Low Back Pain: It's Time for a Different Approach

About the Authors

Yoga Raja Rampersaud, MD, FRCSC, Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.

Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.

Hamilton Hall, MD, FRCSC, Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.



Abstract
In spite of great effort, low back pain (LBP) remains a significant burden on society and one of the most common reasons to see a primary care provider. The conventional medical message about acute LBP is inconsistent with its actual clinical course. There is little agreement on the cause or best treatment. Back pain is "over-medicalized." Routine care is fragmented and episodic. We propose shifting to a practical, stratified approach based on rapid clinical recognition of mechanical syndromes with early identification of psychosocial issues and potentially serious pathologies. LBP is a chronic condition; the goal is control, not cure.
Key words: low back pain, LBP, natural history, medicalization, psychosocial issues, routine back care.

Low back pain (LBP) is one of the most prevalent and costly complaints in North America.1 It is among the most common medical reasons to see a family physician and is an enormous burden to society in general and the delivery of health care in particular.2,3 Whether it is the failure of our current medical paradigm, the widely accepted misconceptions, or misguided policies of third-party payers, the fact remains that unlike many other debilitating conditions and despite great efforts, the problem of LBP continues to grow.3,4 Many patients suffer brief, self-limiting episodes of LBP, but these are not the challenge.5,6 It is persistent or recurrent LBP that strains the system, disrupts society, and adversely impacts the individual. Just 25% of patients with LBP generate 75% of the financial and social costs.7

To better manage these complex patients, we need to distinguish several key aspects of LBP. First, the conventional medical message about acute LBP is inconsistent with its actual presentation.8,9 The current guidelines are correct that LBP is a benign condition with a favourable natural history, but this statement is often misinterpreted by patients and providers to mean that every attack will end quickly and all will be well.5 The majority of patients with a favourable course do not seek care from a physician.6 Growing evidence demonstrates that for patients requiring help, the symptoms are likely to return and, in a number of patients, to become chronic.8 Although this is acknowledged in many guidelines, it is not emphasized and no guideline adequately addresses how to deal with the fear and uncertainty of persistent or repeated LBP.5 Not unreasonably, for the patient who has been told, "Don't worry, it will get better," and for the physician who has followed the initial recommendation of current guidelines, continuing or recurring symptoms

Comments

Drs. Rampersaud, Hall and Alleyne thank Dr. David Murphy for his insightful comments and we are glad that the articles are being read! Our goal in writing this series was to address the common and epidemic issue of mechanical low back pain in an attempt to reduce the incidence of developing maladaptive coping behaviours and chronic pain syndrome that can be triggered by inappropriate and prolonged mismanagement of mechanical low back pain. Our approach is to screen for psychosocial stressors so that they can be addressed with appropriate education like hurt versus harm and if not responsive, referred to an appropriate mental health care provider fr early intervention. We clearly agree that it is important, however, as stated on page 8 this is a very challenging area within primary care delivery. In fact, we have encouraged provincial strategies on low back pain to promote the use of primary care tools to identify and stratify psychosocial risk factors through tools like the Start Back, Yellow Flags and PHQ 9. This area needs more work and more investment of the right model relevant to primary care practice and deliverable within primary care visit timelines. As stated on page 9, the scope of this series was on the focus of the initial assessment and management of low back pain, not to the patient in the chronic state. We felt strongly that sorting out the physical mechanics first (which is representative of the vast majority of spontaneous onset low back pain) would in fact, reduce patient anxiety and social withdrawal by providing them with a hopeful direction for recovery. Our goal was to enable the initiation of more appropriate first line patient messaging and management that could lead to a reduction in chronicity, while highlighting the main issues that require further attention and management. While we do not disagree with the readers comments, they are outside the scope of the current article. Awareness of the psychological factors that co-exist with low back are very important, however, management of such issues are more practical for those who fail to respond to simple self-awareness and -management strategies noted in these articles.

As a physician, I was excited to see a proposal for a patient-centred approach to the management of low back pain. As a medical psychotherapist, who treats chronic pain, I was delighted to read the comments, "physicians tend to spend an inordinate amount of time and expense on the 'bio' portion... Yet the psychosocial aspects, the yellow flags of maladaptive behaviour and social dysfunction, are the most predictive factors for chronicity". I was, therefore, disappointed that the following three articles paid no attention whatsoever to the assessment and treatment any of the important psychosocial components of low back pain. In the article, 'Making Sense of Low Back Pain', the authors provide a detailed roadmap of history-taking questions about physical status but failed to include any questions about psychosocial status. One does not have to be an expert psychiatrist or psychologist to ask straightforward questions about the ability to work, financial stress, marital stress or basic questions about symptoms of depression and anxiety all of which may be contributing to and exacerbating physical symptoms of pain. Similarly, any examination of any patient in pain by any clinician must surely include at least a rudimentary mental state examination and assessment. Sadly, the authors chose only to address the 'bio' aspects of chronic pain. Perhaps, this is not surprising given that the authors of the articles were two surgeons and a sports medicine specialist with a background in physiotherapy. It might have been a good idea to include an author with a background in the psychological assessment and management of chronic pain, so the articles would have a balanced assessment of not only the 'bio' aspects of chronic pain but also the 'psychosocial' aspects of chronic pain. Without a psychosocial assessment and treatment plan, only the body of the patient is being treated while the mind is being ignored. The authors are quite right in stating that psychosocial medical care "is not generally covered by healthcare systems or insurance companies". That does not, however, mean that there is a complete absence of such services. Most insurance companies will provide expert psychological care to the patient in pain, if an indication can be demonstrated. Without a psychosocial assessment, there can be no assessment of the patient's psychological needs, necessary psychological treatment will not be prescribed and "the most predictive factors for chronicity" (as the authors quite rightly state) will be ignored, leading to an unsatisfactory outcome for both patient and clinician.