical management, with appropriate information and advice. Rehabilitation is no substitute, after bad, failed treatment. The primary goal for patients and health care is relief of pain. Many patients will then...

The clinical course of back pain

The onset of back pain 115 The course of a clinical episode 117 Return to work 120 Probability of return to work 122 The development of chronic pain and disability 123 Identifying patients at risk of chronic pain and disability 126 Clinical factors 128 Psychosocial factors 130 Sociodemographic factors 130 The accuracy of screening 130 Conclusion 134 References 134 Let us now return to the clinical picture. The last chapter was about predicting who gets back pain. This chapter is about what...

Psychological factors in illness behavior

There is strong clinical evidence that these clinical observations can also give us information about illness behavior (Table 10.2). We can clearly separate the behavioral symptoms and signs, both clinically and statistically, from the symptoms and signs of physical disease or impairment. They often spread far beyond any likely neurophysiologic mechanism and tend to a body image distribution. They are closely related to other observations of illness behavior. Illness behavior is closely related...

Gordon Waddell Maurits van Tulder

Acute Pain Service

Clinical guidelines 283 References 285 Appendix 15A The scientific evidence base 287 Cochrane reviews of treatment for low back pain 287 Appendix 15B RCGP 1999 Clinical Guidelines for the Management of Acute Low Back Pain 288 Appendix 15C Working Backs Scotland educational sheets for General practitioners therapy providers pharmacists 294 Appendix 15D Preliminary draft of European guidelines for the management of acute non-specific low back pain in primary care 297 Objectives 297 Target...

Kim Burton Gordon Waddell

Risk factors 92 Individual risk factors 94 Genetics 94 Gender 95 Age 95 Body build 97 Physical fitness 98 Smoking 98 Social class 98 Emotional distress 100 Environmental risk factors physical 101 Physical demands of work 102 Manual handling 103 Static work postures and sitting 104 Driving and exposure to whole-body vibration 105 Leisure activities and sports 105 Environmental risk factors psychosocial aspects of work 106 Summary of evidence 106 Interactions between physical and psychosocial...

Gordon Waddell Kim Burton

Information and advice 344 Outcomes 346 Occupational guidance 346 Sample guidelines 346 References 347 Appendix 17A UK Occupational Health Guidelines for the Management of Low Back Pain at Work 349 A Background 349 B Pre-placement assessment 350 C Prevention 352 D Assessment of the worker presenting with back pain 353 E Management principles for the worker presenting with back pain 354 F Management of the worker having difficulty returning to normal occupational duties at approximately 4-12...

The detection of serious spinal pathology

Prader Willi Syndrom

Serious spinal pathology accounts for less than 1 of all back pain. Serious pathology is rare, but one of our most important jobs is to detect it or to Box 2,4 General neurologic examination when there is a question of widespread neurology Brief sensory testing of the arms, the trunk dermatomes, and the saddle area Upper motor neurone signs in the legs include increased muscle tone, brisk reflexes, clonus, upgoing plantar reflexes, loss of position sense in the toes and loss of coordination in...

The results of functional restoration

The first two studies by Mayer et al (1985, 1987) and Hazard et al (1989) gave return to work rates of 85 and 81711. A review by Cutler et al (1994) concluded that functional restoration was effective. However, it is worth looking at these studies in some detail (Teasell & Harth 1996). The key thing is that they were not RCTs. Mayer et al (1985, 1987) studied 199 patients with chronic low back pain who had been off work an average of 13 months. These were selected patients in a workers'...

The South Manchester Study

The best evidence on the epidemiology of back pain is from large, longitudinal surveys of the general population. Let me describe the South Manchester Study because it is a good example, and may help us to understand such surveys. It appears frequently in Table 5.1 Reviews of the epidemiology of back pain Leboeuf-Yde Et Lauritsen (1995) Volinn (1997) Bressler et al (1999) Nachemson et al 2000 Review of Nordic studies to assess trends 1954-1992 26 in the prevalence of low back pain The...

Foreword

Nearly all adults experience back pain during their working lives. This common problem has become one of the leading causes of work loss in industrialised countries. It is clearly an expensive problem for our society, resulting in lost productivity and individual suffering. The effective management of back pain has undergone one of the most radical changes Stay active and modify activities if necessary Report pain if tasks or safety affected Tell work about difficult tasks Follow treatment...

The Development Of Chronic Pain And Disability

Let us relate this to clinical progress. After we rule out serious pathology, there are basically two kinds of patients with non-specific low back pain. Most patients who present with an acute attack get better quite rapidly, no matter what we do. They need little more than analgesics, reassurance, and advice. We can rely on nature to cure them, and our job is only to assist and make sure we do not obstruct that process. The other 10-20 are at risk of developing chronic pain and disability....

Fearavoidance beliefs

Fear Avoidance Model

With experimental pain in the laboratory, forewarning of pain may reduce its impact. Subjects cope better if they feel they have some control over what is happening. Lack of control makes pain feel more intense. In clinical pain also, expectations and fear of pain affect the intensity of pain, emotions, and pain behavior. Fear is a powerful negative drive in humans and in animals, closely allied to pain. Fear is to some extent an innate, inborn instinct, but to a greater extent it is learned....

Chris J Main Gordon Waddell

Early psychological studies in back pain 206 Personality 206 Misconceptions 207 The nature of stress and distress 208 Generalized vs specific distress 209 Clinical presentations 210 Anxiety 210 Increased bodily awareness 210 Fear and uncertainty 211 Depressive symptoms 211 Anger and hostility 213 Psychological questionnaires 214 Distress 216 Clinical management 216 Understanding 216 Communication 217 References 218 Think again about the two patients in Figure 10.1. It should be clear by now...

Medical vs chiropractic care

There is some uncertainty about whether patients who go to a chiropractor are comparable to those who go to a physician (Carey et al 1995b, Nyiendo et al 1996, Hurwitz et al 1998, Cherkin et al 2002, Coulter et al 2002). Some studies suggest they may have less pain and disability, but others suggest they have about the same. Most patients who attend a chiropractor have recurrent pain and anything from 30 to 80 have seen a chiropractor before. Forty to 50 attend within 3 weeks of onset of their...

Personal responsibility and control

Psychologists have shown that, from early childhood, one of our main goals is to try to gain some control over our world. The attempt to reduce uncertainty and establish control seems to be one of the most fundamental human drives. One of the key aspects of personality is the strength of this drive and the balance between our personal needs for control and the needs of others. These beliefs are probably not innate, but more likely a product of learning and social conditioning. Our...

Social interactions

Basic social issues 242 The social context 242 Social learning 243 Social support 244 The sick role 245 Social influences 246 Culture 246 The family 247 Social dass occupatkm education 249 Work 250 Job satisfaction and psychosocial aspects of work 250 Incapacity for work 251 Unemployment 252 Early retirement 253 Socioeconomic issues 255 Workers' compensation 255 Litigation 258 Social security 258 Healthcare 260 Conclusion 261 References 261 We often talk loosely about psychosocial factors, but...

AMA and AAOS

More practical methods of rating lumbar impairment began about 40 years ago. Both the AMA (AMA 1958) and the American Academy of Orthopedic Surgeons (AAOS AAOS 1962) produced guides to the evaluation of permanent impairment. Twenty years later, 60 of US surgeons used the AMA scale, 30 the AAOS scale, and only 5 the McBride system (Brand & Lehmann 1983). Today, the AMA Guides dominate the market. But the AMA and AAOS guides suffer similar problems. They work best in patients with objective...

Emotional distress

Patients with back pain often show emotional distress, but it is usually a secondary consequence of their pain and disability. Here, we are considering the converse is pre-existing distress a risk factor for developing back pain Let us look briefly at a couple of studies that tried to disentangle cause and effect. Mannion et al (1996) studied 403 female nurses and health workers aged 18-40 who had no previous history of serious low back pain, by which they meant no medical attention or work...

The neurophysiology of pain

Stimulation of a nociceptor produces impulses in peripheral nerves that enter the dorsal column of the spinal cord. Traditional physiology then described specific pain pathways in the spinal cord, leading to the sensory cortex. We might imagine it as a kind of giant telephone exchange. Pressing a peripheral button would ring a bell in the corresponding area of the cortex and bring the stimulus to conscious attention as pain. This oversimplification may seem attractive but it is inaccurate....

The dynasty of the disk

Bone Setting

Vesalius (1543) described the intervertebral disk, but that was of purely anatomic interest. In the 19th century there were a number of postmortem reports of major trauma and disk damage causing paraplegia. Luschka (1858) first described two cases of prolapsed intervertebral disk with a connection from the nucleus pulposus through the posterior longitudinal ligament to the protrusion. Later Schmorl (1929) and Andrae (1929) made postmortem studies of large series of spines and described both...

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) Examination....

Illness behavior

Examples of illness behavior in back pain 180 Clinical observation of illness behavior 182 The pain drawing 182 Behavioral symptoms 183 Non-organic or behavioral signs 185 Overt pain behavior 189 History of illness behavior in daily life 190 Observations of illness behavior 190 Important caveats 191 The concept of illness behavior 192 The physical basis of illness behavior 193 Psychological factors in illness behavior 193 How illness behavior affects clinical management 194 Appendix 10A A...

Probability of return to work

Probability Impact Healthcare

We can look at this graph of return to work in another way. For any given time off work, we can use the data in Figure 7.2 to calculate the probability of returning to work (Fig. 7.6). McGill (1968) first pointed out that the longer anyone is off work with back pain, the lower the chance he or she will return to work. More recent large data sets confirm this (Krause et al 1999). It is equally true today and it is fundamental to management. This may seem obvious, but many health professionals...

Acute and chronic pain

Doctors traditionally classify low back pain as acute or chronic. Acute pain is usually defined as being less than 6 weeks' duration. Many patients have recurrent attacks, but these often continue to be like acute pain. In the past, the definition of chronic pain was more than 6 months, which stressed its intractable nature. But 6 months is probably too late to begin thinking about and dealing with chronic pain, and many workers now classify chronic pain as being of more than 3 months'...