Back Pain: A Western Epidemic
Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.
What have we learned from these last 25 years of scientific inquiry and study? In this editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question.
First, it should be noted that in 1987, randomized controlled trials were started. These studies used scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.
Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.
On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often "negative" (no findings of anything "wrong" in the bones or soft tissues). Even knowing this, physicians continued to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.
Not only that, but when clear-cut diagnoses could be made (e.g., lumbar disc herniation), patients with this diagnosis responded differently to treatment. Finding one single approach that worked for everyone just didn't happen. Some experts even recommended providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea was labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.
So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.
Recovering function (daily activities) and the ability to return to work are the main goals of today's treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.
Concepts such as setting "acceptable targets" and forming "patient-based action plans" are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).
Where will we be at the end of the next 25 years? Hopefully, clinical and research efforts will solve the dilemma of chronic low back pain. Whether it is with a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual or some other approach remains to be seen. Lowering costs, preventing low back pain, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration.
Rowland G. Hazard, MD. Goal Achievement Model for Low Back Pain. In Spine. August 1, 2013. Vol. 38. No. 17. Pp. 1431-1435