Repeating Failed Policies Will Not Improve Outcomes

To the Editor: The recently published second edition of Gordon Waddell’s The Back Pain Revolution starts out “Back pain was a 20th-century medical disaster and the legacy reverberates into the new millennium.”1 The article in the recent JABFP Supplement by Rives and Douglass advocates the same failing model.2 Three unfortunately common errors pervert their understanding of the problem and thus prevent a useful conclusion. The errors are: misunderstanding the natural history of low back pain, looking for a diseased tissue instead of analyzing the system, and giving only a superficial look at psychosocial issues.

The authors state that up to 90% of patients with low back pain will recover within 12 weeks. The reference to this was a National Institutes of Health grant guide that did not give a source for this data. We know that approximately 90% of patients with low back pain will not continue to consult a medical practice after 3 months, but this does not mean that they are recovered.3 In fact, a recent review of 36 studies reveals that at 1 year, between 42% and 75% of patients with low back pain continue to have pain.4 Two more recently published studies showed that 52% of patients with low back pain and 53% of patients with sciatic pain still had pain and back-related disability at 5- and 4 year follow-ups, respectively.

Although the authors did note that the recurrence rates are high, they did not note the most relevant aspect of this. All episodes are not created equal. Evidence suggests that chronic low-back pain causes neurologic remodeling, leading to centrally mediated pain.5 With each recurrent episode, the intensity, disability, duration, and peripheralization of symptoms tend to increase and eventually not resolve.6 Time is of the essence. A recent study showed that waiting even 6 weeks for treatment prevented improvement in psychosocial variables with symptomatic improvement.7 The failure to notice these factors falsely casts a shadow of triviality over episodes of low-back pain, leading one to the false conclusion that timely treatment is not important.

Rives and Douglass state that “An exact diagnosis and anatomic pain generator may not always be evident.” That is certainly true, but this implicit assumption that we should search for an anatomic pain generator is misguided. Not to feign omnipotence, but I am unaware of a case in which this has been fruitful—aside from pathology or a clear-cut herniated nucleus pulposus with a predominance of anatomic leg symptoms. Bogduk has shown that painful tissues can be found in most cases,8 but what have we gotten from this? Our affection in previous years for the disk—an undoubtedly painful tissue in many cases—was a complete and utter failure.

The Quebec Task Force said that “the inability to find diagnostic subgroups is the fundamental source of error in low-back pain management.” Emphasis should be on functional classifications that can find relevant—if not yet perfect and complete—low back pain subgroups. As just one example, a McKenzie assessment can provide an excellent predictor of outcomes.9 Most physical therapists and many chiropractors know this. However, the generals (medical doctors) are not talking to their soldiers (physical therapists and chiropractors). Any guidelines or review that hope to positively effect outcomes must address this.

Further, we see that when the pain is effectively treated, the psychosocial issues tend to resolve as well.10 These psychosocial variables are not simply a result of lawyer-induced greed, as the authors implied with their reference to a 31% reduction in claims when pain and suffering settlements were eliminated. Litigation is not a great predictive factor—Waddell’s book has an excellent discussion of this.1 A more reasonable—or at least as reasonable—hypothesis for the 31% reduction in claims is that their treatment was ineffective, so without a monetary settlement, they had no incentive to stay in the system! Nonorganic signs do not indicate psychogenic pain. Evidence is mounting that central hypersensitivity may account for the presence of Waddell’s signs.11

As we have seen, the natural history of low back pain is not a rosy as our authors have led us to believe. Effective and timely treatment is essential to preventing chronicity. To treat effectively, we must have a meaningful diagnosis. Currently the best tools we have are functional analyses. It would be profitable to our patients to have increased interdisciplinary communication so that the gatekeepers are truly aware of the treatment options available. And while psychosocial issues such as comorbid depression do indicate a more complicated case, they do not indicate greed, malingering, or psychosis.