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

the efficacy of a treatment applied too late.

The fourth issue is the fragmented and episodic nature of care.22 Patients with back pain receive conflicting information and advice from medical specialists, allied health professionals, family members and friends, and, of course, the Internet.10,19 Optimal patient management is best delivered in a shared-care model with consistent messaging by primary care, specialist and rehabilitation professionals. Patients select what resonates with them or do nothing in the face of so many contradictory opinions. Many continue to search for something that is going to "fix" their back pain.

Recognizing the pitfalls in our current medical approach to LBP, we propose a paradigm shift to a more practical, stratified approach that changes the messaging and management of LBP to reflect what LBP is—a chronic human condition.4,11,12 We must be both proactive and preventative. The first step is convincing the patient that LBP is manageable albeit likely to recur. The goal is control, not cure, and control is not only possible, it is readily achievable. It consists of phases of symptomatic treatment while engaging the patient in self-management maintenance and preventative strategies. Most LPB arises from minor mechanical derangements that produce an identifiable compilation of symptoms suggesting a probable anatomical source and, more importantly, an initial patient-specific management strategy.11 Appropriate expectations, a primary focus on the return of function and as well as pain reduction, and long-term, self-directed control should reduce both the chronicity and health care utilization.4,12,23-25 Individuals without a specific mechanical pattern, who fail to respond or become less specific over time, or who have a concurrent non-spinal complaint require further attention. Up to 30% of patients with LBP have associated yellow flag psychosocial issues.12,20,26 Less commonly, there may be a red flag for non-mechanical causes such as inflammatory disease, infection, or tumour.27,28,29 Reliably screening for these unusual presentations is possible by through a precise, back-specific history and physical examination. The next three articles provide a practical approach that will enable you to confidently assess and initiate patient-specific management within the continuum of LBP.


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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.