I recently assessed and treated a young professional woman with a three year history of low back pain. She was cheery, intelligent and health conscious and indicated that she had seen many clinicians with limited success and protracted treatment. This woman had stopped any kind of physical exercise as she was scared it would flare her symptoms. She pointed to her right low back region and indicated that her sacroiliac joint was the source of her pain and that she had a weak core. She went on to describe how her pelvis could go out and result in a week of unbearable pain and disability. When we started the clinical examination, I asked her to bend forward and she did so with minimal movement in her low back and she moved in a very slow and cautious manner. When I asked her if it hurt to bend forward, she said no, but noted that she was fearful that she could “Move the wrong way and further damage herself” and that “Everything is so tight in her back”. We’ve all seen this type of patient before. Once again it made me reflect on how she got to a point where a young, otherwise healthy individual moves with caution and lives in fear of their low back pain at all times.
Did her previous treatments help or hinder this person? What would have happened if there was no treatment available for her initial episode of pain?
Iatrogenic illness is defined as a disease that is caused by medical treatment. If we think about low back pain, there have theoretically been great advancements in the diagnosis and treatment of the condition over the last few decades, but has this improved patient outcomes? Could it be that we are actually causing iatrogenic low back pain and disability with some of our treatment approaches? A study that contacted approximately 5,000 households in 1992 and then again in 2006 found an increased prevalence of chronic, disabling low back from 3.9% in 1992 to 10.2% in 2006. Richard Deyo, a well known low back pain researcher, concluded that medical costs had increased significantly for the treatment of spinal pain with no discernable improvement in outcomes after analyzing reports from over 20,000 individuals over the course of a decade. And this is no small amount; the bone and joint decade task force reported that we spend between 6 and 12 billion dollars a year in Canada on back pain alone.
In all likelihood, there are numerous factors contributing to increasing low back pain including things such as a progressively sedentary life style and obesity. Could it be that what we are doing, as a medical community, is also increasing disability and suffering with a condition that is generally benign? Could it be that simple exposure to well intentioned clinicians is also a factor in the increasing frequency, cost and disability associated with low back pain? What is it about interactions with health care providers that could potentially contribute to a patient’s pain experience?
Now I’m a guy who loves numbers but qualitative studies can also provide us with an interesting perspective on people’s thoughts and beliefs. A study conducted in the early nineties identified the Australian aboriginals as a group that experienced little disability secondary to chronic low back pain. The researchers suggested that the cultural beliefs held by these people – low back pain is not a health issue and simply a part of everyday life – made these people resilient to disability and health care seeking. In essence, these individuals didn’t conceptualize low back pain as a disease and as such, did not require any medical management. Fast forward to 2013, Lin and colleagues conducted a study where they interview 32 Australian Aboriginals with chronic low back pain and find that things have changed since the study in the nineties. Many of the individuals in the study had beliefs that their pain was due to a structural problem and they had negative perceptions for recovery. These beliefs were identified as being the result of interactions with health care providers and imaging studies! Here is just one of the quotes from the study participants, it sounds all too familiar:
Not surprisingly, disability rates have increased for Australian Aboriginals over the last 20 years with exposure to Western medicine appearing to be a contributor to these changes. Remember, those patients from the original study did not seek out health care because they believed that the low back pain was not a health related issue and may have been better off for it. I cringe when reflecting back on my own career and how many patients I may have inadvertently disabled with a pathoanatomical diagnosis that I haphazardly threw out in my early years as a physiotherapist.
How can we minimize the risk of iatrogenic low back pain and be part of the solution? First and foremost, providing patient education on the benign nature of low back pain and the importance of remaining active might considerably decrease the risk of prolonged disability. De-emphasizing medical diagnosis and focusing patient recovery on function and active recovery strategies could also make a meaningful difference. This means getting away from “Minutia” based physiotherapy where a patient's pain experience is based on a specific structural fault that needs to be “Fixed”. We should know that not only are we likely wrong when we come to a specific pathoanatomic diagnosis but that we are also increasing the risk for disability. With the time saved by not going on a big 'issue with a tissue' hunt, we can devote some of our assessment to screening for yellow flags like fear, catastrophization and changes in mood and then address these issues in an empathetic manner.
In one of the few perspective cohort studies of low back patients that included imaging, a group of veterans underwent an MRI and various screening questionnaires. At three year follow-up the only significant predictor of experiencing low back pain was depression. Even frank contact with a nerve root by the lumbar disk did not reach significance for predicting low back pain!
When it comes to a diagnosis, use nonspecific and nonthreatening phrases to describe patient’s low back pain and what needs to be done to help improve their pain, because, hey, what they have really is nonspecific low back pain. Sure, they might respond preferentially to one treatment over another but in the grand scheme of things, we are a long way from being able to identify the specific tissue at fault. Remember, words really do matter and a paper called “Words that harm and words that heal” should be required reading for all healthcare workers. We should also educate patients on the limited utility of our imaging studies and the prevalence of findings in asymptomatic individuals. I tell my patients prior to imaging that things like disk bulges, degenerative disk disease and arthritis are common in individuals without pain and can be considered anatomical wrinkles and grey hair that we acquire with age and often have little correlation with pain. Imaging’s purpose is simply to rule out serious pathology and guide surgical intervention and for the vast majority of patients, neither of these is necessary.
What happened with my young female patient with a three year history of low back pain? We discussed why she was fearful and it turned out that she had recently had a baby and worried that she would not be able to care for her child if she had an episode of her back “Going out”. I educated her on how feelings of fear and fragility can actually cause pain to become persistent and we discussed some simple ways to help self-manage her pain when she flared. I had her watch this video at home and start to read this book. At the next visit, I asked her to bend forward and she did so fluidly and quickly without fear! I wish I could say it always works out this way, but it is good to be able to celebrate the occasional success.
Freburger JK, Holmes GM, Agans RP, et al. The Rising Prevalence of Chronic Low Back Pain. Archives of internal medicine. 2009;169(3):251-258.
Martin BI, Deyo RA, Mirza SK, et al. Expenditures and Health Status Among Adults With Back and Neck Problems. JAMA. 2008;299(6):656-664.
Honeyman, Peter T., and Eva A. Jacobs. "Effects of culture on back pain in Australian aboriginals." Spine 21.7 (1996): 841-843.
Lin, Ivan B., et al. "Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians." BMJ open 3.4 (2013): e002654.
Jarvik, Jeffrey G., et al. "Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors." Spine 30.13 (2005): 1541-1548.
Bedell SE, Graboys TB, Bedell E, Lown B. Words That Harm, Words That Heal. Arch Intern Med. 2004;164(13):1365-1368.
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR American journal of neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.