A response to today’s article on the front page of The Times
It’s great to see some truths about back pain starting to come out into the public domain. This article follows the recent one by Kieran O’ Sullivan in The Guardian dispelling the myth of how important posture is.
These messages have been known within our circles for over a decade but it takes time to change culture. This article says that back pain treatment is useless. What it should say is that conventional approaches to the management of back pain are not very effective (ie injections, surgery, drugs). But we should remember that injections and surgery are effective and necessary for some people with spinal problems, just not for the vast majority.
For too long now the focus has been on the wrong thing. The structure. The pathology. Using scans to show the problem and then doing something about it. The trouble is, most things you see on an MRI scan don’t cause back pain. Even degeneration (wear and tear), which is still often the explanation people are (wrongly) given for their pain. This has led to interventions aimed at the wrong things which is why outcomes have been so disappointing.
As the article says, interventions aimed at exercise and psychological factors are more effective. For most people ‘psychological’ merely means fear of movement, low confidence in their back, over-focusing on a structural diagnosis. This leads to protective postures, movements and behaviour which in turn increase muscle tension and pressure on the back, leading to pain. These factors can be changed and therefore so can back pain. Peter O’ Sullivan and his team are leading the revolution in the understanding and management of the combined influences of the physical and the emotional and this approach (that they call Cognitive Functional Therapy) is a simplistic and realistic way of understanding and managing back pain.
Physiotherapy has been guilty as well. The over-focusing on a ‘weak core’ as an explanation for back pain and ‘core stability training’ as the remedy have worked for some (but no more than any other form of exercise) but for others it is ineffective and for others it can make them a lot worse. For some, it confirms the thought that there is something structurally wrong with their back. Individualised exercise aimed at confident, normal, efficient movement and general fitness can be much more effective.
This article goes on to say “We don’t understand what causes the vast majority of back pain”. I would challenge this. I would agree that trying to identify the actual source of pain (ie joint, muscle, disc) is difficult and that MRI’s don’t help with that. But there is a greater understanding of factors that can lead to pain. The biggest predictors of pain are depression, stress/anxiety, poor sleep, lack of physical exercise and low movement variability (being in the same position or performing the same repetitive movements). Not wear and tear, posture, core strength etc.
Often back pain is multifactorial (eg an increase in workload means longer periods of static sitting, often with a tense posture due to increased levels of stress which has also been shown to result in periods of poor sleep) and identifying the actual factors involved on an individual patient by patient basis leads to better outcomes. This is a bit of a paradigm shift for patients and the medical world alike but it is closer to the truth about back pain than we have ever been.