Back pain, 2011

This was posted on Health Beat by Maggie Mahar.   I liked it so much I took the post and have added some comments of my own. 

Dr. Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America and , more recently, Stabbed in the Back: Confronting Back Pain in an Overtreated Society. I admire both books because they are so well-written and richly referenced..

Hadler is Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and Attending Rheumatologist at the University of North Carolina Hospitals.
His commentary on “The Predicament of Backache” is adapted from, Stabbed in the Back. It puts my posts on spinal surgery in a larger context, illustrating how “cutting” is not always a cure for life’s problems


The text starts off with some basics on back pain that therapists hear on a regular basis.

To live a year without a backache is abnormal. Here, I am speaking of the commonest form of low back pain: the backache that bedevils working-age adults who are otherwise totally well. This is a pain that does not involve the legs, and that comes on suddenly, seemingly without cause.

Low back pain is one of many recurring predicaments of life, like heartburn and heartache. To be well is not to be spared. To be well is to have the wherewithal to cope till the pain goes away, cope so well that the episode is not even memorable.

I have commented recently on the importance of posture, strength, and mobility and how it affects our everyday movement.  Our bodies will naturally adapt to the outside forces around it, to be able to continue to function.  After awhile, sometimes it does not matter, it just hurts. 

Low back pain relates to posture and movement. It hurts less recumbent. It hurts more slouched forward in a chair or propped up on pillows, let alone bending over. One is forced to choose between less pain and less invalidity. Compelling science says less pain is not worth it. Feeling useless just enhances the suffering without enhancing the rate of healing. Take an over-the-counter analgesic and get on with life as best you can.

I have mentioned previously that there are many people out there that will promise pain relief if you buy into their system.  Back pain typically does not start from a specific event, it is a combination of many events over time that eventually catch up with us. 

Low back pain will go away, but seldom overnight. Weeks are more like it, and months for a few. One should never despair. Nor should one feel so desperate that one grasps at straws. And there are many offering straws, many who would gird your loins, empty your pockets, push pull and poke you, offer you potions and pills, and attempt to excise the evil.

This response to back pain serves as an object lesson. We live in a time when science seems to be bursting with promise. Details of the very latest for diagnosis and treatment find their way into the headlines of print media and the features of broadcast media. We are told to expect cures. All of us respond with baited breath, some with speculative investing. Yet if we give way to the promise of cure, we risk compromising our sense of well being, our belief that we can cope. We succumb to what some call the medicalization of life, brought to us by an industry dedicated to the proposition that none of us are well.

I believe that physical therapists are better at coming up with dysfunctions that lead to back pain, better than any other health care professional.  That is my own opinion, and do not have any research to support that.   However, I do agree with the next comment, that there is no one specific "modality" that can decrease your pain.   It is a matter of finding the dysfunctions, and addressing them.   This is why PT's are the best qualified to treat back pain.  It is typically a multitude of dysfunctions that casue back pain. 

Realize that despite all the jargon, there is no one who can reliably pin point the cause of the common backache. Realize that despite all their theories and all you hear on the street, no one has a “modality” they can apply to you that can be shown to benefit you. All these helpful people are engulfing you and your pain in their frame of reference, in their belief system. You will no longer suffer alone. But your narrative of illness will change, as will your self-image, permanently. Despite these ministrations, you will not return to your prior state of well-being any more rapidly. If you return at all, you will greet any recurrence of the back pain with idioms that were taught to you. If all this is a pleasing prospect, go for it. But do so informed.

I really enjoy this final paragraph.   There is quite a bit of research that shows job satisfaction is a key indicator for return to work after a back injury.  A person's overall satisfaction with life at home will also contribute to their ability to cope with back pain and return to life.  I have learned recently that we continue to make destructive decisions, not because we like to, but because we do get something out of it.  Until you determine what you are getting out of your decisions, you will have trouble improving your coping, and therefore trouble treating back pain. 

Granted, for some of us, coping becomes impossible. Certainly, that could reflect the severity of the pain. But science informs us that another explanation is far more likely. It is not the pain, but other aspects of life that blunt our coping skills. Leading the list of confounders are adverse aspects of life at home or at work. If you can not cope any longer, find someone trustworthy to discuss the possibility that the pain is surrogate for some assault on your coping skills. In all likelihood, you coped with similar predicaments in the past. If you are unwilling to countenance the possibility that something in life is more a pain than the pain in the back, you run the risk of feeling so desperate that you submit to pills, potions, magical thinking or ineffective surgery before you come to grips with your psychosocial adversity. Surgery can not excise an intolerable job, nor can an intolerable home situation yield to manual therapy. Don’t let the pain cloud your thinking. Don’t let preconceived notions lead you astray.

Take care of your back, but understand when you do have pain, we will be there.   Sometimes to listen, sometimes to advise, and  when needed to treat.