- Email: [email protected]
Progress in Back Pain?
977
Progress in
Back Pain?
THE size of the back-pain problem is daunting. It is responsible for two million adults in Britain consulting their general practitioners each year and for 65% of all general practice consultations. Nearly one in fifty of the population lose time from work, with a total of over1 nineteen million working days lost per annum. Although it is fashionable to claim that much back pain is a form of malingering, the figures for countries where welfare benefits are not nearly as generous are of a similar order. Appreciation of the suffering produced and the social and economic importance of this problem has stimulated research into its causes, prevention, and treatment with the development of specialist scientific societies specifically interested in this intractable problem (the Society for Back Pain Research and the International Society for Study of the
Lumbar Spine).
Although most back troubles are due to structural or mechanical disorders, alternative diagnoses must be considered particularly in those patients whose symptoms have just arisen for the first time. We now believe that ankylosing spondylitis is far more common than previously appreciated and forme-fruste disease may affect 1 0-1.5% of the adult population.2Other types of inflammatory arthritis, infections, neoplasms, reticuloses, and metabolic bone disorders can all be responsible. Abdominal or pelvic disorders can sometimes present as back pain. A careful history with a full physical examination and laboratory tests and indicate the radiographs usually right diagnosis. Prolapse of an intervertebral disc is usually obvious. Ailer some mechanical stress back pain is followed by :ower-limb symptoms and there may be neurological signs and limitation of straight leg raising. An ,mportant question not yet answered is whether the preceding stress was primarily responsible for the Wood PHN, Badley EM.Epidemiology of back pain. In: Jayson MIV, ed.The lumbar spine and back pain, 2nd ed.Tunbridge Wells: Pitman Medical, 1980: 29-55. Calin A, Fries JF Striking prevalence of ankylosing spondylitis in ’healthy’ W27 positive males and females A controlled study. N Engl J Med 1975; 293: 835-39.
damage to the intervertebral disc. In-vitro studies generally show that the normal disc bursts through the vertebral end-plates and only previously abnormal discs will prolapse posteriorly-in other words, the disc was going to prolapse anyway and the particular incident merely acted as a precipitating factor.3 However ADAMS and HUTTON4 have suggested that hyperflexion under excessive load can cause posterior prolapse of a normal lumbar disc. The term lumbar spondylosis as commonly used includes degenerative changes affecting both the intervertebral disc and apophyseal joints. Radiological evidence of lumbar spondylosis is remarkably common, indeed almost universal in older people. It is true that people with the worst X-rays have a slightly higher incidence of back pain than those whose spines seem intact but the difference is remarkably small; therefore, in an individual patient one can seldom be sure that such radiological changes point to the source
of pain.5 Fractures in the spine are another cause of back pain. Large fractures after trauma are obvious but small fractures arise particularly at sites of strain concentration and may be missed. Special techniques are required to show small fractures in the laminae and apophyseal processes.6 Trabecular microfractures are common pathological findings’ and could easily be responsible for acute episodes of pain but we have no method to demonstrate them in life. Another important diagnosis is spinal stenosis. This is an alteration of the size and shape of the vertebral canal so that the nerve roots are tightly packed with no room to accommodate a disc prolapse or any other intrusion into the canal. There may be a characteristic pattern of back and lower-limb symptoms aggravated by rest, relieved by exercise, and superficially resembling intermittent claudication. However, we also know that an element of spinal stenosis puts people at risk of straightforward sciatica.’,’ A disc prolapse into a large canal will probably produce only transient symptoms but, when space is tight, nerve root damage will arise. The diagnosis of spinal stenosis is difficult if not impossible from plain radiographs. New noninvasive procedures that seem helpful include computerised tomography, ultrasonic scanning, and
radiographic_stereo-plotting. it is not possible to define the of back pain. In recurrent attacks the precise is often precipitated by mechanical or postural pain stress. There may be some limitation of spinal In many
patients
source
Herbert CM, Barks JS. Intervertebral discs: nuclear morphology and bursting pressures. Ann Rheumat Dis 1973; 32: 308-15. 4. Adams MA, Hutton WC Prolapsed intervertebral disc—a hyperflexion injury Spine (in press). 5. Lawrence JS. Rheumatism in populations London: Heinemann, 1977: 68-97. 6. Sims-Williams H, Jayson MIV, Baddeley H Small spinal fractures in back pain patients. Ann Rheumat Dis 1978; 37: 262-65 7. Vernon-Roberts B, Pine CJ Healing trabecular micro-fractures in the bodies of lumbar vertebrae. Ann Rheumat Dis 1973, 32: 406-12 8. Baddeley H Radiology of lumbar spinal stenosis In: Jayson MIV, ed. The lumbar spine and back pain Tunbridge Wells: Pitman Medical, 1976. 151-71. 9 Porter RW, Hibbert CS, Wicks M. The spinal canal in symptomatic lumbar disc lesions. J Bone Joint Surg 1978; 60B: 485-87
3. Jayson MIV,
978
with areas of tenderness over the vertebral column or muscles and perhaps radiographic evidence of lumbar spondylosis. It seems better to label these patients as having non-specific back pain rather than attach diagnostic terms that imply pathological changes that must remain unproven. Anatomical examination of the spine indicates many possible sources for back pain, but the complex anastomotic nerve supply renders the precise source hard to identify. 10 Although the central part of the disc itself does not contain pain receptors, the outer rim of the annulus fibrosus and the surrounding ligaments are richly innervated." Systematic analysis of the intervertebral discs shows that tears of the annulus fibrosus are common.12 In the dorsolumbar region, these tears usually occur at multiple levels and are possibly due to degenerative changes: they tend to affect old people. At lower levels they are not associated with disc disease elsewhere and may perhaps be due to direct mechanical damage or fatigue failure from recurrent stress. The posterior longitudinal ligament is also richly innervated. A buttonhole posterior protrusion of the nucleus can produce severe back pain without distortion of the dural sac so that the lesion cannot be displayed by myelography. Discography seems a particularly helpful investigation here.’3 Another source of symptoms is the apophyseal joints. These tiny joints have the same structure as synovial joints elsewhere. If pain can arise in other joints why not in these? The difficulty lies in proving they are responsible, and the answer may come from work in which sensation from these joints is blocked by local anaesthesia.14 The spine is surrounded by a wealth of muscles and ligaments. Pain over the lateral epicondyle of the elbow, known as tennis elbow, seems to be due to some minor inflammation at the site of insertion of ligaments into bone. Why should this syndrome not occur in the back, where so many ligaments are inserted? So often we see patients with localised tender areas but we can only speculate whether this is the movements
reason.
Advice
the forms of management of back pain abounds, yet good data on the merits of the various treatments are remarkably scanty.’S The reasons are threefold-the difficulties in defining the underlying source of the symptoms in the individual case; the lack of generally accepted methods for following the progress of an individual patient; and the very high spontaneous remission rates. Any therapeutic trial must therefore be scrupulously controlled. The few 10.
on
Pederson HE, Blunck CFJ, Gardner E The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerves (sinu-vertebral nerves). J Bone Joint Surg 1956; 38A: 377-91.
11. Yoshizawa H, O’Brien JP, Smith WT, Trumper M. The neuropathology of intervertebral discs removed for low-back pain. J Pathol 1980; 132: 95-104. 12. Hilton RC, Ball J, Benn RT. Annular tears in the dorso-lumbar spine. Ann Rheumat Dis 1980, 39: 533-38. 13. Park WM, McCall IW, O’Brien JP, Webb JK. Fissuring of the posterior annulus fibrosus in the lumbar spine Br J Radiol 1979, 52: 382-87. 14. Mooney V, Robertson J. The facet syndrome. Clin Orthop Rel Res 1976; 115: 149-56 15. Working Group on Back Pain (chairman, A. L. Cochrane). London: HM Stationery
Office,
1979.
that have been undertaken illustrate the dangers of drawing conclusions from uncontrolled observations, since most of the patients, both treated and controls, have recovered and the advantages of the treatments under investigation have been marginal at best. Briefly, acute pain requires bed rest with analgesics. On remobilisation, all patients should receive postural advice and particularly be instructed on the right ways to lift and carry. The kinetic method of lifting seems superior to the more conventional straight-back/bentknees technique formerly in favour. Advice and instruction have been carried to great lengths in "back pain schools" in the belief that an understanding of how the back works will help patients protect themselves against further problems. In an industrial environment, subjects attending a back pain school do as well as those receiving more conventional physiotherapy,16 but it is not known whether this would apply to the more serious back troubles referred to hospital for a specialist opinion. Physiotherapy includes treatments such as local heat, ice, and massage, traction, and exercises of various sorts. The aim of exercises, one might think, should be to strengthen the paraspinal and abdominal muscles rather than to increase the range of movements of a back that is stiff and painful because of some internal damage. Manipulation and mobilisation of the spine is attempted in many ways, by physiotherapists, specialists in manipulative medicine, orthopaedic surgeons, osteopaths, and chiropractors. The clinical trials have been limited to the types of manipulation and mobilisation practised in hospital physiotherapy departments, and they have shown little or no advantage over more conservative or placebo forms of treatment.17-19 Stories of dramatic relief of symptoms by various forms of manipulation are common, yet the hard evidence is lacking. Lumbosacral supports help to relieve symptoms. They may work by limiting spinal movements, by splinting the spine in a good posture, or by increasing the intra-abdominal pressure (much as the weightlifter’s cummerbund helps to protect his back). Although helpful in the short term, a corset may eventually lead to stiffness of the back and weakness of the paraspinal muscles: continuous wearing is therefore not advisable. An epidural injection of steroid and local anaesthetic agent seems of some value.10 Direct injection of proteolytic enzymes into the damaged disc (chemonucleolysis) seems helpful in selected patients 16.
Bergquist-Ullman M, Larsson U. Acute low back pain m industry. Acta Orthop Scand
suppl 170. DML, Newell DJ. Manipulation in the treatment of low back pain—a multicentre study. Br Med J 1975; ii: 161-64 18. Sims-Williams H, Jayson MIV, Young SMS, Baddeley H, Collins E Controlled trial of mobilisation and manipulation for patients with low back pain in general practice Br Med J 1978; ii: 1338-40. 19. Sims-Williams H, Jayson MIV, Young SMS, Baddeley H, Collins E. Controlled trial of mobilisation and manipulation for low back pain: hospital patients. Br Med J 1979 1977:
17. Doran
ii: 1318-20. 20. Dilke
TFW, Burry HC, Grahame R. Extradural corticosteroid injection nerve root compression Br Med J 1973; ii: 635-37
management of lumbar
in
979
dependence on a National Health Service quite strongly centralised in its administration. Naturally enough the same questions are being asked overseas, at
with single disc disease21 but acceptable controlled and long-term studies are still awaited. Surgery is seldom indicated-probably in less than 1% of cases. Surgeons intervene principally when disc prolapse is producing severe nerve-root symptoms in the lower limbs; for the back pain itself an operation is less helpful. When the sacral nerve roots are involved, with sphincter disturbance, surgical decompression is an emergency
procedure. Perhaps in the long run our efforts should be directed at the factors likely to precipitate back troubles. Preemployment screening-to avoid exposing the potential back sufferer to excessive mechanical stress-has proved disappointing. There is little evidence that this is practical, and, in the only study in’ which success was achieved, over a quarter of the potential work force was rejected, often for trivial ‘
reasons.22 Limitation of the load a worker should be allowed to carry seems obvious. However, arbitrary limits are not widely accepted since they take little account of the posture at work and the comparative dangers of one large lift and repeated smaller lifts; they also tend to give the impression that anything up to that load is safe and anything beyond that is dangerous. Nevertheless, workers should be taught how to handle heavy and awkward objects, and this is happening. One preventive approach entails identification of the most demanding component of any job and measuring the maximum force that could be achieved by very strong workers in the identical posture.23 The lift strength rating (LSR) of the job is defined as the maximum load to be lifted, divided by the predicted maximum lift capability. When the job requires an LSR of 0.2 or greater there is a considerable increase in the incidence of low back pain. This research has provided charts
showing the predicted maximum lift capabilities in various positions so that jobs can be altered to reduce the LSR below 0 - 2. This type of approach provides a real advance in understanding of the physical requirements of various types of manual labour, and perhaps more widespread application would reduce the toll of back pain.
Government’s Role in Health Care WHAT part should the public sector play in the
provision of health services? Within the public sector,
what should be done by different levels of government? In Britain, the present government has raised these questions and seems bent on altering the nation’s McCulloch JA
Chemonucleolysis: Experience
with 2000
cases
Clin
Orthop Rel Res
time of economic recession and of some disenchantment (in many countries) with government intervention. The answers reached are bound to vary from country to country, being influenced by history, circumstance, and political choice. Nevertheless, the fundamental issues are the same. A special supplement of The American _7ournal of Public Healthexamines the role of State and local government in personal health services in the United States. The supplement is based on papers prepared for a national symposium at Chapel Hill, North Carolina in January, 1980. Several of the papers document aspects of existing local government and State programmes, such as ambulatory care, child health, primary care in a disadvantaged State, and services in the cities and rural areas. More broadly, G. J. CLARKE considers the role of States in the delivery of health services, and R. J. BLENDON (of the Robert Wood Johnson Foundation, which sponsored the symposium) considers the role of State and local government in the 1980s. Some of the accounts of existing programmes are impressive in themselves. For example, C. A. MILLER and coworkers tell us that "Many people (40 per cent) receive each year some personal health service provided by local health departments. A substantial number of poor children (50 per cent) look to public agencies including health departments for all or part of their medical care. A number of departments ... come close to serving as the guarantor of basic medical care for entire constituent populations, reaching those people who are not reached by other provider systems". H. H. TILSON and P. JELLINEK describe Governor Hunt’s 1977 initiative in North Carolina to use public health services to take primary health care to the poorer counties of the State, which were previously underserved. Despite problems, this initiative is judged by them as, on balance, successful. A. CHANG notes the important role that the local health departments of many cities have come to play in paediatric services, particularly for families with low incomes. Even in the United States, the heartland of private enterprise, it is hard to envisage any future in which government-administered programmes do not play an important part in providing personal health care for major sections of the population. Whether such programmes can escape stigma when compared with the services available to the more affluent is problematical. That in turn raises the question whether such stigma is tolerable. Every country is faced with striking a balance between values of liberty (including a freedom of choice) and equity (or fairness). This applies in personal health care, and the balance has to be found within resource constraints. Private sector solutions usually offer more freedom of choice for those who are a
1980, 146: 128-35.
Kosiak M. Aurelius JR, Hartfiel WF The low back pain problem-an evaluationJ
Occup Med 1968; 10: 588-93 Chaffin DB, Park KS. A longitudinal study of low-back pain as associated with occupational weight lifting factors. Am Ind Hyg J 1973; 34: 513-25.
1. Role of State and local governments Health 1981; 71: suppl. 1.
in
relation
to
personal health services. AmJ Publ
Progress in
Back Pain?
THE size of the back-pain problem is daunting. It is responsible for two million adults in Britain consulting their general practitioners each year and for 65% of all general practice consultations. Nearly one in fifty of the population lose time from work, with a total of over1 nineteen million working days lost per annum. Although it is fashionable to claim that much back pain is a form of malingering, the figures for countries where welfare benefits are not nearly as generous are of a similar order. Appreciation of the suffering produced and the social and economic importance of this problem has stimulated research into its causes, prevention, and treatment with the development of specialist scientific societies specifically interested in this intractable problem (the Society for Back Pain Research and the International Society for Study of the
Lumbar Spine).
Although most back troubles are due to structural or mechanical disorders, alternative diagnoses must be considered particularly in those patients whose symptoms have just arisen for the first time. We now believe that ankylosing spondylitis is far more common than previously appreciated and forme-fruste disease may affect 1 0-1.5% of the adult population.2Other types of inflammatory arthritis, infections, neoplasms, reticuloses, and metabolic bone disorders can all be responsible. Abdominal or pelvic disorders can sometimes present as back pain. A careful history with a full physical examination and laboratory tests and indicate the radiographs usually right diagnosis. Prolapse of an intervertebral disc is usually obvious. Ailer some mechanical stress back pain is followed by :ower-limb symptoms and there may be neurological signs and limitation of straight leg raising. An ,mportant question not yet answered is whether the preceding stress was primarily responsible for the Wood PHN, Badley EM.Epidemiology of back pain. In: Jayson MIV, ed.The lumbar spine and back pain, 2nd ed.Tunbridge Wells: Pitman Medical, 1980: 29-55. Calin A, Fries JF Striking prevalence of ankylosing spondylitis in ’healthy’ W27 positive males and females A controlled study. N Engl J Med 1975; 293: 835-39.
damage to the intervertebral disc. In-vitro studies generally show that the normal disc bursts through the vertebral end-plates and only previously abnormal discs will prolapse posteriorly-in other words, the disc was going to prolapse anyway and the particular incident merely acted as a precipitating factor.3 However ADAMS and HUTTON4 have suggested that hyperflexion under excessive load can cause posterior prolapse of a normal lumbar disc. The term lumbar spondylosis as commonly used includes degenerative changes affecting both the intervertebral disc and apophyseal joints. Radiological evidence of lumbar spondylosis is remarkably common, indeed almost universal in older people. It is true that people with the worst X-rays have a slightly higher incidence of back pain than those whose spines seem intact but the difference is remarkably small; therefore, in an individual patient one can seldom be sure that such radiological changes point to the source
of pain.5 Fractures in the spine are another cause of back pain. Large fractures after trauma are obvious but small fractures arise particularly at sites of strain concentration and may be missed. Special techniques are required to show small fractures in the laminae and apophyseal processes.6 Trabecular microfractures are common pathological findings’ and could easily be responsible for acute episodes of pain but we have no method to demonstrate them in life. Another important diagnosis is spinal stenosis. This is an alteration of the size and shape of the vertebral canal so that the nerve roots are tightly packed with no room to accommodate a disc prolapse or any other intrusion into the canal. There may be a characteristic pattern of back and lower-limb symptoms aggravated by rest, relieved by exercise, and superficially resembling intermittent claudication. However, we also know that an element of spinal stenosis puts people at risk of straightforward sciatica.’,’ A disc prolapse into a large canal will probably produce only transient symptoms but, when space is tight, nerve root damage will arise. The diagnosis of spinal stenosis is difficult if not impossible from plain radiographs. New noninvasive procedures that seem helpful include computerised tomography, ultrasonic scanning, and
radiographic_stereo-plotting. it is not possible to define the of back pain. In recurrent attacks the precise is often precipitated by mechanical or postural pain stress. There may be some limitation of spinal In many
patients
source
Herbert CM, Barks JS. Intervertebral discs: nuclear morphology and bursting pressures. Ann Rheumat Dis 1973; 32: 308-15. 4. Adams MA, Hutton WC Prolapsed intervertebral disc—a hyperflexion injury Spine (in press). 5. Lawrence JS. Rheumatism in populations London: Heinemann, 1977: 68-97. 6. Sims-Williams H, Jayson MIV, Baddeley H Small spinal fractures in back pain patients. Ann Rheumat Dis 1978; 37: 262-65 7. Vernon-Roberts B, Pine CJ Healing trabecular micro-fractures in the bodies of lumbar vertebrae. Ann Rheumat Dis 1973, 32: 406-12 8. Baddeley H Radiology of lumbar spinal stenosis In: Jayson MIV, ed. The lumbar spine and back pain Tunbridge Wells: Pitman Medical, 1976. 151-71. 9 Porter RW, Hibbert CS, Wicks M. The spinal canal in symptomatic lumbar disc lesions. J Bone Joint Surg 1978; 60B: 485-87
3. Jayson MIV,
978
with areas of tenderness over the vertebral column or muscles and perhaps radiographic evidence of lumbar spondylosis. It seems better to label these patients as having non-specific back pain rather than attach diagnostic terms that imply pathological changes that must remain unproven. Anatomical examination of the spine indicates many possible sources for back pain, but the complex anastomotic nerve supply renders the precise source hard to identify. 10 Although the central part of the disc itself does not contain pain receptors, the outer rim of the annulus fibrosus and the surrounding ligaments are richly innervated." Systematic analysis of the intervertebral discs shows that tears of the annulus fibrosus are common.12 In the dorsolumbar region, these tears usually occur at multiple levels and are possibly due to degenerative changes: they tend to affect old people. At lower levels they are not associated with disc disease elsewhere and may perhaps be due to direct mechanical damage or fatigue failure from recurrent stress. The posterior longitudinal ligament is also richly innervated. A buttonhole posterior protrusion of the nucleus can produce severe back pain without distortion of the dural sac so that the lesion cannot be displayed by myelography. Discography seems a particularly helpful investigation here.’3 Another source of symptoms is the apophyseal joints. These tiny joints have the same structure as synovial joints elsewhere. If pain can arise in other joints why not in these? The difficulty lies in proving they are responsible, and the answer may come from work in which sensation from these joints is blocked by local anaesthesia.14 The spine is surrounded by a wealth of muscles and ligaments. Pain over the lateral epicondyle of the elbow, known as tennis elbow, seems to be due to some minor inflammation at the site of insertion of ligaments into bone. Why should this syndrome not occur in the back, where so many ligaments are inserted? So often we see patients with localised tender areas but we can only speculate whether this is the movements
reason.
Advice
the forms of management of back pain abounds, yet good data on the merits of the various treatments are remarkably scanty.’S The reasons are threefold-the difficulties in defining the underlying source of the symptoms in the individual case; the lack of generally accepted methods for following the progress of an individual patient; and the very high spontaneous remission rates. Any therapeutic trial must therefore be scrupulously controlled. The few 10.
on
Pederson HE, Blunck CFJ, Gardner E The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerves (sinu-vertebral nerves). J Bone Joint Surg 1956; 38A: 377-91.
11. Yoshizawa H, O’Brien JP, Smith WT, Trumper M. The neuropathology of intervertebral discs removed for low-back pain. J Pathol 1980; 132: 95-104. 12. Hilton RC, Ball J, Benn RT. Annular tears in the dorso-lumbar spine. Ann Rheumat Dis 1980, 39: 533-38. 13. Park WM, McCall IW, O’Brien JP, Webb JK. Fissuring of the posterior annulus fibrosus in the lumbar spine Br J Radiol 1979, 52: 382-87. 14. Mooney V, Robertson J. The facet syndrome. Clin Orthop Rel Res 1976; 115: 149-56 15. Working Group on Back Pain (chairman, A. L. Cochrane). London: HM Stationery
Office,
1979.
that have been undertaken illustrate the dangers of drawing conclusions from uncontrolled observations, since most of the patients, both treated and controls, have recovered and the advantages of the treatments under investigation have been marginal at best. Briefly, acute pain requires bed rest with analgesics. On remobilisation, all patients should receive postural advice and particularly be instructed on the right ways to lift and carry. The kinetic method of lifting seems superior to the more conventional straight-back/bentknees technique formerly in favour. Advice and instruction have been carried to great lengths in "back pain schools" in the belief that an understanding of how the back works will help patients protect themselves against further problems. In an industrial environment, subjects attending a back pain school do as well as those receiving more conventional physiotherapy,16 but it is not known whether this would apply to the more serious back troubles referred to hospital for a specialist opinion. Physiotherapy includes treatments such as local heat, ice, and massage, traction, and exercises of various sorts. The aim of exercises, one might think, should be to strengthen the paraspinal and abdominal muscles rather than to increase the range of movements of a back that is stiff and painful because of some internal damage. Manipulation and mobilisation of the spine is attempted in many ways, by physiotherapists, specialists in manipulative medicine, orthopaedic surgeons, osteopaths, and chiropractors. The clinical trials have been limited to the types of manipulation and mobilisation practised in hospital physiotherapy departments, and they have shown little or no advantage over more conservative or placebo forms of treatment.17-19 Stories of dramatic relief of symptoms by various forms of manipulation are common, yet the hard evidence is lacking. Lumbosacral supports help to relieve symptoms. They may work by limiting spinal movements, by splinting the spine in a good posture, or by increasing the intra-abdominal pressure (much as the weightlifter’s cummerbund helps to protect his back). Although helpful in the short term, a corset may eventually lead to stiffness of the back and weakness of the paraspinal muscles: continuous wearing is therefore not advisable. An epidural injection of steroid and local anaesthetic agent seems of some value.10 Direct injection of proteolytic enzymes into the damaged disc (chemonucleolysis) seems helpful in selected patients 16.
Bergquist-Ullman M, Larsson U. Acute low back pain m industry. Acta Orthop Scand
suppl 170. DML, Newell DJ. Manipulation in the treatment of low back pain—a multicentre study. Br Med J 1975; ii: 161-64 18. Sims-Williams H, Jayson MIV, Young SMS, Baddeley H, Collins E Controlled trial of mobilisation and manipulation for patients with low back pain in general practice Br Med J 1978; ii: 1338-40. 19. Sims-Williams H, Jayson MIV, Young SMS, Baddeley H, Collins E. Controlled trial of mobilisation and manipulation for low back pain: hospital patients. Br Med J 1979 1977:
17. Doran
ii: 1318-20. 20. Dilke
TFW, Burry HC, Grahame R. Extradural corticosteroid injection nerve root compression Br Med J 1973; ii: 635-37
management of lumbar
in
979
dependence on a National Health Service quite strongly centralised in its administration. Naturally enough the same questions are being asked overseas, at
with single disc disease21 but acceptable controlled and long-term studies are still awaited. Surgery is seldom indicated-probably in less than 1% of cases. Surgeons intervene principally when disc prolapse is producing severe nerve-root symptoms in the lower limbs; for the back pain itself an operation is less helpful. When the sacral nerve roots are involved, with sphincter disturbance, surgical decompression is an emergency
procedure. Perhaps in the long run our efforts should be directed at the factors likely to precipitate back troubles. Preemployment screening-to avoid exposing the potential back sufferer to excessive mechanical stress-has proved disappointing. There is little evidence that this is practical, and, in the only study in’ which success was achieved, over a quarter of the potential work force was rejected, often for trivial ‘
reasons.22 Limitation of the load a worker should be allowed to carry seems obvious. However, arbitrary limits are not widely accepted since they take little account of the posture at work and the comparative dangers of one large lift and repeated smaller lifts; they also tend to give the impression that anything up to that load is safe and anything beyond that is dangerous. Nevertheless, workers should be taught how to handle heavy and awkward objects, and this is happening. One preventive approach entails identification of the most demanding component of any job and measuring the maximum force that could be achieved by very strong workers in the identical posture.23 The lift strength rating (LSR) of the job is defined as the maximum load to be lifted, divided by the predicted maximum lift capability. When the job requires an LSR of 0.2 or greater there is a considerable increase in the incidence of low back pain. This research has provided charts
showing the predicted maximum lift capabilities in various positions so that jobs can be altered to reduce the LSR below 0 - 2. This type of approach provides a real advance in understanding of the physical requirements of various types of manual labour, and perhaps more widespread application would reduce the toll of back pain.
Government’s Role in Health Care WHAT part should the public sector play in the
provision of health services? Within the public sector,
what should be done by different levels of government? In Britain, the present government has raised these questions and seems bent on altering the nation’s McCulloch JA
Chemonucleolysis: Experience
with 2000
cases
Clin
Orthop Rel Res
time of economic recession and of some disenchantment (in many countries) with government intervention. The answers reached are bound to vary from country to country, being influenced by history, circumstance, and political choice. Nevertheless, the fundamental issues are the same. A special supplement of The American _7ournal of Public Healthexamines the role of State and local government in personal health services in the United States. The supplement is based on papers prepared for a national symposium at Chapel Hill, North Carolina in January, 1980. Several of the papers document aspects of existing local government and State programmes, such as ambulatory care, child health, primary care in a disadvantaged State, and services in the cities and rural areas. More broadly, G. J. CLARKE considers the role of States in the delivery of health services, and R. J. BLENDON (of the Robert Wood Johnson Foundation, which sponsored the symposium) considers the role of State and local government in the 1980s. Some of the accounts of existing programmes are impressive in themselves. For example, C. A. MILLER and coworkers tell us that "Many people (40 per cent) receive each year some personal health service provided by local health departments. A substantial number of poor children (50 per cent) look to public agencies including health departments for all or part of their medical care. A number of departments ... come close to serving as the guarantor of basic medical care for entire constituent populations, reaching those people who are not reached by other provider systems". H. H. TILSON and P. JELLINEK describe Governor Hunt’s 1977 initiative in North Carolina to use public health services to take primary health care to the poorer counties of the State, which were previously underserved. Despite problems, this initiative is judged by them as, on balance, successful. A. CHANG notes the important role that the local health departments of many cities have come to play in paediatric services, particularly for families with low incomes. Even in the United States, the heartland of private enterprise, it is hard to envisage any future in which government-administered programmes do not play an important part in providing personal health care for major sections of the population. Whether such programmes can escape stigma when compared with the services available to the more affluent is problematical. That in turn raises the question whether such stigma is tolerable. Every country is faced with striking a balance between values of liberty (including a freedom of choice) and equity (or fairness). This applies in personal health care, and the balance has to be found within resource constraints. Private sector solutions usually offer more freedom of choice for those who are a
1980, 146: 128-35.
Kosiak M. Aurelius JR, Hartfiel WF The low back pain problem-an evaluationJ
Occup Med 1968; 10: 588-93 Chaffin DB, Park KS. A longitudinal study of low-back pain as associated with occupational weight lifting factors. Am Ind Hyg J 1973; 34: 513-25.
1. Role of State and local governments Health 1981; 71: suppl. 1.
in
relation
to
personal health services. AmJ Publ