Does One Size Fit All?
In the treatment of low back pain can we apply the same treatments to all people? In other words, does one size fit all? A simple answer would be no. A more complex answer would be that most medical problems are a complex interaction of multiple factors and proper treatment would entail identifying those factors and addressing each one as best you can. Low back and neck pain can either be a very simple and straightforward problem to treat or very complex. Early in my career I was fortunate to work with some great physicians that really understood the myriad of factors that can affect the recovery process from acute, subacute or chronic low back pain.
There are essentially two basic models of illness, the bio-medical and the biopsychosocial.
The standard treatment approach for medical diseases is the Bio-Medical Model of Disease. This assumes that all the consequences of a musculoskeletal injury, i.e. pain, impairment and disability, are directly attributable to the organic pathology. In theory, if one corrects or addresses the pathology, then all the sequelae should disappear or lessen significantly. Unfortunately, this method of treatment, especially in the workers’ compensation arena has failed miserably. How many times are we faced with the patient that has incapacitating neck or low back pain, yet only minor to no objective findings? We search and search with all of our various advanced diagnostic tests for the cause of the pain but come up empty handed. We become frustrated by the fact that we cannot seem to reduce the agonizing pain that these patients experience. After countless medications trials, spinal injections, P.T. and office visits these patients are no better off. Perhaps there is a better way to manage these patients’ illnesses?
Gordon Waddell, M.D. and others recognized this dilemma and as a result put forth and popularized the Biopsychosocial Model of Illness as a method of treatment for chronic low back pain. This form of treatment proposes that the pain response or behavior that the clinician observes is actually a multifactorial entity and is influenced by the pathology, the patient’s attitudes and beliefs about their pain, the level of psychological distress, as well as work, economic, family, cultural, etc issues. This is a highly individualized approach to care. Some people just need to be told that their pain is safe and it is okay to return to exercise or work even if initially they have more pain. For others, it means discussing their attitudes and beliefs about back pain, working with them to reduce their fears related to moving their spines (kinesiophobia) and to perhaps do epidurals or facet joint injections to reduce pain and allow for less painful exercise. Some patients need to work with a therapist to help them regain flexibility and strength and to improve function. Others need counseling to help them cope with life stressors or changes. This is not a cookie cutter approach and it involves talking to people and finding out what is going on in their lives and how their pain has affected all aspects of their self.
The Biopsychosocial model of illness takes into account the multitude of factors that can influence a person’s illness
One aspect of this approach I find critical especially if the clinician is working with other healthcare providers is that the patient is getting the same message from all. If the therapist and I are giving the same message that it is okay to be active and to work through the pain (if the pain is deemed to be safe) then people do very well. If the message that the PT, massage therapist, chiropractor, spine surgeon or PCP is giving is the opposite of mine then outcomes are less an ideal. The patient is going to believe which ever healthcare provider’s attitudes and beliefs are most in line with their own even if it leads to greater disability and a lower quality of life.
How do you approach the care of the low back pain patient?