There’s no doubt that low back pain presents a major healthcare problem in all parts of the world. It’s probably the most common form of musculoskeletal pain around, it can be highly disabling – and its management is one of the most contentious imaginable. As someone once said “if there was an effective treatment for low back pain, there wouldn’t be such a range of treatments available!”
I want to take a step back and consider people living with nonspecific low back pain only, it’s by far the most prevalent, and while no-one would say there is a single diagnosis that can be applied to all forms of back pain, there seem to be some similarities in how this kind of pain responds.
What we’ve learned over the past year is that acetaminophen hardly touches the pain of nonspecific low back pain Machado, Maher, Ferreira, Pinheiro et al, 2015). This means anti-inflammatory medications (NSAIDs) are the most likely group of medications to be prescribed, or perhaps codeine. Exercise was the recommended treatment for osteoarthritis of the hip and knee, suggesting that this approach might also be recommended for low back pain.
Turning to exercise, it seems that there is no clear indication that any particular type of exercise is any better than any other exercise for low back pain (not even motor control exercise)(Saragiotto, Maher, Yamato Tie, Costa et al, 2016), and all exercise improves pain and disability – and even recurrences (Machado, Bostick & Maher, 2013). What seems important is that people get moving again, and do so quickly after the onset of their back pain.
Graded exposure has also been in the news, latest being a study using graded exposure for elderly people living with chronic low back pain, where it was found to not only improve function (reduce disability) but also found to reduce pain (Leonhardt, Kuss, Becker, Basler et al, in press). OK, pain reduction wasn’t reduced a great deal, but neither have many treatments – and at least this one has few adverse effects and improves disability.
Where am I going with this?
Well, recently I made some apparently radical suggestions: I said that
- sub-typing low back pain doesn’t yet seem to be consistent;
- that no particular exercise type seems better than anything else;
- that ongoing disability is predicted more by psychosocial factors than by physical findings – even when injection treatments are used (van Wijk, Geurts, Lousberg,Wynne, Hammink, et al, 2008).
- that people with low back pain seem to get better for a while, and often find their back pain returns or grumbles along without any particular provocation;
- and that perhaps treatment should focus LESS on reducing pain (which doesn’t seem to be very effective) and LESS on trying to identify particular types of exercise that will suit particular people and MORE simply on graded return to normal activity.
- Along with really good information about what we know about low back pain (which isn’t much in terms of mechanics or anatomy, but quite a lot about what’s harmful and what doesn’t help at all), maybe all we need to do is help people get back to their usual activities.
For my sins I was asked not to remain involved in the group planning health system pathways (I also suggested maybe osteopaths, chiropractors, massage therapists and both occupational therapists and psychologists might also be good to be involved – maybe that was the radical part because I can’t see an awful lot radical about my other suggestions!).
Here’s my suggestion – when one of the most difficult aspects of low back pain management is helping people return to normal activities within their own environment (work, home, leisure), why not call in the experts in this area? I’m talking about YOU, occupational therapists! So far I haven’t been able to find a randomised controlled trial of occupational therapy graded exposure for low back pain. I’m sorry about this – it’s possibly a reflection of the difficulty there is in even suggesting that DOING NOTHING (ie not attempting to change the tissues, just helping people return to normal activity) might be an active form of treatment, and one that could work.
I don’t want to denigrate the wonderful work many clinicians do in the field of low back pain, but I suspect much of what seems to work is “meaning response” – well-meaning clinicians who believe in their treatments, patients who believe in their therapists, treatments that appear plausible within the general zeitgeist of “why we have low back pain”, all leading to a ritual in which people feel helped and begin to do things again.
Many of us have read Ben Darlow’s paper on The Enduring Impact of What Clinicians Say to People with Low Back Pain (Darlow, Dowell, Baxter, Mathieson, Perry & Dean, 2013). We have yet to count the cost of well-meaning clinicians feeding misinformed and unhelpful beliefs (and behaviours) to people with acute low back pain. I think the cost will be extremely high.
I just wonder if we might not be able to cut out much of the palaver about low back pain if we went directly to the “feeling helped and begin to do things again” without the misinformation and cost of the rituals involved. While other clinicians can contribute – the process of doing in the context of daily life is where occupational therapy research, experience and models have focused for the discipline’s history. That’s the professional magic of occupational therapy.
Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine, 11(6), 527-534. doi:10.1370/afm.1518
Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S.(in press). Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study. Journal of Geriatric Physical Therapy.
Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.
Machado, G. C., Maher, C. G., Ferreira, P. H., Pinheiro, M. B., Lin, C.-W. C., Day, R. O., . . . Ferreira, M. L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials (Vol. 350).
Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012004/abstract doi:10.1002/14651858.CD012004
van Wijk, R. M. A. W., Geurts, J. W. M., Lousberg, R., Wynne, H. J., Hammink, E., Knape, J. T. A., & Groen, G. J. (2008). Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain. Pain Medicine, 9(2), 212-221.
HealthSkills Blog 
Bronnie, were your self-confessed sins those of omission or commission?
I rather think that suggesting we don’t know the best treatment, and that we need to include a wider range of health professionals than medical and physiotherapy was not quite what people wanted to hear. And that there isn’t a way to reliably sub-type forms of low back pain, so let’s be pragmatic and modify risk factors (especially avoidance) was a bit too scary for those of conservative disposition. Whatever the case I promise I didn’t argue for more interventions, imaging or surgery!
Hi Bronnie, doesnt sound very radical to me. There is still a lot of push back from health professionals in this area.
Oh tell me about it Nigel! The radical part is just suggesting that none of our treatments work any better than simply taking an active role in getting people to do the things they’d be doing normally! But of course, this latter task is not for people who are afraid of suggesting that people can manage their pain without too much medication or pain reduction…
That’s an interesting point. I follow most of your arguments but even with huge beliefs in the place for many more OTs in chronic pain management I’m somewhat confused by your suggestion that even more HCPs should work their way into acute LBP care when this clearly hasn’t helped anything so far?
I think that if anything we should have less and better skilled clinicians who can deal with the pain and disability in the acute phase.
But thanks for sharing your thoughts. Who knows, maybe the function-approach would make a difference.
I can understand why you’d think that, but my main rationale is that occupational therapists, unlike many other professions, primarily focus on the DOING of returning to function.
That is, helping people establish what they are ready to do, guiding and encouraging return to those activities people are fearful of, without any overlay or attempt to address any underlying “pathology”.
Helping people return to daily occupations (which is the technical term used to refer to daily activities that people need to, want to or might like to do) is the heart of occupational therapy.
To achieve this, occupational therapists don’t look at structures and presumed mechanisms, but believe that just by engaging in normal daily occupations, people begin to feel better.
Occupational therapists are the only profession, as far as I know, that integrates biopsychosocial factors as a fundamental principle in all therapy, rather than beginning by doing exercise (remedial or otherwise) but incorporates purposeful, personally-valued occupations as the heart of therapy.
I’m not suggesting other clinicians have a role to play – physical therapy for movement (because of face validity, more than anything) – but physio doesn’t know the psychosociocultural aspects of occupation, and doesn’t have the expertise to titrate the level of occupation to suit the individual, remembering that it’s not just about movement but also about beliefs, emotions, being in a social context, at work, at play, at home, in relationships. These are all aspects of occupation that occupational therapists know and integrate in their treatments. Occupational therapists are trained in physical movement including anatomy, physiology, kinesiology, biomechanics – so can draw on these skills if needed.
We could refer to psychologists – but they’re not trained in physical anatomy, physiology, nor in the daily life occupations that people do, their focus is typically on thoughts, beliefs and behaviours, but the sociocultural aspects of occupation are not their forte.
Already occupational therapists DO provide interventions in subacute low back pain – there’s little difference in terms of what’s needed for therapy, as far as I can tell, between acute and subacute. Instead, most people who will get well, do so despite our best efforts! And those who fall through the gaps and fail to recover, do so because of psychosocial factors rather more than physical factors. And I argue that occupational therapists are uniquely placed to recognise and actively manage these than any other profession given that psychosocial factors are embedded in the theory and practice of occupational therapy.
Rather than seeing physiotherapists and nurses and even medical practitioners attempt to become “more functional”, wouldn’t it make sense to use the skills of the group already knowledgeable in the area?
Thanks for further insights. I’m still-or even more so – in disagreement with you. I’d be very worried that it might imply a paradigm in which ‘we’ would suggest that getting back to normal function is the new pathology of acute pain. I don’t see any argument for this (remember we are discussing normal people who might have been working two days ago). With all respect to OTs I’d suggest that the patient is the most knowledgeable person about what is necessary to get back into daily life after an acute incident of back pain (remember again that I am in favour of pain and disability focused therapies). So, rather than having new professions I would rather see skills of the existing professionals upgraded (consistently) to include a patient-centred focus to secure a quick and safe pain and disability reduction. Let’s not make ‘return-to-life’ a pathology that needs professional attention in the general population.
With respect, how does “return-to-life” qualify as a pathology? Can you please explain this proposition?
My point is, that I don’t see any reason to have further (new) professional focus on a group of people who – for the majority – is doing very well despite brief periods of acute (non-specific) low back pain.
My reference to this as ‘pathology’ is due to the historical focus on ‘pseudo-pathologies’ such as degeneration as a course of pain and disability in these people, which has misled much therapy over the years – and possibly has been the cause of a problem when there most like was non.
So, if it’s not broken, don’t fix it… And I don’t think that the ability to ‘return to daily occupations’ is broken or even disturbed in the majority of these patients with acute low back pain. So why should we start fixing it?
Let’s focus on the patients and what they report as being the problems during acute episodes of back pain: Pain and disability. Obviously this would include valuable contributions from several professionals and professions.
Can you please identify the nature of these valuable contributions and which professionals and professions are offering them? I must agree with Bronnie that by virtue of their broad and practical training, occupational therapists have much to offer those with back pain.
I would in no way disagree that OTs have valuable contributions. But to me there’s a fine line between suggesting that OTs CAN help and that a new approach is needed.
What I bring into the debate is simply the concern that perhaps ‘less is more’ in this particular group of patients. It seems these patients are very good – in general – at getting back to life once their pain and disabilities are gone. So, what do they need help for – other than pain and disability reduction?
As for the valuable contributions: Meeting patients with an empathic desire to help them, positive expectations and relevant knowledge that is passed on to the patients, excellent communication skills, skilfull and mindfull handling of the patients and many more (I’m sure you know where I’m going).
And the professional backgrounds of these professionals: Whatever works – including OTs.
My two pennies worth: Mostly I agree, the majority of people with acute low back pain do recover quickly, and I suspect need nothing in the way of treatment or support. I disagree that they don’t experience occupational disruption – that’s precisely why people seek treatment (because their experience of pain is interfering with what they want to do – Ferreira et al demonstrated this in the study I quoted). Occupational disruption and disability are synonymous. I’ve used the technical term because it’s time to recognise that occupation is what people do in daily life – not just paid employment, not just unpaid employment, but the routines and habits of getting up, dressed, driving the car, sitting at work, watching TV, playing sport etc. And these are precisely the things people say they can’t do as a result of their pain.
While many people will return to normal activities independently, the thing is that as soon as they see a GP (at least in NZ) they’ll be referred to physiotherapy. Irrespective of the degree of distress, disability or anything else – the almost automatic response in NZ is to refer to physiotherapy. No-one quite knows what a person will receive when they see a physiotherapist, but amongst possibly useful approaches, those people are also likely to hear about potential disc prolapses, weak core muscles, the need to use directional preference for movements, and often prescribed a bunch of exercises which may or may not be carried out. Passive modalities such as ultrasound, heat packs, interferential, acupuncture and hands-on therapies are also likely to be added to the mix, in the name of pain reduction – although there’s little evidence to suggest these actually reduce pain.
I’m not just picking on physiotherapy, other professions also provide very similar treatments – all the while, the person receiving them gets very limited (if any) input with respect to returning to normal daily activities.
To me this poses several problems: firstly there’s the over-treatment aspect. As you say, many people with ALBP will return to normal activities very quickly – the question is why they are referred for, and receive treatment at all. Therefore their treatments do little to promote a return to function and instead can delay recovery at the very least from a psychological perspective where their daily routines and beliefs about their own ability to manage their pain is eroded by virtue of having to attend appointments.
Secondly, the explanations given by treatment providers vary enormously, and while some can be very helpful and useful, there are certainly many clinicians giving unhelpful explanations that can and do linger.
Thirdly, there is an enormous assumption that if a person is doing exercises competently within a clinic setting, they are doing normal daily activities outside the clinic. I think this assumption is mistaken. Having seen numerous people who are quite fit, doing in-clinic exercises beautifully, and appear superficially to be doing everything right – only to find they’re avoiding movements in the real world, stop doing enjoyable and demanding activities, and begin to “protect” themselves from potential harm. While I openly admit to seeing those with long-term pain, the seeds were sown early on in their trajectory, and no-one identified this.
Do people develop occupational disruption with ALBP? Mostly yes. They stop doing the things we normally need and want to do. Do many return without help? Yes, many do. And so for most ALBP I agree we don’t need to provide input.
What we do need to focus on are those people who are at risk of prolonged recovery, or failing to recover at all. I argue these individuals are readily identified at the acute stage, and there are many instruments that can be used to find out who is most likely to need more support than those who recover spontaneously.
It’s this group of people, usually in the first two weeks I believe, who need to be seen not by physiotherapists (nonspecific LBP doesn’t appear to be a deficit of muscle control, identifiable pathology, or anything that can be remedied by special exercises) but by people who focus on supporting and titrating return to usual activities while also being competent to identify psychosocial risk factors. I think this group exists already and I think it’s time to turn the focus away from potential tissue mechanisms and back on to supported return to normal.
Bronnie, you do not really have to prove your point – that all therapeutic approaches to people with low back pain of whatever duration have been spectacular failures.
Much of what is currently on offer – prescribed medications, the various physical therapies (physiotherapy, chiropractic, osteopathy), the needling of tissues (muscles, zygapophyseal joints and intervertebral discs) and the more esoteric folk remedies (including needle acupuncture) – are seriously lacking in evidence of benefit beyond placebo (contextual factors).
Those who unfairly excluded you from their deliberations on planning health system pathways may not have read the little paper by Carr and Bradshaw (2014). Should they have done so, you would have been welcomed with open arms.
Let us hope that eventually this “penny will drop” upon more fertile ground.
Reference: Carr DB, Bradshaw YS. Time to flip the pain curriculum. Anesthesiology 2014; 120: 12-14.
That paper is such a good one John! I know you understand what I’m on about, it’s an odd thing that the very basic problem-solving approach to returning to everyday activities has never been directly supported. Instead there is this mishmash of therapies that supposedly help but lack support and ultimately confuse the very vulnerable people they’re meant to be helping. I do like Norton Hadler’s idea of calling LBP “activity intolerance” and be done with the peculiar and pseudo-diagnoses that are tossed about with enthusiasm.
I see that we agree on most elements and as such I don’t consider this response a ..but-response.
The issues regarding rudimentary concepts of pain control are not (to my knowledge) based solely on education: I teach all professions in pain science and each has their own ideas that could be revised according to updated views on neuroscience and behavioural sciences. This leads me to highlight one particular approach with a fairly well established evidence that targets the very group you refer to: The STarT Back screening Tool. Albeit not flawless, it does provide a systematic approach to find those at risk for chronicity.
I am positive towards the idea that not only specially trained PTs but also OTs and some doctors could provide relevant and needed expertise to the high risk group, which is what you also suggest. But no matter what I completely agree that a new approach is needed and that focus on effect rather than tissue is needed!
I agree with you that advocates of various therapy groups are competing rather than co-operating. Aust govt decisions to constrain imaging (and thus CT-guided steroid injections) hasn’t helped.
http://www.FnMyalgia.com/2014/02/28 describes the most readily prescribed treatment, which is also the solution favoured by our institutions.
I have to say, I do support using TCA’s and/or gabapentin/pregabalin as primary treatments for fibromyalgia. They seem to do less harm, are less intrusive, and for those for whom they work, a godsend. Neither are helpful for me, but far less intrusive than attending for ongoing injection procedures.
Bronnie, I do hope that those who present to their clinicians with chronic widespread pain (aka fibromyalgia) are not being subjected to injection procedures (either into their spines or muscles). Such treatment has neither a rational nor ethical basis.
John, I wish I could reassure you, but there are clinicians who believe they can eliminate “tender spots” and thus “sources of nociception” to get rid of central sensitivity processes and thus the experience of widespread pain. TBH I have yet to see any evidence for this approach, but that has never stopped this kind of thing from happening!
Bronnie, as long as there is an item number for “useless treatment” such unscrupulous clinicians will exploit it.
I’m trying to be charitable and hope that they do so because they sincerely believe their treatments help alleviate distress – but to me it’s an expensive and temporary way of treating a problem that might be better solved through discussing the meaning of what it’s like to experience the pain, and helping people develop more flexible ways of responding to that experience. But clearly I’m not a medical practitioner, so my word doesn’t carry a lot of weight!
Bronnie, you might well be surprised by the weight of opinion you carry. But I am less charitable than you in these matters and, to me, the words of Sir Thomas Browne [1605-1682] still ring true: “No one should approach the temple of science with the soul of a money changer.”
I’d love to be surprised John! And yes those words are very apt – I feel the socialist in me coming forward whenever I look at the woes of the North American health system (and unfortunately Australasian systems have bought into some of those same principles. sigh.)
@ Mortenhoegh. When you have identified those “at risk” individuals whose pain is likely to persist, what do you then have to offer them? The last time I looked, the available scientific evidence is quite strong on what NOT to do, but is remarkably deficient in telling us what might help these patients. Has this situation changed for the better?
Dearest Bronnie,
I believe you are spot on with your suggestions. The type of “non-specific” treatment you’ve outlined to improve a person’s occupations is, I believe, what has been proven to work for pain. Treatments such as walking, education, and activity pacing are certainly evidence-based for the treatment of pain, and these treatments don’t belong to any particular profession. The more healthcare providers who can empathetically apply pain science, the better, for acute and chronic LBP. Occupational therapists are better prepared to provide biopsychosocial pain care. Hopefully more OTs can live up to the challenge as you have!
Thanks so much Connie, I think occupational therapists are certainly up for the challenge, but what seems to be holding things back is the climate in which this “functional” approach isn’t “sciency” enough, or perhaps doesn’t fit the model of “there must be a pathology somewhere or why would they have pain?”!!
Bronnie, in my opinion the “sciency” people have not done all that well. They have focused their attention upon the brain without understanding that “brains can know nothing”. On the other hand, occupational therapists will naturally direct their efforts towards helping the person in pain to better understand and cope with their biological predicament.
I completely agree John – and I have a lot of confidence that in general our bodies are pretty good at self-regulating and returning to homeostasis, as long as we begin to return to normal activities. It seems to work for a sprained ankle, and for “tension” headache, so why wouldn’t it work for common low back pain which is the most common musculoskeletal complaint on the planet?!
Bronnie, I don’t think this strategy will solve the problem but at the very least it could save some people with persistent spinal pain from having to undergo endless investigations and assessments and being offered useless and/or irrational treatment. For what it is worth, in my opinion answers will slowly emerge as we begin to understand the complex (epigenetic) mechanisms that regulate our stress response systems. Here is a useful reference: Stankiewicz et al. Epigenetics of stress adaptations in the brain. Brain Research Bulletin 2013; 98: 76-92.
I loved this post!! Thank you for framing the information and for the call to action to promote and study the graded activity approach. Being a LB pain sufferer myself — I have done best with graded activity when the back pain is “active” along with a regular general stretching routine.
Hi Denise
I really do think we are more than capable to manage nonspecific low back pain and do it well. There seems to be this belief that other practitioners have healing hands that can take the pain away – but I haven’t been able to find evidence of anything much, and most is very short-term. So…. it seems to me the problem with back pain is that people DON’T return to their normal daily lives and this IS what occupational therapists are trained to work with. The relatively low risk of something terrible going on (like a tumour, undiagnosed fracture or cardiac event) is very low compared with the very real and visible risk of people either being told things that don’t help/over-complicate or of having psychosocial risk factors not identified, poorly managed or completely mismanaged which is very high. An occupational therapy biopsychosocial framework is, I think, ideal for this kind of work – and now it’s up to occupational therapists to get on and do it.
Modern hectic lifestyle has made lot of strain on human bodies; the result comes in the form of lower back pain and other joint pain. I think we must consult a good clinic and doctor as soon as possible.