Learning from old research (digging into history)


I recently submitted a manuscript to a journal. After the usual delay as the reviewers commented on my draft, I received the feedback – one comment stood out to me: “the references are quite old”. I scurried around to find some more recent references and resubmitted, but as I did, I started pondering this drive to continually draw on recent research even if the findings of the older references had not been superseded. There is a sense that maybe journal editors and perhaps people reading the journals think that old research has no merit.

As someone who relishes reading about the history of pain and pain management (If you haven’t yet read Melanie Thernstrom’s The Pain Chronicles or Joanna Bourke’s The Story of Pain, it’s time to do so!), and because some of the best and most revolutionary papers in pain and pain management were published in the 1980’s (Fordyce, W. E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43(4), 276-283. ; Waddell, G. (1987). 1987 volvo award in clinical sciences: A new clinical model for the treatment of low-back pain. Spine, 12(7), 632-644. ; Waddell, G., Main, C. J., Morris, E. W., Paola, M. D. I., & Gray, I. C. (1984). Chronic low-back pain, psychologic distress, and illness behavior. Spine, 9(2), 209-213.), I find it extraordinary that some of the concepts being discussed today as New! Improved! Radical! are pretty much the same as those introduced waaaay back then…

Examples? Well one is the whole notion of helping people understand something of what’s know about neurobiology of pain. The “Pain Neuro Education” or “Explain Pain” thing. I’ve read several papers touting the idea that before Lorimer Moseley and colleagues published their paper on “intensive neurophysiology education in chronic low back pain” we never included information about what we knew about distinctions between acute and chronic pain. There’s this really weird disconnect between the practice discussed in the 1970’s and 1980’s where at the very least the Gate Control Theory was integral to helping people distinguish between hurt and harm – and this New! Improved! Radical! pain ‘education’. Seriously, incorporating what’s know about pain neurobiology has been part of a cognitive behavioural approach to pain management since the 1970’s if not earlier. It was even provided to me when I first developed chronic pain, and that was the mid-1980’s.

What can we learn from old research, and why does history matter?

Well, one of the things that strikes me about learning from history is that in the general population, and possibly even more so in the health professional population, there are “legacy models” of pain hanging on. Most of us will have encountered someone we’re treating/working with who holds a really strong belief that if there’s a problem with a disc (it’s degenerated, bulging, or otherwise misbehaving), then it just needs to be removed and maybe a new one put in, and everything will be just fine. Where does that come from? And some of us will point to our orthopaedic colleagues and suggest that it’s something “they’ve” encouraged. But perhaps if we take a closer look at the things that contributed to a shift away from “oh I can live with this aching back” to “it must be fixed” we might learn something about how to help shift beliefs back towards a more accommodating and accepting view of the problem.

The history of low back pain

Gordon Waddell, orthopaedic surgeon (Sept 21 1942 – April 20 2017) was, amongst many other things, a keen historian. His fascination came from his desire to understand how it was that low back pain went from being something most people experienced but were not troubled by, to the epidemic of disability that it had become – and still is.

David Allan and Gordon Waddell wrote a paper in 1989 for Acta Orthopaedica Scandinavica, called An historical perspective on low back pain and disability.  The paper was written to try to outline the genesis of the increasing epidemic of low back disability since World War II. In it, Allan and Waddell detail historic understandings of backache from as early as 1500 BC (Egypt) through Greek times (Galen, ~150AD) when back pain was described as “one of the fleeting pains that affected joints and muscles. Treatment was symptomatic. Spas, soothing local applications and counter irritants were used.” (p. 1). Back pain was not often talked about, possibly because it was so common and settled mainly by itself. Over the period 1493 (Paracelsus) to 1642 (Baillou) back pain was gradually classified as one of the diseases of “rheumatism” – a watery discharge or evil humour which flowed from the brain to cause pain in the joints or other parts of the body. Rheumatism was thought to be caused by damp and cold but not trauma – note that well!

By 1800, said Allan and Waddell, doctors started to seek a cause of low back pain itself. Maybe it was “rheumatic phlegm” – let’s rub the area, let’s heat it, let’s blister the area, let’s use cupping… And in 1828 a doctor from Glasgow (Brown) described “spinal irritation” and the vertebral column and nervous system could be the source of low back pain. This radical notion “swept Europe and had a profound effect on medical thinking for nearly thirty years”. The exact nature of “spinal irritation” was never shown… and the specific diagnosis faded away but by then and until today the idea that a painful spine “must somehow be irritable” remains.

Back pain and trauma

Chronic low back pain was not thought due to injury until the latter half of the 19th century. In other words – not all that long ago. And we can blame the industrial revolution and railways for the development of an association between back pain and trauma. In the fear that often arises during the introduction of new technology (remember RSI in the 1980’s and 1990’s? due to all these new-fangled computers we were using… and maybe, just maybe “text neck” could go the same way…) people attributed back pain and a number of other ailments on “minor injuries and cumulative trauma” to the spine because of the speed of early railway travel. This was when trauma and back pain became firmly linked.

But wait – there’s much more to come! Next week I’ll talk about the rise of the “Dynasty of the Disc” and why orthopaedic surgeons got in on the act…

 

Allan, D. B., & Waddell, G. (1989). An historical perspective on low back pain and disability. Acta Orthopaedica Scandinavica, 60(sup234), 1-23.

Moseley, G., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi:http://dx.doi.org/10.1097/00002508-200409000-00007

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8 comments

  1. Bronnie, as you so well point out in the case of low back pain, those who believe that old research has no merit might need to rapidly disillusion themselves. Delving into the History of Medicine can be intellectually rewarding to those who take the trouble to do so.

    For this reason, in the 1990s Milton Cohen and I set about reviewing the history of two of the most controversial issues of the times, “RSI” (Quintner & Cohen, 1994) and “post-traumatic fibromyalgia” (Cohen & Quintner 1996). This work served as a launch pad for our further research into both poorly understood conditions.

    Quintner JL, Cohen ML. Occupation neuroses and the psychogenic connotation of “repetition strain injury”: the misconstruction of neurosis. Integrative Psychiatry 1994; 10: 165-176.

    Cohen ML, Quintner JL. The derailment of Railway Spine: a timely lesson for post-traumatic fibromyalgia. Pain Reviews 1996; 3: 181-202.

    1. I completely agree! It’s a shame, however, that history keeps being repeated. I’ll be discussing Railway Spine and post-traumatic issues in the next exciting instalment – it’s so intriguing to see how politics, insurance/compensation, and the knotty problem of a person’s experiences needing to be “verified” by some external authority before they can be believed… and how various health professionals have capitalised on the zietgeist of the moment and retain their grip today…

  2. Bronnie, because in certain influential medical circles what I call “psychalgic fundamentalism” continues to hold sway.

  3. Excellent post. Many thoughtful points. Especially about knowing our own history of the “new” pain science. Although those foundational papers were published back then, there is now an acceleration of the paradigm shift. We are moving from clinician-focused “fix-it” ideas, to more of a patient-centered focus.

    Did the “opioid crisis” create more opportunities for the voices of empowermen and psychosocial approaches to be heard?

    Thank you.

    1. I think the opioid situation in the US has really been a problem of medical management not being able to/ready to consider self management as the main approach. Insurers in the US also have not helped – and a market-based approach to healthcare often isn’t going to reflect an evidence-based approach to health because the market forces aren’t “buying” on the basis of rational logic but emotion… and popularity… and loud voices!
      The person-centred approach to pain management within interdisciplinary/interprofessional teams has been around for a very long time, but faded when US insurers decided they were “too expensive” – yet there is enough evidence to show that for bang for buck these approaches are better than most.
      Thankfully there are people like you and the rest of the emerging therapists interested in this approach who are ready to listen to the voices of the people they work with – and I hope this reflects a longterm movement towards whole person healthcare. Fingers crossed!

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