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Approaching the patient with lower back pain

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Filed under Back Pain
Posted on Sat, 23 February 2008 at 6:19 pm
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The factors that determine the degree of lower back pain, and especially the amount of disability associated with the pain, are therefore the result of multiple factors. Structural pathology sets the stage and is the origin of the painful stimulus. The natural healing process, in most situations, results in the resolution of lower back pain within relatively short periods. Physical stress placed on the back through work and leisure activities may slow the healing process or irritate spinal pathology such as degenerative changes or disc protrusion. It is, however , the psychosocial situation of the patient that determines the level of discomfort and the response of a patient to the painful stimulus. The patient’s psychological state, level of satisfaction with work and personal life as well as his/her social and spiritual life may impact upon the central modulation system in the brain and modify the response to pain.

In this volume, a great deal of emphasis is placed on visualization of spinal lesions that can result in spinal pain. To rely on anatomical changes to determine the cause of lower back pain can, however, be very misleading to the clinician through the mechanisms described above. There are other examples in science that can be used as a model for looking at spinal pain. The Danish pioneer of quantum physics, Niels Bohr , claimed that science does not adequately explain the way the world is but rather only the way we, as observers, interact with this world. Early in the last century, it was discovered that light could be explained in terms of either waves or particles, depending on the type of experiment that was set up by the observer. Bohr postulated that it was the interaction between the scientist, as the observer, and the phenomenon being studied, in this case light, that was important. The same thing can be said for the clinician approaching a patient with lower back pain. The conclusions reached by the clinician regarding the etiology of lower back pain in a specific case are often dependent on the interaction between the patient and the clinician and the training and experience brought to the decision-making process by both individuals.

There are other ways of looking at lower back pain. Chaos theory postulates that there is a delicate balance between disorder and order. The origin of the universe is generally explained by the “Big Bang” theory which states that, in the beginning, there was total disorder which was followed by the gradual imposition of order through the creation of galaxies, stars and planets. This process is perceived as occurring through a delicate balance between the forces of gravity and the effects of the initial explosion. This process emphasizes that small changes at the beginning of a process or reaction can result in large changes over time. If one applies this analogy to the interaction between patients with lower back pain and their physicians, the outcome of treatment can be perceived as being impacted upon by a number of beneficial influences or “little nudges” and harmful attitudes or “little ripples” (Table 1). The patient’s symptoms can be positively impacted through such processes as listening, caring, laughter, explanation, encouragement, attention to detail and even prayer and negatively impacted by fear, anxiety, anger , uncertainty, boredom and haste. The manner in which a physician uses these nudges and helps the patient avoid the ripples can have a large effect on the impact of lower back pain on the patient’s life. The most accurate diagnosis possible is dependent on

Table 1 Beneficial influences (nudges) and harmful influences (ripples) which impact on the outcome of treament for lower back pain

Harmful influences Beneficial influences
Fear Listening and caring
Anxiety Laughter
Anger Explanation
Uncertainty Encouragement
Boredom Attention
Haste Prayer

accurately observing and listening to the patient, the physical examination and the results of all testing in combination with the intuition that is gained from experience from treating multiple similar patients.

The fine balance between different factors impacting on lower back pain can be illustrated by a few simple examples.

Example 1

A 50-year-old woman presented to her doctor with symptoms and signs of a disc herniation confirmed by CT scan. She was the owner of a small cattle range and was worried about the condition of her animals. She underwent surgery to correct the disc herniation but her convalescence was prolonged for no apparent reason. After several months, the condition of her cattle herd improved and, at the same time, the patient’s symptoms improved. This raises the question as to the link between the patient’s symptoms, the disc herniation and the condition of her cattle.

Example 2

A 45-year-old gentleman in a position with a responsible insurance company presented to his doctor with symptoms and signs of severe L4-5 instability confirmed by stress X-rays. The patient underwent a posterolateral fusion. At 3 months, the fusion was solid but the patient’s symptoms did not improve. Further questioning revealed that he felt stressed and was unhappy in his work. At 6 months, he became symptom-free without further treatment. The only evident change in his status was the resolution of his difficulties at work.

Example 3

A 35-year-old gentleman with a wife and two small children was admitted to the hospital on an emergency basis with suspected cauda equina syndrome. A psychotherapist assigned to the case discovered that the patient found the presence of his mother-in-law intolerable. Arrangements were made for the mother-in-law to live elsewhere and the patient made an uneventful recovery without the necessity of surgery.

Source: Athlas of Back Pain, Editor Scott D. Haldeman (2002)

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