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Πέμπτη, 22 Μαΐου 2003 00:00

New Directions in the Management of Low Back Pain - and Optimism

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Are researchers on the verge of "solving" the back pain problem? This might be a stretch, but there was a notable sense of optimism about the management of low back pain and low back pain disability at this year's International Forum for Primary Care Research on Low Back Pain in Israel. 
As the discussions below indicate, many researchers are hopeful that the back pain crisis in Western societies will begin to abate, in response to rational, evidence-based management approaches.

Introduction
Are researchers on the verge of "solving" the back pain problem? This might be a stretch, but there was a notable sense of optimism about the management of low back pain and low back pain disability at this year's International Forum for Primary Care Research on Low Back Pain in Israel. 
As the discussions below indicate, many researchers are hopeful that the back pain crisis in Western societies will begin to abate, in response to rational, evidence-based management approaches.

"We know how to manage low back pain," asserted Cochrane Collaboration coordinating editor Alf L. Nachemson, MD. "At this point the major challenge is implementation." Not everyone is this confident, but Nachemson is certainly not alone in his optimism. And that is a major change in a field that has often been marked by frustration and futility.

For those unfamiliar with this impressive conference/research group, the forum originated in Seattle in 1995. Daniel C. Cherkin, PhD, and colleagues at the Health Cooperative of Puget Sound brought together a group of 60 or 70 researchers and clinicians to discuss research developments in the primary care field.

Although Cherkin expected this to be a one-time meeting, it was such a success that there have been successive forums in the Netherlands in 1997; Manchester, UK, in 1998; and in Israel this year. The next meeting will take place in Montreal in 2001.

Each meeting has been limited in size to encourage open discussion, consensus--building, and the development of a primary care research agenda. The quality of scientific papers and discussions has grown steadily with each conference, and the forum has become one of the world's premier venues for scientific discussion of back pain as a public health issue. This group appears to be an influential spearhead in the movement toward evidence-based back care.

The following sections reflect the interpretations of the BackLetter editors and not the conference organizers or attendees who were kind enough kind enough to comment on these issues.

Growing Consensus About the Management of Low Back Pain
There is growing confidence among researchers that low back pain can be managed successfully in primary care settings - through a combination of reactivation, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the relationship of back pain to impairment and disability.

This type of consensus did not exist five years ago and reflects an impressive step forward in research and health care policy development. It also reflects a growing body of scientific evidence.

Several speakers at the forum noted that there is a now a large evidence base in this field - in the form of randomized, controlled trials; systematic reviews- (particularly at the Cochrane Collaboration website); and evidence-based guidelines. These provide a consistent message regarding the management of low back pain.

"There are now a wide range of international evidence-based guidelines that really have very much the same message," said Scottish orthopaedic surgeon Gordon Waddell, MD, in a keynote address. "They say that back pain should not be a serious problem. Obviously, you must do an adequate diagnostic triage and look for red flags to exclude serious disease. The issues for acute, nonspecific back pain are reassurance, simple symptomatic measures, and avoiding medicalization of this problem," said Waddell. He exhorted attendees to keep back pain in perspective. "Don't turn a subjective health complaint into a medical condition or a medical disaster. Treat it as a simple thing that should get better."

Encouraging Results in Managing Workplace Disability
There is also progress on the work--disability front. There is evidence that the combination of an evidence-based medical approach, active rehabilitation, interventions at the workplace, and getting all the stakeholders onside can have a positive impact on disability. (See top cover story.) At this point, these developments should probably be viewed as baby steps rather than a giant leap forward, but any progress regarding this thorny problem is welcome.

Workplace disability is not strictly a medical problem and must be addressed at a variety of levels. Nachemson noted in a keynote address that the solution to workplace disability may be as much political - in terms of reforming the disability system and de-incentivizing low back disability - as it is medical. However, physicians and other health care providers can play a role in reducing disability through their own efforts and by active collaboration with other interested parties.

Changing View of Back Pain
The view of back pain in medicine is changing, as this newsletter has often observed. Back pain as seen in primary care settings is not the acute, self--limited condition it was once thought to be. It is more typically a recurrent or chronic symptom that erupts periodically over the course of a lifetime. Given the recurrence rate of low back pain, the dis-tinctions among acute, sub-acute, and chronic low back pain are becoming increasingly fuzzy.

Peter Croft, MD, from Keele University in Great Britain noted that there is scant evidence that any form of medical treatment can alter the natural history of this common condition over the long term. Hence the general goal for health care providers is enlightened, cost-effective management, and not a heroic cure.

Back pain was once thought to be an affliction of people of middle years. However, it is now clear that back pain is extremely common from the teenage years into old age. However, only a small proportion of sufferers slides from chronic or recurrent physical symptoms to chronic disability and heavy utilization of medical resources. This expensive, long-suffering group is the ultimate target of enlightened, cost-effective back care. It would be a major step forward if its symptom burden, and society's cost burden, could be leavened.

Should Medicine Abandon Its Traditional Approach to Back Pain?
The traditional biomedical model of low back pain has generally proven to be a failure in primary care settings. "From the end of World War II until about 10-15 years ago, low back pain in primary care, as in orthopaedics, was considered a purely biomedical condition - a 'spinal disorder' - whose care was based largely on orthopaedic folklore and local tradition, with a strong emphasis on elusive abnormalities of the intervertebral disc," observed Jeffrey Borkan, MD, chairperson and program director at this year's forum.

"Until relatively recently, the clinical and research literature on low back pain, as observed in leading journals, textbooks, and conference reports, contained almost no mention of anything but physiological etiologies, diagnostic procedures, and treatments," Borkan added.

Waddell made a similar observation. "The story of most of the last hundred years of back pain is really one of orthopaedic understanding and management," he noted. "This involved looking for anatomical damage and trying to find a way of fixing it. It has been a very mechanical approach and ignores a host of other issues. And really, this approach hasn't worked."

The inadequacy of this model and resulting management strategy has led to a radical shift in thinking about back pain, Borkan observed. In research circles, at least, there has been a -transition from thinking about back pain as a biomedical "injury" to viewing back pain as a multifactorial biopsychosocial pain syndrome.

The Biopsychosocial Approach: Is "Bio"Getting Short Shrift?
With the rise of the biopsychosocial model, the search for physical causes of low back pain has been de-emphasized in primary care research. This is in some respects a reaction to the excessive focus on the biomedical "injury model" in the past.

"While some researchers are still looking for the anatomical source of back pain, others of us think that is probably a futile search," said Waddell. "The source of most back pain," he suggested, "may not be gross anatomic disruption but rather a disturbance of neuromuscular function and neurophysiology." Waddell said that he personally views back pain as a signal of dysfunction rather than structural damage.

Most researchers in this field agree that back pain has been overly medicalized and now needs to be demedicalized. So the pursuit of elusive physical causes of pain beyond the search for red flags may be counter-productive.

Some researchers, however, are concerned that the physical causes of back pain are being given short shrift in the biopsychosocial model. Orthopaedist Ron Donelson, MD, of Dartmouth University suggested that the "bio" is being dropped out of this model altogether. He acknowledges that the precise physical causes of pain often cannot be identified, but believes that clinicians should not totally abandon their search for pain generators and/or patterns of symptoms.

Croft also suggested that researchers may have gone too far in de-emphasizing the physical in the way the biopsychosocial model is currently being employed.

"I would register some concern over this," said Croft. "I think that what is being lost is that something has to trigger the pain in the first place and locate it in the spine.

"Much of the de-emphasis of the bio is about reducing the emphasis on structural damage as a reason for CHRONICITY - which is fair," said Croft. "However, this does not mean that some injury, overuse, or structural damage did not start the whole thing going in the first place."

The biopsychosocial view of back pain is really a large-scale group picture, Croft observed. "Within that group there are plenty of individuals who have spinal stenosis or true sciatica with a disc prolapse, and who will benefit from a bio approach," Croft suggested. What is good for the group may not be appropriate for every individual.

"The point is that applying the injury model to all back pain is what has failed," said Croft. The biopsychosocial model developed as a result of this failure. However, the new approach must be employed flexibly if it is to be beneficial for patients.

The Importance of Psychosocial Factors
Although there is general agreement that psychosocial issues are key factors in the transition to chronicity and long-term disability, simple tools/management strategies that would allow primary care physicians to accurately and efficiently identify the 5% or 10% of patients at greatest risk of long-term problems have not yet emerged. And there is little agreement on the best types of interventions to address these problems. Not everyone agrees with these points, but this appears to be a reasonable generalization.

"Many clues point to the importance of psychosocial issues and expectation for patients with chronic low back pain," commented Cherkin, "and the- -relative unimportance of physiologic factors." However, Cherkin cautions clinicians not to expect simple solutions to complicated problems.

Researchers are beginning to come to grips with the psychosocial factors that make individuals vulnerable to long-term disability problems. However, these are very complex issues. A systematic review by Tamar Pincus, PhD, et al. presented at the forum noted that pain, impairment, and disability are distinct phenomena, and each may be associated with a distinctive set of psychosocial risk factors. And various factors may operate at different stages in the road to chronicity and disability. (See Pincus et al., 2000.)

"The report of injuries and pain is usually mediated by a complicated interaction of medical and work-related beliefs and behaviors," observed Borkan. While clinicians should be vigilant for obvious psychological problems (clinical depression, for instance) and inappropriate beliefs and attitudes, there is great need for further work to identify the best screening instruments and strategies for detecting psychosocial problems in primary care settings.

As for psychosocial interventions, this is again fertile ground for further research. "There is too easy an assumption that because psychosocial factors are big- predictors of outcome, that psychosocial interventions are necessarily the most effective treat-ments," said Croft. "We do not know this. This is really extrapolated from trials in secondary care settings. This is an area where scientific trials and creative thinking are needed."

Convincing Health Care Providers to Change
There were several presentations at the forum about the dissemination and implementation of back care guidelines and policies in various health care systems. While some researchers reported progress in this area, there was a general view that implementation is a dark area.

Cherkin suggested that researchers and clinicians shouldn't expect changes over-night. He believes the natural dissemination of research results in this area has led to discernible progress. "Research results seem to have resulted in decreases in recommendations of bed rest, possible decreases in imaging, and the greater use of activating treatments," he noted. "We shouldn't be too cynical," he added. "Change takes time. This is not a problem unique to low back pain."

Cherkin observed that providers in primary care systems have a limited ability to change rapidly. -"Primary care physicians are con-strained by health care systems, 10-minute visits, and other factors," he suggested.

Croft noted that the slow pace of change is not necessarily a bad thing. "I am not sure we should expect policies to be implemented in a rush - that is the politician's problem. One can argue that there is a safety mechanism in not seeing every new idea put straight into the marketplace."

A more fundamental concern, said Croft, is the current lack of fundamental knowledge about the best ways to change the behavior of clinicians. "We do not really know what influences clinicians in changing practice. A concern is that commercial pressures will always manage to influence health care providers more effectively than national guidelines or sensible conservatism."

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