Chronic back and joint pain is a health problem which affects a relatively small number of people within the US, but has profound impacts on society and our healthcare system. This article looks to explain why the current medical model is failing the chronic back pain patient. The goal is to provide an understanding of why a greater focus on psychosocial factors and patient empowerment through education and progressive reactivation through physical activity, rather than imaging and exam findings, may result in improved management and outcomes for the chronic pain patient.
The Problem with the Traditional Medical Model
Back pain was believed to be a self limiting condition for the majority of individuals, meaning that the nature of back pain is that it would "run its course" and eventually pain would go away on its own. Current research has demonstrated that this understanding of back pain is flawed, yet many clinicians still hold this belief. In fact, 85% of people with a single episode of low back pain will likely experience future recurrences and 2-8% of those individuals will develop chronic back pain. How is chronic pain defined? Chronic pain is considered to be pain lasting longer than 12 weeks. Even though the percentage of chronic back pain patients remains relatively low, the impact on healthcare cost is significant. Chronic pain accounts for 75% of all healthcare costs related to low back pain, is second only to the common cold in missed days from work, and is the number one reason for workmen compensation claims.
Considering the burden chronic back pain places on healthcare resources, effective patient management appears to be an issue in need of addressing appropriately.
When dealing with the chronic back pain patient, the primary goal within the traditional medical model is to identify the structure responsible for generating pain by means of diagnostic imaging. This could mean the use of x-ray, ultrasound, MRI, CT or a combination of these procedures to determine what specific structure is the responsible for your pain. In his text, Rehabilitation of the Spine: A Practitioner's Manual
, Liebenson states this is done for two main reasons:
- The belief that structural pathologies seen with imaging are strongly correlated with pain symptoms.
- Fear of missing serious disease, such as cancer, infection, or fracture.
When put into practice, these beliefs ultimately result in an over-reliance on costly imaging procedures. This is often times futile, considering research has demonstrated that findings from diagnostic imaging, such as degeneration, has more to do with age than being the reason for pain symptoms. Also consider that up to 64% of asymptomatic individuals have signs of abnormal lumbar disc anatomy (i.e. disc bulge) on imaging, one should wonder if relying on imaging findings to identify a patient's problem is practical or productive. Sure structures such as discs and spinal joints can be sources of pain, but failing to correlate imaging findings with clinical presentation and examination findings may result in poor diagnosis and mismanagement of the patient. As for the case of using imaging to identify serious disease as the source of back pain, serious disease accounts for less than 1% of back pain cases. The use of imaging appears to be over-utilized in this realm as well, since typically information in the patient history and physical exam can raise a clinician's suspicion of serious disease.
The take home is that if the diagnosis and/or management of chronic back pain is based on imaging findings as the reason for your pain, this can result in poor outcomes and may prove to frustrate and confuse the patient and provider, enabling the process of chronicity and disability.
Developing a Better Approach
When it comes to the management and treatment of the chronic back pain patient, psychological and behavioral factors correlate better with symptoms than imaging or exam findings. Examples of such factors include fear avoidance behavior, catastrophizing, and lack of perceived control.
What do all these fancy terms mean and how do they relate to chronic pain?
Essentially, they are beliefs held by the patient that activity will be painful or make their condition worse. It is the anticipation of pain which results in avoidance of activity and promotes behaviors which enable deconditioning due to lack of activity, thus perpetuating the pain cycle. Ultimately, these beliefs can cause the patient to identify with their diagnosis (i.e. disc bulge or arthritis) as their problem, hindering progress since they will have a limited expectation of improvement.
For chronic back pain patients, if a fear of pain exists, it must be recognized and treated. If the fear is not recognized and dealt with accordingly, it will lead to avoidance of activity and disuse. Thus, a new model must be applied to chronic back pain which focuses on patient-centered reactivation through treatment and education. The goal becomes not only to address injury and symptoms, but also address biomechanical dysfunction and emotional or behavioral components contributing to the pain cycle. Behavioral components correlate strongly with chronicity and providing proper education to patients allows them to understand the nature of their back pain and how self-management strategies can be used to regain control through progressive physical activity. Physical activity is important for re-training of spinal stabilization muscles, decreasing fear avoidance behaviors and improving the rate of return to normal daily or sport-related activities.
The key in transitioning chronic back pain patients back to normal activity is to help them remove the fear that additional pain or re-injury will be caused by increased physical activity. This proves to be a huge obstacle since too many back pain patients are instructed by clinicians to rest and avoid activity if they feel pain. However, this advice is misplaced. Back pain patients should be provided advice that hurt does not equal harm and educated on how deconditioning from lack of physical activity is related to back pain. Utilizing progressive exposure to physical activity through therapeutic exercise can help a patient realize their symptoms did not worsen or increase as a result of movement or activity. Specific exercises and advice should be implemented to develop adequate motor control and reinforce ideal mechanics during activity. Such exercises would re-train spinal stabilization patterns and teach spine-sparing strategies to be incorporated into routine daily movements.
Managing Central Sensitization
One complicating factor in the treatment of chronic back pain patients is addressing central sensitization and neuropathic pain. These neurosensory changes occur from prolonged nociceptive (pain) bombardment, resulting in increased sensitivity of dorsal horn neurons to both noxious and nonnoxious stimuli, and thus the central nervous system’s ability to learn pain. This generates a situation in which an ongoing perception of pain occurs in the absence of any anatomical lesion, long after injury has occurred. To alleviate the role of central sensitization and neuropathic pain, spinal adjustment/manipulation may be effective. A suggested mechanism of manipulation’s role in reducing spinal pain is through the stimulation of sensory fibers, which interferes with pain function in the central nervous system and potentially leads to a reprogramming of the dysfunctional pain pathway.
Managing the chronic back pain patient with an approach which addresses emotional and behavioral components through proper education and progressive reactivation into daily and/or sport activities can prove to be an effective means to improving outcomes. The same can be said of chronic pain in any joint, such as shoulders, knees, and hips. At Gallagher Performance, we take these steps to help provide each patient with an understanding of their condition, the course of treatment, and self-management strategies to help empower them to regain control. It is our hope that this approach will demonstrate the role of spinal manipulation and active care in returning chronic pain patients to normal activity levels and improving their quality of life. We also acknowledge that in some cases, co-management with other healthcare specialists can prove to be beneficial and provided truly patient-centered care.
Liebenson C, Yeomans S. Assessment of psychosocial risk factors of chronicity. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, 2nd ed. Baltimore: Lippincott Williams and Wilkins. 2007; 9:183–200.
Andersson, Gunnar BJ. Epidemiological features of chronic back pain. Lancet. 354:581-585, 1999.
Merskey H, Bogduk N, eds. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms, 2nd ed. Seattle: IASP Press, 1994.
Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22:263-71.
Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. AM J Public Health. 1999;89:1029-1035.
Wainner R, Whitman J, Cleland J, Flynn T. Regional interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658-660.
Liebenson C. Putting the biopsychosocial model into practice. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, 2nd. Baltimore: Lippincott Williams and Wilkins 2007;4:72–90.
Siemionow K, Steinmetz M, Bell G, Ilaslan H, Mclain R. Identifying serious causes of back pain: Cancer, infection, fracture. Cleveland Clinic J Med. 2008; 75(8):557-566.
Jensen M, Brant-Zawadzki M, Obuchowski N, Modic M, Malkasian D, Ross J. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69-73.
Bogduk N, Aprill C. The sources of back pain. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, Baltimore: Lippincott Williams and Wilkins 2007;6:112-121.
Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine. 2005;5(1):24.
Severeijns R, Vlaeyen J, van den Hout M, Weber W. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain. 2001;17(2):165-172.
Koleck M, Mazaux J, Rascle N, Bruchon-Schweitzer M. Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: A prospective study. EuroJPain. 2006;10(1):1-22.
Mercado A, Carroll L, Cassidy D, Côté, P. Passive coping is a risk factor for disabling neck or low back pain. Pain. 2005;117(1):51-57.
Leeuw M, Goossens M, Linton S, Crombez G, Boersma K, Vlaeyen J. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behavioral Med. 2007;30(1):77-94.
Jacob G. Biopsychosocial perspective on low back pain: patient provider communications. J Minim Invasive Spinal Tech. 2003;3(Spring):27-35.
Liebenson C. Active care: Its place in the management of spinal disorders. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, 2nd ed. Baltimore: Lippincott Williams and Wilkins 2007;1:3-29.
Crombez G, Vlaeyen J, Heuts P, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999; 80:329–339.
Middleton P, Pollard H. Are chronic low back pain outcomes improved with co-management of concurrent depression? Chiropractic and Osteopathy. 2005;13(8):1-7.
Vlaeyen J, Crombez G. Fear of movement/(re) injury, avoidance and pain disability in chronic low back pain patients. Manual Therapy. 1999;4:187–195.
Vlaeyen J, Linton S. Fear-avoidance and its consequences in chronic musculoskeletal pain. A state of the art. Pain. 2000;85:317–332.
Sung P, Yoon B, Lee D. Lumbar spine stability for subjects with and without low back pain during one-leg standing test. Spine. 2010;35(16):753-60.
Escolar-Reina P, et al. Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Arch Phys Med Rehab. 2009;90(10):1734-1739.
Liebenson C. The role of muscles, joints, and the nervous system in painful conditions of the spine. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, 2nd ed. Baltimore: Lippincott Williams and Wilkins 2007;2:30-50.
Murphy D, Morris C. Rehabilitation strategies in low back syndromes. In: Low Back Syndromes: Integrated Clinical Management, USA: McGraw-Hill 2006;26:709-726.
Seaman D, Winterstein J. Dysafferentation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: a look at likely mechanisms of symptom generation. J Manip Physiol Ther. 1998;21:267-80.