Back pain inflicts western society more than any other disability. It is a huge burden on our system and sadly it is a largely manageable and preventable injury. Why has it become so out of control? There are appear to be numerous factors contributing to the ballooning costs (not in any order of importance).

1. We assume a simple cause and effect but multiple factors are often at play. A bio-pyschosocial approach is more comprehensive and is important for both acute and chronic injuries.
2. We have demonized pain. Medical professionals have made it their job to reduce pain and are on the hunt for more patients to treat.
3. When our only job is to reduce pain it means we are quick to administer drugs, provide passive care and choose complicated exercises to rid people of their pain.
4. Medical associations have described the spine as weak and susceptible to injuries. These claims are largely unsubstantiated. The back is a strong and adaptable structure, much like the rest of the body.
5. Over use of diagnostics and the medical terminology that follows have created iatrogenic effects on the population.
6. A largely mechanical and biological view of a persons pain caused blind spots to potential other contributors.
7. It paid to makes things complicated. From physiotherapy to chiropractic to massage therapy, health professionals used greater levels of complication to explain a person’s pain. From slipped SIs, to weak cores, to rotated feet the seamingly endless mechanical explanations made it more and difficult to understand. These explanations increased dependence on professionals to fix problems and propagated the idea of a weak body prone to injury. It is human nature to hunt for answers but we went too far down certain roads!
8. Rest and reduced movement was encouraged. This doesn’t appear as large a problem as it once was but the notion has not entirely left our dialect.

Much of this can change but it will take a monumental shift for healthcare providers – who rely on fixing problems – and patients seeking the irradiation of pain.

Our current best evidence supports the following as line 1, primary care.

1. A good history to clear anything serious (this is standard medical care and should apply to any patient – clinician interaction.
2. Advice to remain active – a period of rest following acute strains is totally normal.
3. Exercise therapy – this should be patient centred and progressive. It does not need to be core-centric.
4. Cognitive behavioural therapy – the use of talk therapy to reframe negative associations with pain and back injuries. The goal is to turn negative associations into positive behaviours.
5. Education: understanding pain, their injury, and how to get back to their prior state.

Adjunct or secondary care include

1. Spinal manipulation, massage, acupuncture, and Advil.
2. For most spinal injuries surgery is not recommended. For certain cases (loss of strength, sensation, drop foot) surgery is indicated.

Our current system offers too many adjunct or secondary forms of treatment. These interventions are now expected – they are a burden on the healthcare system and have created a generation of patients who believe their body needs fixing.

Even if secondary care is still used, if first line treatments can become standard care, we will empower more patients to self manage. This switch will not be easy. It relies on healthcare providers, who make a living out of offering secondary treatments, to change the way they care. It will take strong willed professionals to do what is right for the community at large, not what is right for them. The public needs to be educated and expect less interventions and more self management tools.  Patients should demand education, better ongoing support, and the time for a good conversation between provider and patient.

Patients often come to me knowing that I don’t do a lot of hands on care and I believe a large portion of the population would be happy to receive education, reassurance and a concise action plan. Experience has shown me that passive interventions for pain reduction have become so engrained therapists use them even when they are not expected by patients. If a patient expects a certain treatment the conversation can be more difficult but offering rational explanations and gaining a patients trust we can nudge our patients toward a different view point (see my article on dry needling for more ideas).

Low back care will continue to evolve but I believe we are at an important junction. We need to be in this together and make a conscious decision to change the way we care for backs:)

Thanks for reading
Dave

There is a lot that goes into a clinical encounter but for a shapshot of what graded exposure looks like following a back injury check out this video.