October 20, 2021
I should add another line to that heading: in one easy step! And I’d be...

I should add another line to that heading: in one easy step! And I’d be inundated with hits and if I could cash in on them I’d be rich! And wrong.

If there was a simple recipe for success, I’d expect that by now we’d have it. The very fact that SO MANY options for managing a bout of low back pain exist is a good reason for skepticism should you ever get tempted to take a headline like mine as a cause for celebration. However I do want to talk about acute low back pain because I think clinicians are often probably doing it wrong.

First of all, low back pain doesn’t include pain that also goes down the leg. Let’s get the definitions clear before we talk! In 2008 a Delphi study by Dione, Dunn, Croft, Nachemson, Buchbinder, Walker and colleagues (2008) developed two definitions: a minimal definition, and an optimal definition. These definitions were developed for epidemiological studies and the minimal definition is very simple – “In the past 4 weeks, have you had pain in your low back?” and “If yes, was this pain bad enough to limit your usual activities of change your daily routine for more than one day?”

from Dionne, Dunn, Croft, Nachemson, Buchbinder, Walker et al, (2008)

Now when it comes to defining a first bout of acute low back pain, Ardakani, Leboeuf-Yde & Walker (2019) raise some very interesting points: researchers investigating acute low back pain don’t clearly distinguish between the factors associated with the disease of low back pain (as they put it, the onset of the very first episode) from its recurring episodes – as they put it, “the continued manifestations of the “disease”.” In fact, in their systematic review for identifying risk factors from “triggers” (their term for subsequent episodes), they could find only one study dealing with the true incidence of first time low back pain – and this was low back pain caused by sports injury. All the remaining studies either explored new episodes, or recurring episodes. The major problem with these studies? They didn’t define how long a person should have had no low back pain at baseline. And given many of us develop back pain in adolescence (see Franz, Wedderkopp, Jespersen, Texen and Leboeuf-Yde, 2014, or Jones & MacFarlane, 2005) for example) it’s probable that studies investigating those over 18 years old will include a lot of people who have had that first bout already.

The trajectories for those of us who do develop low back pain are also reasonably murky because of the challenges around definitions, and there are several studies with slightly different results as you’d expect. Essentially, though, most researchers find that there are three or four patterns that emerge from longitudinal studies: lucky ones who have one bout and no or low levels of pain thereafter; those who have persisting mild pain, those who have fluctuating bouts over time, and those who develop persistent and severe pain. Chen and colleagues (2018) found that “lower social class”, higher pain intensity at the beginning, the person’s perceptions of more challenging consequences and longer pain duration, and greater “passive” behavioural coping were most significantly associated with the more severe trajectory over five years.

So, what does this mean for clinicians – and how well are we doing?

Acute low back pain can really frightening for people, especially if the pain is severe. As clinicians generally choose this work because we care about people, we get hooked into wanting to reduce pain and help. There’s nothing wrong about this – unless it means we also get hooked into trying to offer something we cannot. We’re inclined to believe that people seek help for their back pain because of the pain – but as Mannion, Wieser & Elfering (2013) found from a study of over 1,000 people with back pain at the time of the survey, 72{81fee095584567f29e41df59d482e70712cfc555e382220efc71af2368c27a36} hadn’t sought care over the previous four weeks; 28{81fee095584567f29e41df59d482e70712cfc555e382220efc71af2368c27a36} had sought care – and most from more than one provider. Women were more likely to seek care, those who had experienced more previous bouts, those who had trouble with activities of daily living and more trouble with work activities. While pain intensity did feature, it wasn’t as much of a predictor as many clinicians would expect. Indeed, an earlier meta-analysis by Ferreira and colleagues (2010) found that disability was a stronger predictor for seeking treatment than pain intensity.

So what do clinicians focus on? I suspect, though I aim to be proven incorrect, that almost every clinician will ask “what is your pain intensity on a scale from 0 – 10?” Frankly, this question is one that irritates me no end because how on earth do you rate pain? Seriously. Yes, there are a lot of clinicians who then ask about activities a person wants to be able to do (yay!) though when we look at the treatments offered, I wonder how many follow through with practical goal-setting for daily activities like getting shoes and socks on, carrying the groceries, sitting while driving the car or at work… And treatments? the arguments on social media between clinicians would be fun to watch if only they weren’t accompanied by such vehemence!

What I don’t see are conversations about how we help people recognise that they’re likely to follow one of those four trajectories, and what we do to help people self manage a life alongside low back pain.

I don’t see much attention paid to helping people sleep well.

Lots of conversations about pain neurobiology – in an attempt to use this explanation to bring someone on board to engage in treatments.

I don’t see a lot of discussion about how to ask about the person’s main concern – perhaps it’s nothing to do with pain, but more about “my niece is coming to visit and I’m not sure I can cope with entertaining her and managing my back pain”, or “we’re coming up to the busy time at work and I can’t not go in, but when I get home I’m trashed, how can I manage that?”, or “Monday’s are our busiest day, and I have to keep going because the team needs me, what do I do?”

I wonder whether clinicians could be persuaded to get out of the way and stop confusing people with recipes or algorithms or “special exercises” that “must be done this way” – I wonder if we could offer some very simple steps: specific answers to the person’s main concerns (best form of reassurance there is!); goal setting around the things the person needs and wants to do over the first six to eight weeks; sleep strategies including some mindfulness because that’s likely to help long-term; and lots of encouragement as the person returns to activity. Developing a relationship with the person doesn’t need lots of prescriptive steps or cookie cutter programmes, it does mean listening, showing trust in the person’s own capabilities, and willingness to let go of a few sticky thoughts we’ve acquired during our training. Maybe 2021 could be the year clinicians get back to basics and begin to support resilience in the people we see – firstly by showing them that we trust they have the capabilities.

Ardakani, E. M., Leboeuf-Yde, C., & Walker, B. F. (2019). Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature. Pain Res Manag, 2019, 6959631. doi: 10.1155/2019/6959631

Dionne, C. E., Dunn, K. M., Croft, P. R., Nachemson, A. L., Buchbinder, R., Walker, B. F., . . . Von Korff, M. (2008). A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine, 33(1), 95-103.

Franz, C., Wedderkopp, N., Jespersen, E., Rexen, C. T., & Leboeuf-Yde, C. (2014). Back pain in children surveyed with weekly text messages-a 2.5 year prospective school cohort study. Chiropractic & Manual Therapies, 22(1), 35.

Jones, G. T., & MacFarlane, G. J. (2005). Epidemiology of low back pain in children and adolescents. Archives of disease in childhood, 90(3), 312-316.

Mannion, A. F., Wieser, S., & Elfering, A. (2013). Association between beliefs and care-seeking behavior for low back pain. Spine, 38(12), 1016–1025