INTRODUCTORY NOTE

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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
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