Monday, 18 September 2017

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 pain6–9

In some cases of back pain biomechanics can be relevant10–12 – 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.

5 comments:

  1. will work on compiling some new and interesting research on back pain. In the meantime I have something to tide you over. Painful back injuries 

    ReplyDelete
    Replies
    1. Recently, a business associate shared with me an intriguing story about someone with back pain...

      Michelle Onoff is a successful yoga instructor. Yet for some reason, she suffered with lower back pain.

      As a chiropractor, and someone in the healthcare field, I was fascinated by this.

      I don't know about you, but I was under the impression that yoga instructors, given their active, stretch-filled, muscle-focused, posture-perfect profession and lifestyle, would be the LAST PEOPLE ON EARTH to experience back pain.

      Actually, I was kind of shocked.

      If a health-minded yoga instructor can be dealt a crippling back pain blow, what does this say about the rest of us?

      Here's Michelle story in her own words. I think it'll inspire hope if you're suffering...

      "I was feeling very weak in my core area. And I was having some radiating pain in my lower back.

      And I was going to the doctors, and they were telling me things like you need to have disc replacement.

      You need to have all these surgeries...

      You need to be on these pain medications;

      And they wanted to put me through a lot of surgical procedures...

      I didn’t want to do ANY of that. But the pain was so bad... I needed some relief.

      So I went to two neurosurgeons and I went to a back pain specialist...

      The surgeons wanted to operate on me in different places...

      … and the back pain specialist wanted to do various procedures, including implanting something permanent in my spine.

      I’ve had four procedures that involved needles in my spine, epidurals in my spine and that only gave me a little bit of temporary relief for a couple days.

      But it did not cure or really help anything.

      It just put a band-aid on a pain for couple of days and that was it.

      After my first session of Back Pain Relief4Life, I felt an opening in my back that I haven’t felt in a long time.

      I felt stronger to my core and I felt that that radiating burning heat pain that I was feeling, seem to dissipate a little bit.

      It seemed to just open up my back in general.

      And then after my second session today, I noticed EVEN MORE the stretch in my lower back and more strengthening in muscles that had been weak that I think might help support my lower back.

      I was VERY SKEPTICAL about doing Back Pain Relief4Life. Because, as I am a yoga instructor, I feel very knowledgeable in anatomy. And how to help people that come to me in pain.

      But I was not aware of certain muscles that I was not using in the body that might help my lower back."

      - Michelle Onoff

      Here's the back pain program she's referring to:

      ==>Back Pain Relief 4 Life

      I share this with you today because if you suffer from back pain (like 3/4 of the population), I'm told this pain relief program WORKS WONDERS.

      People, in as little as 16 minutes, have experienced nothing less than total relief. Do nothing more than a specific sequence of 8 simple, pain-relieving movements.

      Sounds incredible, but yet Michelle is a prime example.

      See for yourself. Especially if you're being told surgery, needles and medication are in your immediate future.

      ==>Back Pain Relief 4 Life

      You've got nothing to lose.

      Rajinder Singh

      PS: My personal takeaway? Michelle was humble to admit yoga wasn't working for her.

      To me? That takes guts.

      She was also smart enough to stay away from drugs and surgery when there were other more natural options.

      But sometimes, one gets to the point where you'll try ANYTHING to get even a little bit of relief. If you're at that point, I encourage you to check out:

      ==>Back Pain Relief 4 Life

      Delete
  2. Having this condition is very hard and quite expensive. When I undergo the back pain therapy sessions because I fell down accidentally in the bench.

    ReplyDelete
  3. It's really informative article. Thanks for you have shared that with us. Today back pain is a common issue but You don’t need to suffer from back and neck pain any more. Exercise is really good for our body it will be helps to live fit and fine mentally and as well as physically. Pain And Spine Specialists

    ReplyDelete
  4. Great blog. All posts have something to learn. Your work is very good and i appreciate you and hopping for some more informative posts.

    Kalgoorlie Physio

    ReplyDelete

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