Low back pain

Chris J. Main ; Salford, U.K.

According to Papageorgiou et al (1996), 60-80% of people have low back pain at some time in their life, 35-40% of people report low back pain lasting 24 hours or more each month and approximately 6% have had longstanding or seriously disabling low back pain during the previous 12 months. The costs of low back pain disability to the individual sufferer, to their families, to employers and to society are massive. Indeed the treatment of back pain has been described as a 20 th Century disester (Waddell, 1998).

There have been attempts to explain the problem of LBP and LBP-associated disability from a wide variety of epidemiological, socio-economic, occupational and political perepectives, but it is perhaps necessary to reexamine some of the assumptions inherent in our clinical management strategies.

Much of medicine is based on the narrow cellular pathology of disease. This model has failed to account for the variability in symptomatic response to apparently similar organic findings. Cross-sectional studies research into LBP-associated dysfunction (or disability) heve shown disability to be multifaceted (Waddell et al., 1984) and best understood within the framework of a biopsychosocial model of iliness (Turk, 1996 ; Waddell, 1998). Studies into outcome of treatment (REF) also heve demonstrated the need for a model of iliness which encompasses psychosocial as well as blomedical factors.

There has been much research into the nature of the psychological component in pain. Early theorists viewed psychological influences with suspicion and to be an indicator of malingering or in terms of unconscious conflicts or psychiatric disorder. Most influential however have been the more recent behavioural perspective (Fordyce, 1976) and the cognitive perspective, frequently blended clinically into cognitive-behavioural therapy or CBT (Turk, Meichenbaum and Genest, 1983). In later years these components have been further developed and refined, as in more recent conceptualisations addressing the role of fear in LBP (Vlaeyen et al, 1995). The development of multi-and inter-disciplinary pain programmes (Main and Spanswick, 2000) have shown that it is possible to modify some of the adverse influences on LBP disability. In such approaches cognitive-behavioral therapy or CBT seems to be the most frequently adopted treatment approach, and indeed has shown to be an effective method of treatment (Morley, Eccleston and Williams. (1999) A major component in such treatment programmes is amelioration of iatrogenic distress and misunderstandings. The need for some sort of preventative strategy seems compelling.

Prevention can be considered in terms of primary prevention or secondary prevention. In various countries, considerable resources have been spent on primary prevention, designed to reduce the risk of musculoskeletal injuries at work such as by the ergonomic redesign of the nature or work or by the promulgation of safe manual handling techniques (McCaig and Harrington, 1998). Unfortunately, such initiatives have failed to influence the level of LBP-related incapacity, perhaps because in secondary prevention, psychosocial factors are more important than ergonom ic or biomech an ical factors (Burton and Main, 2000).

What can we tell from evaluation of risks of poor outcome ? The concept of Risk can be considered from an epidemiological, an occupational or a clinical perspective. each perspective is illuminating on the problem of LBP, but in terms of individual clinical management, the concept of risk might be more useful construed in terms of an individual’s obstacles to recovery. Can anything be done to prevent people people becoming chronically incapacitated with LBP ? Several Scandinavian studies on secondary prevention have shown that focused CBT can reduce sickness absence from LBP (Linton, 2000).

A system for the identification and management of these psychosocial obstacles to recovery, or Yellow Flags Yellow flags has been integrated into a systems approach for the management of acute and sub-acute LBP (Kendall, Linton and Main, 1997) which recognises the importance of both clinical and occupational perspectives in the management of LBP at work. For many years, research into occupational stress has identified work characteristics (such as time-pressure and low job satisfaction associated with ill-health, in the context of LBP symptomatology, such factors can become perccived obstacles to recovery. A distinction shouid however be made between Blue flags (or perceived obstacles to return-to-work) and Black flags (such as policies regarding sickness over which the individual has no control). (Burton and Main, 2000, Main and Spanswick, 2000).

Central to the delivery of any intervention is competency in assessment and in clinical intervention.

A number of lessons have been learned from pain management programmes in which obstacles to recovery are addressed. Focus on pain-associated distress, mistaken beliefs and pain behaviour are essential components in modern approaches to pain management. This framework can serve as a basis for secondary prevention in health-care and occupational settings. In the context of secondary prevention or work retention, it is important to identify, recognise these potential obstacles to recovery, but also to prevent iatrogenic mismanagement and try to facilitate recovery. Some recent U.K. initiatives will be described, including the development of occupational guidelines for the management of low back pain at work (Carter and Birrell, 2000). Finally, a new “systems approach” to the management of backpain in the workplace will be described (ACC, 2000).

In conclusion, if back pain is to be understood and managed, it must be recognised as a biopsychosocial problem, in which each of the components nseds to be addressed as appropriate. Strategies appropriate for primary prevention, secondary prevention and tertiary rehabilitation will oUviously differ. There will be different emphases also in programmes delivered within healthcare and occupational settings. It is time to take the lessons from tertiary pain management into secondary prevention and occupational retention. Attention nceds to be foeused on obstacles to recovery, whether considered from an individual, an organisational or a societal perspective. Only then are we likely to have a significant impact on the effects of back pain.


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