Dear Dr Mel C Siff
Re: PP124: BACK PAIN PARADOX
Thank you for posing the question.
For an excellent new model in the management of chronic pain see
Loius Gifford's work presenting the 'mature organism model' as an
explanation for the appreciation of pain and why the 'pathological
model' does not hold all the answers. Gifford and others argue for a
shift in paradigm from a tissue based model to explain the patients
pain.
See;
Gifford L (1998). Pain the tissues and the nervous system: a
conceptual model. Physiotherapy, 84, 1, p27-36.
The Physiotherapy Pain Association Yearbook (1998), edited by Loius
Gifford, NOI Press, Falmouth, Adelaide. ISBN 0 9533423 0 1.
For interesting theories on the causes of low back pain work
discussing the "neutral zone" (Panjabi 1988) and spinal stability
(Richardson 1995, Hides 1996) are an interesting read. If one of the
stabilising mechanisms of the spine is compromised there is a
potential for (re)injury to occur. This could be the ligamentous
system, or the neuromuscular system (strength or control). As a
follow on from this, the work by Richardson and others suggestes that
the problem may be one of sequencing of contraction of the deep
stabilisers rather than strength.
Richardson CA, Jull GA (1995). Muscle control-pain control. What
exercises would you prescribe. Manual Therapy (1), 10(Feb).
Panjabi M, Abumi K et al (1988). Spinal stability and intersegmental
muscle forces. A biomechanical model. Spine, 14 2 p194-200
Hides J A, Richardson C A, et al (1996). Multifidis Muscle Recovery
is not Automatic after Resolution of
AcuteLowBackPain Spine 21 23 p2763-2769
Hodges P W and Richardson C A,(1996). Inefficient Muscular
Stabilisation of the Lumbar Spine Associated with Low Back
Pain Spine, 21 22 p2640-2650
Happy Christmas
> Date: Sat, 19 Dec 1998 18:59:30 EST
> Subject: PP124: BACK PAIN PARADOX
> From: [log in to unmask]
> To: [log in to unmask]
> Reply-to: [log in to unmask]
> INTRODUCTORY NOTE
>
> For newcomers to this forum, these P&Ps are Propositions, not facts or
> dogmatic proclamations. They are intended to stimulate interaction among users
> working in different fields, to re-examine traditional concepts, foster
> distance education, question our beliefs and suggest new lines of research or
> approaches to training. We look forward to responses from anyone who has
> views or relevant information on the topics.
>
> PUZZLE & PARADOX 124: BACK PAIN PARADOX
>
> Use of a 'pathological model' to consistently predict back pain and
> disability, especially of a chronic nature, or to select a uniquely successful
> treatment modality may be seriously limited and inaccurate.
>
> There has been a great deal of discussion about the causes and treatment of
> back pain, all of it being based on what is known as the 'pathological model'
> of back pain. Recently I have been searching peer-reviewed journals on this
> problem and so far have collected over 2000 references and I have not even
> vaguely exhausted the English language literature.
>
> Despite this prolific research, it is apparent none of the authorities, who
> are all scientists, doctors, therapists or clinicians, believes that anyone
> knows how to predict pain or that there is any consistently effective way of
> resolving back pain, especially since a great deal of back pain resolves
> itself anyway, no matter what one does.
>
> In this respect, the limitations of examining any pathology which appears to
> exist concurrently with the back complaint loom very large. The existence of
> a cause-effect relationship between chronic back pain and certain behavioural
> characteristics (such as poor posture, 'weak abdominals', 'imbalance' of trunk
> extensors and flexors, and obesity) is extremely tenuous.
>
> Though a causal relationship between serious musculoskeletal trauma and acute
> back pain and disability can usually be established, the treatment of such
> events is not always as clear-cut as the medical profession would like. The
> more insidious occurrence of non-traumatic back complaints is an entirely
> different matter.
>
> Numerous articles (many from "Spine" Journal) conclude that the incidence of
> back pain and its ultimate resolution do not show any consistently significant
> correlation between abdominal strength and training of any of the abdominal
> muscles. Some patients with very strong abdominal muscles and backs, and with
> apparently favourable trunk flexor-extensor ratios still suffer from back
> pain, while others who test poorly in those same tests, may never experience
> low back pain.
>
> Others attempt to relate the problem to deficiencies in pelvic tilt or
> hamstring capabilities, but no clear cause-effect relationship has yet been
> established between back pain and strength of trunk muscles. Confusingly for
> many in the fitness business, research has even shown that obese folk do not
> necessarily suffer from more chronic back pain than their skinnier colleagues.
>
> It has been estimated that, even in the case of patients with acute low back
> pain, as few as 20 percent can be given a precise clinical diagnosis of their
> condition (Haldeman S 'Breakdown of the Pathology Model in Chronic Back Pain'
> Proc of S African International Chiropractic Conf 12 Oct 1993).
>
> Yet, there are numerous authorities who claim that they know most of the
> answers and that their practical experience shows that they indeed do have
> methods which work. Yes, scientists and therapists acknowledge that many folk
> do seem to have methods which help, but research reveals that it may often
> have less to do with their unique methods and more to do with psychosocial
> factors.
>
> As Dr Haldeman in his Presidential Address to the N American Spine Society
> ('Spine' 15(7) 1990) stated:
>
> "The close correlation between psychosocial factors and patients with chronic
> back pain is now conclusive, although the relative importance of various
> factors has yet to be worked out. An extensive multivariant analysis by Bigos
> et al demonstrated that physical measurements were much less important than
> psychosocial factors in predicting low-back injuries."
>
> He went on to say that people who do not enjoy their physical work or
> activities are at significantly greater risk of back complaints. Furthermore,
> he commented that "many individuals in detrimental psychosocial settings seem
> to develop long-term disabling symptoms in the absence of documented
> pathology" and that "...individuals with pathology in poor psychosocial
> settings appear to have enhanced pain and disability beyond that anticipated
> by the pathology".
>
> It has also been commented that the success of some therapists compared with
> others in treating back pain seems to correlate with the amount of interested
> contact time spent with the patient, irrespective of treatment, once again
> suggesting the importance of psychological factors in the aetiology and
> treatment of back pain and disability.
>
> To conclude, Haldeman ended his conference presentation in S Africa (see
> above) with the following remarks:
>
> "Although physicians and patients tend to feel more comfortable with a clear-
> cut relationship between pathology and symptomatology, attempts to make a
> clinical fit between pathological findings and patient symptomatology have
> tended to fail. . . . It is not possible to look at pathology and determine
> any confidence of symptoms a patient may be suffering. It is also not
> possible, except in the most classic, unequivocal and usually acute
> situations, to look at a patient with a back pain and determine the nature of
> the pathology than can be anticipated on testing."
>
> He suggested that an alternative to the classical pathology model, possibly
> involving appropriate psychosocial assessment, will have to be found to
> explain and treat back pain. Others have suggested that a great deal of the
> therapeutic advice on strengthening the abdominal musculature is futile and
> superfluous in most cases and that isokinetic testing is of very limited
> value.
>
> What do you think about this problem? Do you agree with the comments made
> above? Give reasons and any relevant references which may support your
> argument.
> _____________________________________________________________
>
> Dr Mel C Siff
> Littleton, CO, USA
> [log in to unmask]
>
>
>
>
Gerard
Newcastle upon Tyne
UK
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