Back pain was a 20th-century medical disaster and the legacy reverberates into the new millennium.

Medicine has made great advances over the past two centuries and especially since World War II. We have developed powerful tools to treat disease. Medical technology and resources reached a peak in solving the mystery of life itself in DNA, in our ability to replace hip joints and even transplant hearts. We now have cures that past generations would literally have thought were miracles. We have vaccines to prevent polio and drugs to cure tuberculosis. We have high-tech investigations that lay bare the anatomy and pathology of the spine. We can perform bigger and better operations. Yet we have no answer for ordinary backache. Modern medicine has been very successful in treating many serious spinal diseases, but this whole approach failed with back pain. For all our efforts and skill, for all our resources, low back disability got steadily worse.

Rising trends of work loss, early retirement, and state benefits all show our failure to solve the problem. By the end of the 20th century, simple back strains disabled many more people in western society than all the serious spinal diseases put together.

There are many paradoxes about back pain. Over the past few decades we have learned much about back pain, about pain itself, and about how people react and deal with pain. We should now be able to manage back pain better, even if we still cannot offer a cure. Chronic back pain and disability should be getting less, but for too long the opposite was true. Why? Why is regular medicine not delivering better and more effective health care for back pain? There are many reasons. It does not seem to put better understanding of pain into clinical practice. Regular medicine is poor at dealing with disability. Too often, disability is ignored and it is assumed it will get better if only the pain is treated. There has also been a shift in social attitudes and behavior. It is now acceptable to stay off work, get workers’ compensation or social security benefits, and retire early because of back pain. So we can already see that health care is only part of a larger story.

Much of this applies to all kinds of chronic pain. So why is back pain, in particular, such a problem?
What is different about it? Part of the trouble is that back pain is only a symptom, not a disease. Most of us get back pain at some time of our lives, but most of the time we deal with it ourselves and do not regard it as a medical condition. But back pain can also be the presenting symptom of serious spinal disease. The symptom of pain in the back is the common link between that everyday bodily symptom, serious disease, and chronic disability. We get into trouble when we confuse them. It is the health care system and health professionals who label ordinary backache as a serious spinal disease. We do not really understand the cause of most back pain and there is usually little or no serious pathology that we can demonstrate. We often regard back pain as an injury, but most episodes occur spontaneously with normal everyday activities. Our high-tech investigations for spinal disease tell us very little about back pain.

So back pain is a problem. It is a problem to patients, to health professionals, and to society. It is a problem to patients because they cannot get clear advice on its cause, how to deal with it, and its likely outcome. It is a problem to doctors and therapists because we cannot diagnose any definite disease or offer any real cure. So medicine is unsure and uncomfortable dealing with back pain. To society, back pain is one of the most common and fastest-growing reasons for work loss, health care use, and sickness benefits.

Patients, therapists, and doctors are now more aware of the limitations of regular medical care for back pain. The scientific evidence shows that most treatments in routine use are pretty ineffective. Indeed, many of the things done may be worse than no treatment at all, especially if they divert attention from dealing with the real issues. The sheer range of treatments betrays our ignorance. The variation in clinical practice suggests that many patients receive care that is less than ideal. Much of the health care we get for back pain is inappropriate. Too often, the choice of treatment reflects the skills of the professional rather than the needs of the patient. To put it simply, what treatment you receive depends more on who you go to see than on what is wrong with your back. Many patients are now so dissatisfied with orthodox medical treatment for back pain that they seek alternative health care instead, and we are seeing that they are much more satisfied.

There is much agreement on the need for change. There is growing demand from patients and family doctors for better health care services for back pain. Policy makers and those who fund health care are in a position to enforce this demand. But health professionals are conservative. Traditionally, medical doctors are slow to change their professional practice. Until recently, there was also lack of a clear direction for change. There are still many gaps in our knowledge, but there is now a growing body of scientific evidence from which we can begin to draw principles for better treatment. There is now the start of a consensus, and change is begun. There is still a long way to go, and a great deal of inertia and resistance to overcome. But I believe there is now the dawn of a revolution in the care of back pain.

Dr. Gordon Waddell, a famous orthopedic surgeon wrote, “Near the end of my training as an orthopedic surgeon, I was still unsure about treating spinal disorders. So I went to Toronto and worked for a year with the late Drs John McCulloch and Ian Macnab. I reviewed 103 Workmen’s Compensation patients who had had repeat back operations. To a young surgeon at the start of my career, the results were frightening. A first operation made 70–80% of patients better, but 15% were worse after surgery and sooner or later had another operation. The results of repeat surgery got worse. By the third operation there was only a 25% chance of a good result and an equal chance it would make the patient worse. It was also obvious that the outcome of surgery depended only partly on physical factors. Sixty-five percent of these patients had psychological problems by the time I saw them. That year changed my thinking. Ian Macnab (one of the kings of spinal fusion!) taught me to “know as much about the patient who has the back pain as about the back pain the patient has.” John McCulloch introduced me to the non-organic signs. Neville Doxey taught me, to my surprise, that doctors can learn something from clinical psychologists. I went to Toronto to learn about spinal surgery, but ever since I have been intrigued by back pain, how it affects people, and how they react. I learned that back pain is not simply a mechanical problem. Low back disability and how people react to pain and to treatment depend just as much on psychological and social factors as on the underlying physical problem.”

Compare a patient with back pain with one who has a hip replacement for osteoarthritis. In back pain we often cannot find the cause or even the exact source of the pain. Patients do not understand what is wrong and cannot get clear answers to their questions. If back pain becomes chronic, patients soon realize that we do not know what is wrong.

                  Spine arthritis                                                           Painful hip arthritis

       in person with NO symptoms

In contrast, with hip arthritis the problem is clear to both patient and surgeon and both can see it on X-ray. Treatment of hip arthritis is logical. Complications and failures do occur, but they are relatively uncommon and the reason for failure is usually obvious.

Treatment for back pain is empiric and has a high failure rate. Understandably, many patients are reluctant to accept, and many medical doctors or therapists to admit, the limitations of treatment for back pain. So, when treatment for back pain fails, the professional may look for psychological reasons or other excuses. The patient is likely to become defensive. Both patient and medical professional may become angry and hostile. It should come as no surprise that some patients develop psychological problems.

People in less developed societies get much the same back pain as we do, but they have much less disability. Only with the introduction of western medicine does chronic back disability become common . Indeed, the new back cripples in the third world are those who have had the “advantage” of surgery in. Similarly, in North America and in Europe, 25–50% of patients in most pain clinics are the failures of modern treatment for back pain. Perhaps it is time to stop and ask what modern medicine thinks they are doing to patients with back pain.

Once again, the problem is that back pain is only a symptom, not a disease. Western medicine works best for acute physical diseases with clearly understood anatomy and pathology. Then, we can demonstrate and deal with the problem. It is much less successful in chronic and poorly understood conditions, particularly if there are psychosomatic features, like back pain. Most back pain is simply a mechanical disturbance of the musculoskeletal structures or function of the back. That’s why you can’t see most of the problems on x-rays, CT scans and MRIs. We cannot diagnose any specific pathology. We cannot even localize the exact source of most soft-tissue pain. Some doctors and therapists claim to be able to diagnose the site and nature of the lesion, but that often tells us more about the health professional than about the patient’s back. And it is striking how these professionals disagree! To confuse the issue further, back pain is often a recurrent problem and patients are often distressed.

So perhaps it is not surprising that diagnosis and health care are not nearly as logical as they appear in textbooks. This is particularly obvious in patients with failed back surgery, even when we look at a clear-cut condition like an acute disk prolapse. Most doctors know how to diagnose the nerve that needs surgical decompression. It is a logical decision based on well-known criteria. We can all produce the right answer in an exam. However, experience shows that practice can be different from theory. Morris et al (1986) confirmed this in a prospective study of routine spinal surgery. They found that surgical decisions depend on the severity and duration of the patient’s symptoms, their distress and failed conservative treatment, more than on objective evidence of a surgically treatable lesion. “Because the pain is so severe and has not got better with bed rest it must be a disk prolapse.” That is a direct quote from the record of a patient with non-specific low back pain who never had any symptoms or signs of a disk prolapse. Depending on how strongly the patient demands and the surgeon feels that “something must be done,” there is a strong temptation to proceed to investigations. We rationalize this by saying that we “want to make sure we are not missing anything.” Or when the clinical picture is not clear, maybe they will use tests as a short cut to diagnosis. They order a magnetic resonance imaging (MRI) instead of taking a more careful history or physical exam and using time to clarify the picture. If these sensitive tests show even minor changes, they sometimes forget about false-positives and the lack of matching clinical features. The trap is then complete. The patient has genuine needs and demands, the medical physicians have run out of options, and they want to help. It is then difficult to withhold the knife. Too often, in such a case, the surgical findings are unimpressive. Despite best intentions, the brutal reality is that the patient has had an unnecessary operation. Surprise, surprise, it does not help. But more important, and often forgotten, even when there are no complications failed surgery may make the patient’s pain, disability, and distress worse. (And do not fall into the trap of thinking this patient’s condition is so bad you cannot make it any worse. You can, always!)

All my clinical experience and research have convinced me that regular medical treatment of back pain has failed because they have lost sight of basic principles. What matters is not the technical detail but their whole strategy of clinical management. They need to rethink the whole approach. If they can get the basic principles right, the detail can follow. Here are a few of the basic clinical principles:

• Why and how do some people become chronic back cripples due to ordinary backache?
• Why have their numbers increased?
• What went wrong with medical management of back pain?
• How can we stop this epidemic?
• How can we improve health care for patients with back pain?

We all agree in principle that we should treat people, not spines. Plato taught in ancient Greece: “So neither ought you to attempt to cure the body without the soul.” All health care still has its roots in Hippocratic concepts of caring. We cannot separate the doctor’s role as healer from the more ancient role as personal adviser and comforter in illness. Chiropractic and osteopathy share similar philosophy. Physical therapists spend their whole working life helping people to regain function and get back to normal life. The problem is that in busy modern practice medical physicians too often forget about such ideals and get on with treating pain and physical disease. I think we can all agree on the ideals – the challenge is to put them into routine clinical practice.

I can report to you about my 24 years of clinical experience, not about academic research or scientific results. My interest has always been in the clinical care of patients with back pain, and we must apply the lessons of research to daily practice in the office. So this is clinical type of information. I like to refer to more about the clinical problem of back pain. Some teachers claim that anatomy, biomechanics, and pathology are the basis for clinical practice. In one sense that is true: of course we need to know that basic science. But we must also remember these are only tools to serve our patients’ needs. They cannot and must not drive our clinical practice. If we build our theories upwards from the foundation of these basic sciences, then it is too easy to select or bend the clinical facts to fit our theories. It is no surprise that the regular medical approach to back pain failed. The real study of medicine and the foundation of clinical practice is human illness. Only if we start from clinical reality can we select and use those basic sciences that help us to understand and explain our clinical observations.

The fascination and challenge of health care are the variety of ways in which human beings react to illness. You cannot learn this by reading a book. You can only learn by working with patients. There is a wonderful quote from Sir Isaac Newton:

I seem to have been only a boy playing on the seashore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me.


References

Morris E W, Di Paola M P, Vallance R, Waddell G 1986 Diagnosis and decision-making in lumbar disc prolapse and nerve entrapment. Spine 11: 436–439