Low Back Pain: What Are We Doing Wrong and What Can We Do Better?

            Low back pain (LBP) is one of the largest causes of disability worldwide. Approximately 80-90% of people have LBP at some point in their lives. For most people with LBP the prognosis is good as the vast majority get better on their own and don’t need to seek treatment. However, despite an increase in research and treatment options, the rate of chronic LBP has alarmingly increased as of late¹.

            I initially wanted to call this article “Low Back Pain: What Are We Doing Wrong” but I decided to reframe it and try to provide some positive advice & alternatives to what is commonly done in healthcare. The purpose of this article is not to come up with a panacea for LBP as none exists but rather to show some areas that we as healthcare professionals (myself included) can improve on to reduce the impact of LBP on society.

Disclaimer: As outlined in this article my website is tailored towards professionals and is not intended to be medical advice for patients or lay people.

Disclaimer 2: As with some of my previous articles, to keep it short & not bog it down in references, this will not and should not be considered a systematic lit review.

So where are we going wrong with back pain?

1) Overimaging

One of the major issues in the LBP epidemic is the overuse of imaging technologies such as X-Rays and MRI scans.

Well won’t they show what’s wrong with my back?

The problem is that many PAINFREE people have degenerative disc disease, disc herniations and facet joint arthritis (among other things). As such it’s very difficult to rely on imaging as the sole method of diagnosis due to the higher number of false positives (i.e. positive findings in people WITHOUT back pain).

This table below came from a 2014 review done on PAINFREE people and shows that “abnormal” imaging findings are quite common in painfree people².

Now imaging does have a time in a place in certain situations such as

-          Suspected cancer, fracture, infection, cauda equina syndrome or inflammatory disease

-          Worsening neurological deficit (i.e. loss of sensation, reflexes and/or strength in an area innervated by a specific nerve root) that isn’t improving with treatment

However, back pain in and of itself is not an indication for an MRI and research shows that people who get unwarranted imaging actually do worse in the long term³. As such it’s appropriate to save medical imaging for the few times its indicated.

2) Lack of understanding of pain science & the biopsychosocial model

Many people think that pain is solely due to an injury or something wrong. In reality that’s not the case. Research has shown that only 10-20% of back pain cases are attributable to a specific diagnosis such a fracture, symptomatic disc herniation or other cause⁴. I often hear of people that were diagnosed as having a “pinched nerve” or “arthritis” or “degenerative disc disease” yet these diagnoses don’t match the symptomatic presentation that the patient has.

Side note: just because your clients’ back pain doesn’t fit into a specific pathoanatomical diagnosis doesn’t mean you can’t develop a specific treatment plan based on their presentation, general health, psychosocial factors, and goals.

Yet pain in reality is a product of the nervous system which can be caused by a variety of factors. Pain isn’t a sole 1:1 result of injury and can be influenced by biological, psychological and sociological factors⁵ and as such should be viewed as a complex, multifactorial experience.

3) Overpathologizing

Some may disagree with me, but I do believe that biomechanics are still important in pain & injury. The problem that I have is that many patients are diagnosed with “pseudobiomechanical” faults that either

-          Can’t be reliably assessed and/or

-          Don’t correlate well with pain^6–9

In some cases of back pain biomechanics can be relevant^10–12 – but too often we tend to assume that “pseudobiomechanical” faults are the root causes of back pain without doing a proper, thorough assessment of the individual such as the McGill Method and/or the McKenzie method.

The other issue is the impact of what clinicians say to people with back pain. Nocebo, the opposite of placebo, can have very powerful and negative effects on people’s pain¹³. If a patient is told that they’re a complete dysfunctional mess and should be in pain than they probably will be. Read this paper if you don’t believe me¹⁴. Using positive language is critical to helping your clients believe in themselves and their backs.  

4) Overuse of surgeries

Some back surgeries such as discectomies (disc removal) have very high rates of complications¹⁵ and spinal fusion surgeries have been shown to be no better than placebo surgery¹⁶. Following with points 1 & 2 many, unfortunately uneducated, people feel that by “cutting out” the cause of the pain than symptoms will reside but as stated above many of these findings are common in painfree populations & may not be clinically relevant. Going through surgery and failing can, in my opinion, create a nocebo effect and a sense of hopelessness in the patient.

Surgeries, as with imaging, have a time and a place – mostly for the same reasons. As such surgeries should only be performed when indicated.  

I hope this gives you, the reader, some ideas as to how you can improve your own practice.

As always I’m interested to hear your thoughts.

References

1.           Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating Chronic Back Pain: Time to Back Off? J Am Board Fam Med. 2009;22(1):62-68. doi:10.3122/jabfm.2009.01.080102.

2.           Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

3.           Darlow B, Forster BB, O’Sullivan K, O’Sullivan P. It is time to stop causing harm with inappropriate imaging for low back pain. Br J Sports Med. 2017;51(5):414-415. doi:10.1136/bjsports-2016-096741.

4.           O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther. 2005;10(4):242-255. doi:10.1016/j.math.2005.07.001.

5.           Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. J Pain. 2016;17(9):T70-T92. doi:10.1016/j.jpain.2016.01.001.

6.           Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002;10(1):24-39. doi:10.1179/106698102792209585.

7.           Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. J Can Chiropr Assoc. 2016;60(1):36-46. http://www.ncbi.nlm.nih.gov/pubmed/27069265. Accessed July 21, 2017.

8.           Tüzün C, Yorulmaz I, Cindaş A, Vatan S. Low back pain and posture. Clin Rheumatol. 1999;18(4):308-312. http://www.ncbi.nlm.nih.gov/pubmed/10468171. Accessed July 8, 2017.

9.           Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. J Bodyw Mov Ther. 2011;15(2):131-138. doi:10.1016/j.jbmt.2011.01.011.

10.         Rannisto S, Okuloff A, Uitti J, et al. Leg-length discrepancy is associated with low back pain among those who must stand while working. BMC Musculoskelet Disord. 2015;16(1):110. doi:10.1186/s12891-015-0571-9.

11.         McGill SM. Low Back Disorders: The Scientific Foundation for Prevention and Rehabilitation. Champaign, IL: Human Kinetics; 2002.

12.         Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015;36(12):2394-2399. doi:10.3174/ajnr.A4498.

13.         Petersen GL, Finnerup NB, Colloca L, et al. The magnitude of nocebo effects in pain: A meta-analysis. Pain. 2014;155(8):1426-1434. doi:10.1016/j.pain.2014.04.016.

14.         Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-534. doi:10.1370/afm.1518.

15.         Shriver MF, Xie JJ, Tye EY, et al. Lumbar microdiscectomy complication rates: a systematic review and meta-analysis. Neurosurg Focus. 2015;39(4):E6. doi:10.3171/2015.7.FOCUS15281.

16.         Mannion AF, Brox J-I, Fairbank JC. Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. Spine J. 2016;16(5):588-590. doi:10.1016/j.spinee.2015.12.001.