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Persistent back pain
Complementary Therapiesin Medicine (1995) 3, 224-229 © 1995 Pearson Professional Ltd
CLINICAL FORUM
Persistent back pain D. Peters, A. Lyster, A. Szmelskyj and J. Campbell
The rubric complementary medicine covers a variety of approaches that may seem alike only in their being outside conventional care and training. We have asked experienced practitioners to present their own pieces of the jigsaw, realising that these clinical fragments, when seen together, create excitement but also confusion. Of course, this forum is not intended to be a comprehensive review of relevant complementary treatments, and often the individual approaches to clinical problems will appear totally unrelated, while their apparent effectiveness stretches the biomedical model and conventional research methodology beyond their capacity. With this in mind, we intend that forthcoming articles and reviews will expand on the therapies themselves, and discuss the evidence supporting them.
INTRODUCTION THE P R O B L E M
T H E PATIENT
Our understanding of persistent pack pain has been confused by conflicting studies and changing approaches to management. 1 Surgical intervention is now less common, but the relative contribution of mechanical and psychosocial factors is far from clear; for instance, in one study the strongest predictor of persistence was poor work satisfaction. Illness behaviour perpetuated by inappropriate advice is also a significant factor.: The trend to evidence-based medicine and the production of guidelines for clinical management can be seen as a response to the recognition that public sector resources for healthcare are limited. Back pain, whose management can be costly and problematic, is a major and increasing cause of work-days lost; clinicians and patients alike express dissatisfaction with treatment outcomes. Despite the relatively slight evidence for their effectiveness, the 1994 CSAG guidelines 3 for managing acute back pain recommend the use of nonconventional manipulative therapies as part of a multidisciplinary approach. The view of acupuncture as effective in chronic pain is a widely held one, though it too has not been researched adequately. Perhaps it is reasonable to include complementary therapies in a multidisciplinary approach to managing persistent back pain, as do many pain management units. But though the pendulum is currently swinging towards its active multidisciplinary management, the benefits of using complementary therapies in this condition have yet to be fully established, and their proper evaluation should become a research priority.
Patrick H, a publican, 'strained his back' three years ago while handling barrels in the cellar. At first he found he could carry on, but after several days of worsening lumbar pain and vague sciatica, he needed a hard bed on the floor and the GP's strong analgesics to keep him comfortable. He was also given NSAIDs for weeks after this because of constant 'lumbago' which he thinks his doctor said was due to an 'inflamed disc'. Whether or not his doctor told him so, Mr H has always believed his pain is due to a 'slipped disc', an idea he felt was confirmed when he was referred to an orthopaedic surgeon. He waited several months for the appointment, but luckily a back class in the local physiotherapy department helped, and Patrick returned to work in his understaffed hostelry, albeit cautiously, after a further two months' sick leave, although he found he had to rest every few hours. Nonetheless, when the orthopod finally saw him two months later, with things steadily improving, it was to tell him that no sign of a disc prolapse could be found. Confused and irritated at hearing there was no obvious cause for his still appreciable disability, he took himself off to a local osteopath, whose advice and manipulation at first helped him manage his discomfort better. Yet over the next two years he was more often in pain than not; a nagging discomfort that would often remind him of his 'weakness', limiting his strength and stamina at work, undermining his authority as landlord, and the final straw - causing some sexually difficulty with his wife. Mr H had a growing thirst for his own porter and a spreading waistline by 224
PERSISTENT BACKPAIN 225 the time she sent him to see the GP 'for a blood pressure check'. It took skilful facilitation from his GP to get the picture, but he does not think the problem is psychological for, as Mr H says, his back seems 'stiff as a board and sore to touch'. The doctor tells Mr H that his problem probably stems from an occupational injury, so Mr H has recently sought the advice of a solicitor. Subsequently, Mr H has been seeing his GP every week, trying a variety of analgesics, anti-inflammatories and muscle relaxants, none of which seems to help the pain nor improve his sleep. The GP has
heard of three local practitioners with reputations for treating persistent pain. Well aware that there will be no 'quick fix' for this unhappy man, but still wanting to explore any way of making headway, he calls them up to ask how they would approach the problem. David Peters MB, ChB, DRCOG, MFHom, MRO
Medical Practitioner Marylebone Health Centre 17 Marylebone Road London NWl 5LT, UK.
ACUPUNCTURE BACKGROUND
Acupuncture is widely believed to be effective for back pain. However, the research studies do not distinguish between sub-acute (6-12 week) episodes and chronic back pain. 4 Patrick H's back pain is chronic and this must be regarded as a complex multi-causal condition involving psychosocial factors. 5 Acupuncture approaches to back pain can be broadly divided into the traditional/TCM6which uses an energetic model, and the modern which uses a musculoskeletal model. 7 Both approaches can be holistic, acknowledging social/environmental context and influence, and mind-body interactions. Their respective interpretations of the phenomenology will determine explanation and choice of points; the traditional will use points distal to the site of pain to influence the Qi energy, the modern concentrates on points within affected muscles and areas of skin. The modern approach is more likely to use adjunctive techniques such as psychology and advice to tackle the non-pathological symptoms, both may include massage and exercise, albeit from different traditions, as adjuncts to needling. My approach in this case will be the modern.
his general fitness and activities have decreased. He is becoming increasingly unable to perform well at work or within his marriage and is consequently deriving less support and, it might be assumed, satisfaction.
ASSESSMENT General health check - BE alcohol, weight, activities,
sleep, systems. B a c k examination - Flexion/extension to determine
location of original area of pain and subsequent compensation and guarding of muscle groups, check buttocks and legs for reinforcing musculo-skeletal factors such as tight hip flexors, shortened hamstrings, tight and weak TFL. 8 Approach psycho-social and marital relationships - It might be assumed that being a publican there is considerable investment in the social rewards of 'pub life' and possibly less development of other social recreational activities. Have Patrick and his wife shared their respective plans, scripts, rewards and dissatisfactions? Has he considered a new career? Is he scared that he cannot do anything else yet cannot do this work now?
THE PATIENT TREATMENT Patrick H has a three-year history of back pain. Previous treatments have failed to explain or resolve the pain or provide a coping strategy. He misattributes the cause of the pain to 'disc inflammation', whichconfirms the pathological nature of the pain within an inappropriate acute medical model. Collusion between the GP and patient perpetuates the acute pain model by multiple repeated prescriptions of analgesics and others. His alcohol consumption, weight and blood pressure have increased whilst
Emphasize that surgery is not an option. Explain the multi-causal factors that aggravate his pain, such as weight, posture, work-style/lifting etc. Encourage reduction of analgesics by pointing out current poor relief and the euphoria/dysphoria cycle of waiting for the next dose of tablets; liaise with GP to support this, suggest TENS as alternative. Encourage alcohol- and weight-reduction, and replace with other recreations and increasing activities such as walking. If receptive,
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explain relaxation techniques. Most importantly, emphasise exercise such as the McKenzie back exercises9 for medium term and Tai Chi Chuan for long term, if available; then suggest referral for an intensive physiotherapy regime. ~°,11 Acupuncture will be used initially to establish trust and acceptance of needles, probably superficially in segmental regions to establish an endorphinergic response and gain patient confidence in a non-painful technique. Move towards trigger points or needling around facet joints or intervertebral small muscles via Hua Tuo Jia Ji points. '2 Possibly use Tui Na/Chinese massage as single finger massage along Hua Tuo points and rolling method along lumbar erectors.13
PROGNOSIS Acupuncture will produce relief within 6 treatments if at all; I then suggest 4 weeks' break, then reassessment. If no residual change, then attempt similar approach using Tui Na and McKenzie exercise alone for 4 further treatments, and assess at 4-week follow up. If no change then, suggest healing; then, if, the pain is relieved, revert to former rehabilitation plan.
Adrian Lyster, MTAcS Clinical Acupuncturist, Pain Clinic, Cheltenham General Hospital, Sandford Road, Cheltenham, Glos GL53 7AN, UK.
OSTEOPATHY
THE PATIENT He is a busy publican suffering with a long-term history of back problems. He has seen a number of healthcare practitioners in an attempt to find a solution to his chronic but intermittently acute exacerbations of pain and disability which are causing increasing levels of disturbance to his lifestyle. He seems to be developing a reliance on various crutches to help him cope with his problems, including psychological dependency on medical experts, particularly his GR He is also developing a pharmacological dependency via medication and alcohol. His model of belief in what is wrong with him vis4tvis a slipped disc seems to have been undermined, thus causing confusion and uncertainty, and a possible loss in the credibility and validity of medical advice. However, he also appears to exhibit many features of chronic pain illness. 14His work-role as the bread-winning head of the family has also been reduced by the physical inability to complete his work comfortably, thus producing a lower level of occupational performance, the effect of which has been exacerbated by his employers' loss of confidence in him. His problem appears to be complicated by sleep disturbance, anxiety and possibly depression through the uncertainty the effect that his ill-health will have upon his job security, livelihood and ultimately his marriage. His wife presumably thinks he is stressed and is sufficiently concerned about his health to suggest he has his blood pressure tested. She may also be sufficiently worried about the outcome of his developing alcoholism and the effect this may have on his behaviour. On a physical level his sleep problem may be due to difficulty in finding comfortable sleeping postures; whilst his sexual difficulty may be a problem because
of painful physical/mechanical sexual motion aggravating his back. Alternatively, he may be troubled by some impotency due to over-indulgence in alcohol which may help ease his pain, but may reduce his sexual potency. Like a wounded, cornered animal, his fight back from helplessness may be to divert any pent-up resentment and aggression and pursue his frustration through the injury compensation courts, which in itself may have some impact upon his rate of recovery.
MANAGEMENT AND TREATMENT An holistic osteopathic management of this man's problems would need to be multifaceted and would certainly need to consider psychological factors.2,15His pub is understaffed; he therefore needs more help in the physical handling of barrels in the cellar, thus allowing him to concentrate more on the less physically demanding management side of the pub, and ultimately improving his employers' confidence in him. He and his employees may need manual handling advice and training to help prevent future work-related back pain. As he is 'more in pain than not', this raises a concern that his management may not have been taken beyond the symptomatic (easing the pain) level to an objective level of improvement. He has been taking NSAIDS for a prolonged period. There may be a negative effect of this on the healing rate as a result of the medication. ~6Since the NSAIDS, etc. do not appear to be helping him, is there much point in continuing with them rather than just prescribing a placebo? He may, however, need anxiolytics from his GP to help deal with some of the psychological symptoms.
PERSISTENT BACKPAIN 227 He needs time spent with him; in common with many patients he needs re-education to correct the frequently held believe about having 'slipped discs' or 'bones out of place'. Before embarking on any definitive treatment plan, I would want to know the result of any tests he had, since it is not clear how the orthopod came to his decision. Was it purely a clinical judgement or was it based on radiological confirmation? It is debatable whether reducing his developing obesity would eventually improve his problem. A recent study casts doubt on the link between obesity and the aetiology of back pain. ~7However, from a logical biomechanical perspective, flexing an increasingly large trunk will result in increased loading on his spine, thereby acting as a maintaining factor limiting his recovery. Therefore, I would provide education in manual handling and postural advice, as well as recommending a strategy for weight loss. His self-esteem needs improving; this has probably been weakened by his inability to perform sexually. Thus, advice on the delicate subject of sexual postures
and positions to lessen the strain on his back, and advice on the negative effect of stress and alcohol on sexual function would be given in a light-hearted or serious manner dependent on his mood at the time of the consultation. Once the appropriate osteopathic diagnostic triage and biomechanical testing procedures had been completed, it is probable that a working diagnosis would include a conclusion that his back would have varying degrees of somatic dysfunction including stiffness, spasm, fibrosis and physiological facilitation needing a gentle form of manual therapy; 18,i9 in particular, using a combination of functional and soft-tissue stretch techniques to re-educate the lumbar area, and the body in general, to a more normal level of basal activity?° Alan O. Szmelskyj DO, MRO Practising Osteopath, Back Care Adviser, Papworth NHS Trust, Papworth Everard Cambridgeshire, UK.
MUSCULOSKELETAL MEDICINE THE PROBLEM One of the primary functions of a hospital specialist is to provide the patient with an authoritative diagnosis, and this would have to be my starting point with Mr H. He has already been given a variety of different diagnoses by different practitioners and, although health professionals will recognise most of these as synonyms and convenient labels, to the patient it must appear both confusing and possibly conflicting. The management guidelines produced by the Clinical Standards Advisory Group 3 apply to acute back pain, but many of the principles can be applied to chronic back pain. First, we apply triage, categorising patients as having simple 'mechanical' back pain, nerve root pain, or possible serious spinal pathology. There are many pointers to more serious disease - so-called 'red flags'- which would suggest the need for further investigation. By this stage, it is likely that Mr H has had an X-ray examination and possibly an ESR blood test, and our diagnostic process will confirm a 'mechanical' problem. However, a further specific diagnosis to consider is that of primary depression presenting with a somatic symptom. From a diagnosis, it is possible to discuss prognosis with the patient. Before doctors had effective therapies at their disposal, explaining the natural history of disease was one of their most useful functions. Mr H
may have unreasonable fears that his condition will continue to deteriorate and that he will 'end up in a wheelchair'. Persistent back pain tends to be a problem of middle life and it is helpful to be optimistic about the future. It is not therapeutic to tell patients 'you will have to live with it'; or 'you have arthritis in your spine', or 'your discs are crumbling!'.
THE PHYSICAL DIMENSION Mr H has tried two kinds of physical therapy (physiotherapy and osteopathy), has tried a variety of drug treatments, and has seen a surgeon who has little to offer. I would not dismiss further physical therapy if I felt this might help, and would want to know more detail about the treatments already tried. However, after three years the problem essentially becomes one of chronic pain management, and I would hesitate to offer further passive treatments. Management of chronic benign pain requires a multidisciplinary approach, and measures to reduce pain should be used in conjunction with general rehabilitation. NSAID tablets and/or non-narcotic analgesics can be continued if they are beneficial, but otherwise stopped. Low-dose tricyclic therapy can help both as a co-analgesic and also by promoting sleep. TENS and acupuncture may be useful, and there are a number of
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injection techniques which can be tried (epidurals, sclerosants, facet joint blocks, trigger points). One o f the main perpetuating factors in chronic back pain is physical deconditioning. The main emphasis o f physical therapy should be on building fitness. Some motivated individuals m a y be able to do this on their own, but there is some evidence that supervised fitness classes can help. ~1
THE P S Y C H O L O G I C A L D I M E N S I O N
A p a r t f r o m his chronic pain, M r H has other issues, such as his drinking and sexual problems, which would benefit f r o m skilled counselling. Psychological approaches for pain m a n a g e m e n t have been evaluated and can show g o o d results. 2~ Behavioural principles can be applied, preferably with the understanding and co-operation o f the family. This means ignoring pain behaviour and reinforcing beneficial behaviour. Learning relaxation skills can be helpful. M a n y people swing f r o m overactivity to rest with resulting decrease in physical condition. This can be overcome by learning how to pace activities, and working towards sensible targets - 'do what you plan, n o t what y o u feel'.
THE S O C I A L D I M E N S I O N
A n individual cannot be treated in isolation from his surroundings. Effective rehabilitation requires an occupational assessment, and there may be a number of simple changes to the workplace which could reduce lumbar strain. The Health and Safety Executive can provide advice and publish useful guides (including Manual Handling in Drinks Deliveries which might be relevant to M r H's business!).
CONCLUSION Effective multidisciplinary intervention will enable M r H to keep at work, and recover his general health. Back pain treatment has been characterised by a series o f fashions over the years, ~but at least this current a p p r o a c h is endorsed by all current guidelines and supported by the best evidence available. However, facilities for multidisciplinary rehabilitation are n o t widely available, and the case for their effectiveness has yet to be fully proven, but the general principles involved can be applied successfully by all individual practitioners. James Campbell MD, MRCGP, M L C O M , D M - S M e d Consultant in Musculoskeletal Medicine Princess Margaret Rose O r t h o p a e d i c Hospital Frogston R o a d Edinburgh E H 1 0 7ED, U K .
FURTHER READING
Frank A. Low back pain. BMJ 1993; 306: 901-929. [A short review of current management]. Jayson MIV. The lumbar spine and back pain, 4th edn. Edinburgh: Churchill Livingstone, 1992. [Standard textbook]. REFERENCES
1. Deyo RA. Fads in the treatment of low back pain. New Engl J Med 1991; 325(14): 1039-1040. 2. Burton AK, Tillotson M, Main Jet al. Psychosocial predictors of acute and subchronic low back trouble. Spine 1995; 20(6): 722 728. 3. Clinical Standards Advisory Group. Back pain. London: HMSO, 1994. 4. Vincent C, Richardson R Acupuncture for the treatment of pain: a review of evaluative research. Pain 1986; 24: 15-40. 5. Waddell G. Biopsychosocial analysis of back pain. Bailli6re's Clinical Rheumatology 1992; 6(3): 523-557 (134 refs). 6. Maciocia G. The foundations of Chinese medicine. Edinburgh: Churchill Livingstone, 1989. 7. Baldry PE. Acupuncture: trigger points and musculoskeletal pain. Edinburgh: Churchill Livingstone, 1989. 8. Chaitow L. Soft tissue manipulation. Wellingborough: Thorsons, 1988. 9. McKenzie R. Treat your own back. West Byfleet: Spinal Publications, 1988. [Spinal Publications UK, PO Box 275, West Byfleet, Surrey]. i0. Manniche C et al. Clinical trial of intensive muscle training for chronic low back pain. Lancet 1988; 2 (24-31 Dec): 1473-1476. 11. Frost H et al. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ 1995; 310: 1151-154. 12. O'Connor J, Bansky D. Acupuncture; a comprehensive text. Seattle: Eastland Press, 1981. 13. Sun Chenguan, ed. Chinese massage therapy. Shandong, China: Scienceand Technology Press, 1990. 14. France RD, Krishnan KRR. Chronic pain. Washington: American Psychiatric Press, 1988. 15. SzmelskyjAO. The difference between holistic osteopathic practice and manipulation. Hol Med 1990; 5(3): 67-79. 16. SzmelskyjAO. Rheumatology Symposium. Letter to the Editor. Practitioner 1993; 237: 90. 17. Garzillo MJD, Garzillo TAE Does obesity cause low back pain? J Manip Physiol Therap 1994; 17(9): 601-604. 18. MacDonald RS. An osteopathic view of back pain classification. Br Osteo J 1992; 9: 14-19. 19. Bowles CH. Functional technique: a modern perspective. J Am Osteo Assoc 1981; 80(5) 326-331. 20. Janda V. Muscles, central nervous motor regulation and back problems. In: Korr I, ed. The neurobiologic mechanisms in manipulative therapy. New York: Plenum, 1978: pp. 27-41. 21. Williams ACC, Nicholas MK, Richardson PH et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. Br J Gen Pract 1993; 43: 513-518.
CONCLUSION While all three practitioners would consider careful use o f non-conventional techniques, they a p p r o a c h this patient's chronic pain as a bio-psycho-social problem needing holistic and, possibly, multidisciplinary management. In such a case, foreseeing no quick c o m p l e m e n t a r y therapy 'fix', they emphasise the importance o f empowering the patient by encouraging appropriate understanding, expectations, and his involvement in rehabilitation. David Peters
PERSISTENT BACK PAIN
Realising the importance of pursuing more complex models of health and illness, but recognising too that confusion and debate are inevitable when new theories are emerging, Complementary Therapies in Medicine invites your correspondence.
229
David Peters MB, ChB, DRCOG, MFHom, MRO
Medical Practitioner Marylebone Health Centre 17 Marylebone Road London NW1 5LT, UK.
CLINICAL FORUM
Persistent back pain D. Peters, A. Lyster, A. Szmelskyj and J. Campbell
The rubric complementary medicine covers a variety of approaches that may seem alike only in their being outside conventional care and training. We have asked experienced practitioners to present their own pieces of the jigsaw, realising that these clinical fragments, when seen together, create excitement but also confusion. Of course, this forum is not intended to be a comprehensive review of relevant complementary treatments, and often the individual approaches to clinical problems will appear totally unrelated, while their apparent effectiveness stretches the biomedical model and conventional research methodology beyond their capacity. With this in mind, we intend that forthcoming articles and reviews will expand on the therapies themselves, and discuss the evidence supporting them.
INTRODUCTION THE P R O B L E M
T H E PATIENT
Our understanding of persistent pack pain has been confused by conflicting studies and changing approaches to management. 1 Surgical intervention is now less common, but the relative contribution of mechanical and psychosocial factors is far from clear; for instance, in one study the strongest predictor of persistence was poor work satisfaction. Illness behaviour perpetuated by inappropriate advice is also a significant factor.: The trend to evidence-based medicine and the production of guidelines for clinical management can be seen as a response to the recognition that public sector resources for healthcare are limited. Back pain, whose management can be costly and problematic, is a major and increasing cause of work-days lost; clinicians and patients alike express dissatisfaction with treatment outcomes. Despite the relatively slight evidence for their effectiveness, the 1994 CSAG guidelines 3 for managing acute back pain recommend the use of nonconventional manipulative therapies as part of a multidisciplinary approach. The view of acupuncture as effective in chronic pain is a widely held one, though it too has not been researched adequately. Perhaps it is reasonable to include complementary therapies in a multidisciplinary approach to managing persistent back pain, as do many pain management units. But though the pendulum is currently swinging towards its active multidisciplinary management, the benefits of using complementary therapies in this condition have yet to be fully established, and their proper evaluation should become a research priority.
Patrick H, a publican, 'strained his back' three years ago while handling barrels in the cellar. At first he found he could carry on, but after several days of worsening lumbar pain and vague sciatica, he needed a hard bed on the floor and the GP's strong analgesics to keep him comfortable. He was also given NSAIDs for weeks after this because of constant 'lumbago' which he thinks his doctor said was due to an 'inflamed disc'. Whether or not his doctor told him so, Mr H has always believed his pain is due to a 'slipped disc', an idea he felt was confirmed when he was referred to an orthopaedic surgeon. He waited several months for the appointment, but luckily a back class in the local physiotherapy department helped, and Patrick returned to work in his understaffed hostelry, albeit cautiously, after a further two months' sick leave, although he found he had to rest every few hours. Nonetheless, when the orthopod finally saw him two months later, with things steadily improving, it was to tell him that no sign of a disc prolapse could be found. Confused and irritated at hearing there was no obvious cause for his still appreciable disability, he took himself off to a local osteopath, whose advice and manipulation at first helped him manage his discomfort better. Yet over the next two years he was more often in pain than not; a nagging discomfort that would often remind him of his 'weakness', limiting his strength and stamina at work, undermining his authority as landlord, and the final straw - causing some sexually difficulty with his wife. Mr H had a growing thirst for his own porter and a spreading waistline by 224
PERSISTENT BACKPAIN 225 the time she sent him to see the GP 'for a blood pressure check'. It took skilful facilitation from his GP to get the picture, but he does not think the problem is psychological for, as Mr H says, his back seems 'stiff as a board and sore to touch'. The doctor tells Mr H that his problem probably stems from an occupational injury, so Mr H has recently sought the advice of a solicitor. Subsequently, Mr H has been seeing his GP every week, trying a variety of analgesics, anti-inflammatories and muscle relaxants, none of which seems to help the pain nor improve his sleep. The GP has
heard of three local practitioners with reputations for treating persistent pain. Well aware that there will be no 'quick fix' for this unhappy man, but still wanting to explore any way of making headway, he calls them up to ask how they would approach the problem. David Peters MB, ChB, DRCOG, MFHom, MRO
Medical Practitioner Marylebone Health Centre 17 Marylebone Road London NWl 5LT, UK.
ACUPUNCTURE BACKGROUND
Acupuncture is widely believed to be effective for back pain. However, the research studies do not distinguish between sub-acute (6-12 week) episodes and chronic back pain. 4 Patrick H's back pain is chronic and this must be regarded as a complex multi-causal condition involving psychosocial factors. 5 Acupuncture approaches to back pain can be broadly divided into the traditional/TCM6which uses an energetic model, and the modern which uses a musculoskeletal model. 7 Both approaches can be holistic, acknowledging social/environmental context and influence, and mind-body interactions. Their respective interpretations of the phenomenology will determine explanation and choice of points; the traditional will use points distal to the site of pain to influence the Qi energy, the modern concentrates on points within affected muscles and areas of skin. The modern approach is more likely to use adjunctive techniques such as psychology and advice to tackle the non-pathological symptoms, both may include massage and exercise, albeit from different traditions, as adjuncts to needling. My approach in this case will be the modern.
his general fitness and activities have decreased. He is becoming increasingly unable to perform well at work or within his marriage and is consequently deriving less support and, it might be assumed, satisfaction.
ASSESSMENT General health check - BE alcohol, weight, activities,
sleep, systems. B a c k examination - Flexion/extension to determine
location of original area of pain and subsequent compensation and guarding of muscle groups, check buttocks and legs for reinforcing musculo-skeletal factors such as tight hip flexors, shortened hamstrings, tight and weak TFL. 8 Approach psycho-social and marital relationships - It might be assumed that being a publican there is considerable investment in the social rewards of 'pub life' and possibly less development of other social recreational activities. Have Patrick and his wife shared their respective plans, scripts, rewards and dissatisfactions? Has he considered a new career? Is he scared that he cannot do anything else yet cannot do this work now?
THE PATIENT TREATMENT Patrick H has a three-year history of back pain. Previous treatments have failed to explain or resolve the pain or provide a coping strategy. He misattributes the cause of the pain to 'disc inflammation', whichconfirms the pathological nature of the pain within an inappropriate acute medical model. Collusion between the GP and patient perpetuates the acute pain model by multiple repeated prescriptions of analgesics and others. His alcohol consumption, weight and blood pressure have increased whilst
Emphasize that surgery is not an option. Explain the multi-causal factors that aggravate his pain, such as weight, posture, work-style/lifting etc. Encourage reduction of analgesics by pointing out current poor relief and the euphoria/dysphoria cycle of waiting for the next dose of tablets; liaise with GP to support this, suggest TENS as alternative. Encourage alcohol- and weight-reduction, and replace with other recreations and increasing activities such as walking. If receptive,
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explain relaxation techniques. Most importantly, emphasise exercise such as the McKenzie back exercises9 for medium term and Tai Chi Chuan for long term, if available; then suggest referral for an intensive physiotherapy regime. ~°,11 Acupuncture will be used initially to establish trust and acceptance of needles, probably superficially in segmental regions to establish an endorphinergic response and gain patient confidence in a non-painful technique. Move towards trigger points or needling around facet joints or intervertebral small muscles via Hua Tuo Jia Ji points. '2 Possibly use Tui Na/Chinese massage as single finger massage along Hua Tuo points and rolling method along lumbar erectors.13
PROGNOSIS Acupuncture will produce relief within 6 treatments if at all; I then suggest 4 weeks' break, then reassessment. If no residual change, then attempt similar approach using Tui Na and McKenzie exercise alone for 4 further treatments, and assess at 4-week follow up. If no change then, suggest healing; then, if, the pain is relieved, revert to former rehabilitation plan.
Adrian Lyster, MTAcS Clinical Acupuncturist, Pain Clinic, Cheltenham General Hospital, Sandford Road, Cheltenham, Glos GL53 7AN, UK.
OSTEOPATHY
THE PATIENT He is a busy publican suffering with a long-term history of back problems. He has seen a number of healthcare practitioners in an attempt to find a solution to his chronic but intermittently acute exacerbations of pain and disability which are causing increasing levels of disturbance to his lifestyle. He seems to be developing a reliance on various crutches to help him cope with his problems, including psychological dependency on medical experts, particularly his GR He is also developing a pharmacological dependency via medication and alcohol. His model of belief in what is wrong with him vis4tvis a slipped disc seems to have been undermined, thus causing confusion and uncertainty, and a possible loss in the credibility and validity of medical advice. However, he also appears to exhibit many features of chronic pain illness. 14His work-role as the bread-winning head of the family has also been reduced by the physical inability to complete his work comfortably, thus producing a lower level of occupational performance, the effect of which has been exacerbated by his employers' loss of confidence in him. His problem appears to be complicated by sleep disturbance, anxiety and possibly depression through the uncertainty the effect that his ill-health will have upon his job security, livelihood and ultimately his marriage. His wife presumably thinks he is stressed and is sufficiently concerned about his health to suggest he has his blood pressure tested. She may also be sufficiently worried about the outcome of his developing alcoholism and the effect this may have on his behaviour. On a physical level his sleep problem may be due to difficulty in finding comfortable sleeping postures; whilst his sexual difficulty may be a problem because
of painful physical/mechanical sexual motion aggravating his back. Alternatively, he may be troubled by some impotency due to over-indulgence in alcohol which may help ease his pain, but may reduce his sexual potency. Like a wounded, cornered animal, his fight back from helplessness may be to divert any pent-up resentment and aggression and pursue his frustration through the injury compensation courts, which in itself may have some impact upon his rate of recovery.
MANAGEMENT AND TREATMENT An holistic osteopathic management of this man's problems would need to be multifaceted and would certainly need to consider psychological factors.2,15His pub is understaffed; he therefore needs more help in the physical handling of barrels in the cellar, thus allowing him to concentrate more on the less physically demanding management side of the pub, and ultimately improving his employers' confidence in him. He and his employees may need manual handling advice and training to help prevent future work-related back pain. As he is 'more in pain than not', this raises a concern that his management may not have been taken beyond the symptomatic (easing the pain) level to an objective level of improvement. He has been taking NSAIDS for a prolonged period. There may be a negative effect of this on the healing rate as a result of the medication. ~6Since the NSAIDS, etc. do not appear to be helping him, is there much point in continuing with them rather than just prescribing a placebo? He may, however, need anxiolytics from his GP to help deal with some of the psychological symptoms.
PERSISTENT BACKPAIN 227 He needs time spent with him; in common with many patients he needs re-education to correct the frequently held believe about having 'slipped discs' or 'bones out of place'. Before embarking on any definitive treatment plan, I would want to know the result of any tests he had, since it is not clear how the orthopod came to his decision. Was it purely a clinical judgement or was it based on radiological confirmation? It is debatable whether reducing his developing obesity would eventually improve his problem. A recent study casts doubt on the link between obesity and the aetiology of back pain. ~7However, from a logical biomechanical perspective, flexing an increasingly large trunk will result in increased loading on his spine, thereby acting as a maintaining factor limiting his recovery. Therefore, I would provide education in manual handling and postural advice, as well as recommending a strategy for weight loss. His self-esteem needs improving; this has probably been weakened by his inability to perform sexually. Thus, advice on the delicate subject of sexual postures
and positions to lessen the strain on his back, and advice on the negative effect of stress and alcohol on sexual function would be given in a light-hearted or serious manner dependent on his mood at the time of the consultation. Once the appropriate osteopathic diagnostic triage and biomechanical testing procedures had been completed, it is probable that a working diagnosis would include a conclusion that his back would have varying degrees of somatic dysfunction including stiffness, spasm, fibrosis and physiological facilitation needing a gentle form of manual therapy; 18,i9 in particular, using a combination of functional and soft-tissue stretch techniques to re-educate the lumbar area, and the body in general, to a more normal level of basal activity?° Alan O. Szmelskyj DO, MRO Practising Osteopath, Back Care Adviser, Papworth NHS Trust, Papworth Everard Cambridgeshire, UK.
MUSCULOSKELETAL MEDICINE THE PROBLEM One of the primary functions of a hospital specialist is to provide the patient with an authoritative diagnosis, and this would have to be my starting point with Mr H. He has already been given a variety of different diagnoses by different practitioners and, although health professionals will recognise most of these as synonyms and convenient labels, to the patient it must appear both confusing and possibly conflicting. The management guidelines produced by the Clinical Standards Advisory Group 3 apply to acute back pain, but many of the principles can be applied to chronic back pain. First, we apply triage, categorising patients as having simple 'mechanical' back pain, nerve root pain, or possible serious spinal pathology. There are many pointers to more serious disease - so-called 'red flags'- which would suggest the need for further investigation. By this stage, it is likely that Mr H has had an X-ray examination and possibly an ESR blood test, and our diagnostic process will confirm a 'mechanical' problem. However, a further specific diagnosis to consider is that of primary depression presenting with a somatic symptom. From a diagnosis, it is possible to discuss prognosis with the patient. Before doctors had effective therapies at their disposal, explaining the natural history of disease was one of their most useful functions. Mr H
may have unreasonable fears that his condition will continue to deteriorate and that he will 'end up in a wheelchair'. Persistent back pain tends to be a problem of middle life and it is helpful to be optimistic about the future. It is not therapeutic to tell patients 'you will have to live with it'; or 'you have arthritis in your spine', or 'your discs are crumbling!'.
THE PHYSICAL DIMENSION Mr H has tried two kinds of physical therapy (physiotherapy and osteopathy), has tried a variety of drug treatments, and has seen a surgeon who has little to offer. I would not dismiss further physical therapy if I felt this might help, and would want to know more detail about the treatments already tried. However, after three years the problem essentially becomes one of chronic pain management, and I would hesitate to offer further passive treatments. Management of chronic benign pain requires a multidisciplinary approach, and measures to reduce pain should be used in conjunction with general rehabilitation. NSAID tablets and/or non-narcotic analgesics can be continued if they are beneficial, but otherwise stopped. Low-dose tricyclic therapy can help both as a co-analgesic and also by promoting sleep. TENS and acupuncture may be useful, and there are a number of
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injection techniques which can be tried (epidurals, sclerosants, facet joint blocks, trigger points). One o f the main perpetuating factors in chronic back pain is physical deconditioning. The main emphasis o f physical therapy should be on building fitness. Some motivated individuals m a y be able to do this on their own, but there is some evidence that supervised fitness classes can help. ~1
THE P S Y C H O L O G I C A L D I M E N S I O N
A p a r t f r o m his chronic pain, M r H has other issues, such as his drinking and sexual problems, which would benefit f r o m skilled counselling. Psychological approaches for pain m a n a g e m e n t have been evaluated and can show g o o d results. 2~ Behavioural principles can be applied, preferably with the understanding and co-operation o f the family. This means ignoring pain behaviour and reinforcing beneficial behaviour. Learning relaxation skills can be helpful. M a n y people swing f r o m overactivity to rest with resulting decrease in physical condition. This can be overcome by learning how to pace activities, and working towards sensible targets - 'do what you plan, n o t what y o u feel'.
THE S O C I A L D I M E N S I O N
A n individual cannot be treated in isolation from his surroundings. Effective rehabilitation requires an occupational assessment, and there may be a number of simple changes to the workplace which could reduce lumbar strain. The Health and Safety Executive can provide advice and publish useful guides (including Manual Handling in Drinks Deliveries which might be relevant to M r H's business!).
CONCLUSION Effective multidisciplinary intervention will enable M r H to keep at work, and recover his general health. Back pain treatment has been characterised by a series o f fashions over the years, ~but at least this current a p p r o a c h is endorsed by all current guidelines and supported by the best evidence available. However, facilities for multidisciplinary rehabilitation are n o t widely available, and the case for their effectiveness has yet to be fully proven, but the general principles involved can be applied successfully by all individual practitioners. James Campbell MD, MRCGP, M L C O M , D M - S M e d Consultant in Musculoskeletal Medicine Princess Margaret Rose O r t h o p a e d i c Hospital Frogston R o a d Edinburgh E H 1 0 7ED, U K .
FURTHER READING
Frank A. Low back pain. BMJ 1993; 306: 901-929. [A short review of current management]. Jayson MIV. The lumbar spine and back pain, 4th edn. Edinburgh: Churchill Livingstone, 1992. [Standard textbook]. REFERENCES
1. Deyo RA. Fads in the treatment of low back pain. New Engl J Med 1991; 325(14): 1039-1040. 2. Burton AK, Tillotson M, Main Jet al. Psychosocial predictors of acute and subchronic low back trouble. Spine 1995; 20(6): 722 728. 3. Clinical Standards Advisory Group. Back pain. London: HMSO, 1994. 4. Vincent C, Richardson R Acupuncture for the treatment of pain: a review of evaluative research. Pain 1986; 24: 15-40. 5. Waddell G. Biopsychosocial analysis of back pain. Bailli6re's Clinical Rheumatology 1992; 6(3): 523-557 (134 refs). 6. Maciocia G. The foundations of Chinese medicine. Edinburgh: Churchill Livingstone, 1989. 7. Baldry PE. Acupuncture: trigger points and musculoskeletal pain. Edinburgh: Churchill Livingstone, 1989. 8. Chaitow L. Soft tissue manipulation. Wellingborough: Thorsons, 1988. 9. McKenzie R. Treat your own back. West Byfleet: Spinal Publications, 1988. [Spinal Publications UK, PO Box 275, West Byfleet, Surrey]. i0. Manniche C et al. Clinical trial of intensive muscle training for chronic low back pain. Lancet 1988; 2 (24-31 Dec): 1473-1476. 11. Frost H et al. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ 1995; 310: 1151-154. 12. O'Connor J, Bansky D. Acupuncture; a comprehensive text. Seattle: Eastland Press, 1981. 13. Sun Chenguan, ed. Chinese massage therapy. Shandong, China: Scienceand Technology Press, 1990. 14. France RD, Krishnan KRR. Chronic pain. Washington: American Psychiatric Press, 1988. 15. SzmelskyjAO. The difference between holistic osteopathic practice and manipulation. Hol Med 1990; 5(3): 67-79. 16. SzmelskyjAO. Rheumatology Symposium. Letter to the Editor. Practitioner 1993; 237: 90. 17. Garzillo MJD, Garzillo TAE Does obesity cause low back pain? J Manip Physiol Therap 1994; 17(9): 601-604. 18. MacDonald RS. An osteopathic view of back pain classification. Br Osteo J 1992; 9: 14-19. 19. Bowles CH. Functional technique: a modern perspective. J Am Osteo Assoc 1981; 80(5) 326-331. 20. Janda V. Muscles, central nervous motor regulation and back problems. In: Korr I, ed. The neurobiologic mechanisms in manipulative therapy. New York: Plenum, 1978: pp. 27-41. 21. Williams ACC, Nicholas MK, Richardson PH et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. Br J Gen Pract 1993; 43: 513-518.
CONCLUSION While all three practitioners would consider careful use o f non-conventional techniques, they a p p r o a c h this patient's chronic pain as a bio-psycho-social problem needing holistic and, possibly, multidisciplinary management. In such a case, foreseeing no quick c o m p l e m e n t a r y therapy 'fix', they emphasise the importance o f empowering the patient by encouraging appropriate understanding, expectations, and his involvement in rehabilitation. David Peters
PERSISTENT BACK PAIN
Realising the importance of pursuing more complex models of health and illness, but recognising too that confusion and debate are inevitable when new theories are emerging, Complementary Therapies in Medicine invites your correspondence.
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David Peters MB, ChB, DRCOG, MFHom, MRO
Medical Practitioner Marylebone Health Centre 17 Marylebone Road London NW1 5LT, UK.