Changing the focus from managing back-pain to providing back-care
A three-part series about low back pain was published in the Lancet on March 22, 2018.
In the Lancet papers we can read that:
“Low back pain is the leading cause of disability worldwide, and for nearly all the people it is not possible to identify a specific cause of their pain”. (Non-specific low back pain diagnosis)
“Low back pain occurs in all age groups from children to the elderly population”
“Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling.”
“Disability and costs attributed to low back pain are projected to increase in the coming decades”
“By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate”
“Early supervised exercise therapy is typically unnecessary; however, it can be considered if recovery is slow or for patients with risk factors for persistent disabling pain”.
“Improved and better integrated education of health-care professionals could support implementation of best practice for low back pain, help to break down professional barriers, develop a common language, and create new and innovative strategies for practice. Examples of such support include, the integrated education of medical doctors with chiropractors in Denmark”
Following these articles has media worldwide published articles claiming that back pain is not being treated properly.
I would propose that the biggest problem is not that back-pain is not being treated properly, but that the emphasis is on treating back-pain, not preventing it from occurring.
How can the cause of back-pain not be explained when it is such a huge problem worldwide?
The answer is simply that they are trying to find a structural explanation for a soft-ware problem.
The papers state: “Many imaging (radiography, CT scan and MRI) findings identified in people with low back pain are also common in those without such pain” If the structure is the same what else can the difference be?
The answer is function- back pain is a symptom not a disease, and it is a symptom of movement dysfunction. The problem is that we cannot measure the quality of movement.
The report found that: “People with low back pain often have concurrent pain in other body sites, and more general physical and mental health problems”, which again can be explained by inadequate stabilization of joints during movement. Dysfunctional movements in one area are easily transferred to other regions. DNS (Dynamic Neuromuscular Stabilization) emphasize the importance of trunk stability for not only prevention of back pain, but also to ensure proper stabilization of all other joints.
Another statement is that: “By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate”
Studies about prevention are not only lacking in number, but when they have been performed they have been aimed at reducing the external strain on the individuals by work-place education, limiting lifting, using back belts and ergonomic furniture. The future emphasis has to be on making people move better and become stronger to withstand both the external and internal forces loading their joints. More injuries are caused by the internal forces imposed on the body by moving poorly than from external forces. Reducing the external loading on the individuals will only make them weaker and even more susceptible to injuries.
What is the solution?
The entire discussion is about finding the best treatment for low back pain, not preventing it. We need to change our focus and start concentrating on spinal care!
When it comes to back care I usually use Dental care as a comparison- In dental care, from an early age are children taught to brush their teeth twice a day, floss, avoid sugar and visit a dentist 1-2 times a year for a check-up.
Discussions solely aimed at finding the best treatment for back pain would be as if dentist were only discussing whether teeth should be pulled out or drilled and filled. The focus would be on different drills, the best filling material, or whether caps, crowns, implant or dentures would be best for people.
And so with back pain. The problem is not weak muscles or bad postures, the problem is in the inability to control movements sufficiently. It is a software problem not a structural lesion-
Joints are not being overloaded and worn by moving too much, they are strained and gradually deteriorate because they are loaded incorrectly in movements.
A Functional joint movement can be described as a movement with good joint centration.
Joint centration is where there is maximum contact of the joint surfaces and symmetrical activation of the stabilizing muscles of the joint, which allows for maximum loading with minimal strain.
Simply advising back pain sufferers to stay active and do more exercises is generally not to be recommended as their movement patterns are usually poor, and it would therefore not be advisable to load them and further reinforce the dysfunctional patterns. Exercises should initially be supervised by someone who has good knowledge of functional movements. It is all about quality, not quantity! Movements are controlled by the nervous system and the sensory integration drives the motor output. We can therefore state that exercises are neurology and the emphasis should be on improving the brains ability to control movements. Centration, stabilization, eccentric control and relaxation are all factors contributing to the quality of functional movements.