What the physician tells the patient is key in treating those with low back pain

In some cases, the muscular system, rather than the structure of the spine, may cause the pain.

Issue: Issue 2 2008

Patient consultation remains an integral part of the treatment process, and explaining exactly what to expect during treatment for low back pain may help patients avoid further degeneration.

In his presidential lecture at the 9th Annual Meeting of the Spine Society of Europe, Charles G. Greenough, FRCS, presented an overview on how to most effectively discuss low back pain with patients.

“I think that as far as back pain is concerned, my feeling is that the key to recovery is patient understanding,” Greenough said. “It turns out that what is said is far more important than what is done. I don’t think that we can go to patients, probe them with a screwdriver and fix everything.”

Physicians have attempted to explain the etiology of simple low back pain through imaging, which has an effect on patients, Greenough said. He cited research that found that diagnosing patients with an underlying condition for low back pain was associated with a fivefold risk for chronicity.

Paradoxically, offering a diagnosis for the pain can make it difficult for patients to change their attitudes about their condition, he said. In cases of low back pain without serious pathology, he noted that using MRI is contraindicated.

Muscular system causes

Disability is a disorder of function, not anatomy, he said. Greenough also noted that measuring muscle function can help physicians predict future back pain.

“There are many studies now that have demonstrated that the EMG results are different in patients with back pain,” he said.

Patients with low back pain want to know why they hurt and what activites should be limited. The key to answering these questions is to understand why some patients with degenerative changes do not have low back pain, Greenough said.

He believes that the muscular system of the spine acts to dampen the effects of abnormal movement from degenerative changes in most people, but is ineffective in patients with pain.

“The problem with low back pain may not be that there is anything abnormal about the structure of their spine,” Greenough said. “The problem of low back pain may well be that these people have a massively deficient active control system as far as their muscles are concerned.”

Why me?

He believes that many patients could experience pain relief through improved muscular control.

“When I use this sort of a model, it explains to the patient, ‘Why me?’” Greenough said. “Well, because you are not as fit as you ought to be. Often you will find that when there is back pain, these patients do less, and then they [experience] more back pain, so they do even less. In sum, the spine is deteriorated.”

Essentially, patients may not have experienced pain relief from previous exercise because pain restricted them from exercising on a routine basis over time.

“If they understand that it’s supposed to hurt [somewhat], then at least they’re able to get on without fear, and it’s fear and anxiety, I think, that is really the main problem,” he said.

A physician’s job is to reassure the patient, explain why the patient may be experiencing pain and give a realistic time frame regarding pain relief.

“It’s really important to tell them that they’re going to have relapses and then you must discuss activites permitted, which is practically all of them, and restricted, which should be few, and time limited, you must say no lifting for 10 days,” Greenough said.

Orthopaedists should advise patients to continue with activity if they are willing to endure the pain or modify their activities, he said. Greenough cited a study by Eugene J. Carragee, MD, in which patients with low back pain were not given postoperative restrictions. Carragee found that 50% returned to work within 2 weeks and 90% did so within 6 weeks.

For more information:

Charles G. Greenough, FRCS, is a consultant spinal surgeon. He can be reached at James Cook University Hospital, Marton Road, Middlesbrough, England TS4 3BW; +44-1642-854311; e-mail: greenough@stees.nhs.uk.

References:

Greenough CG. EuroSpine Presidential Lecture: Talking about back pain. Presented at the 9th Annual Meeting of the Spine Society of Europe. Oct. 2-6, 2007. Brussels.