The Back Pain Revolution, ed 2.

The Back Pain Revolution, ed 2 Waddell G Edinburgh, United Kingdom, EH1 3AF, Churchill Livingstone Inc, 2004, hardcover, 475 pp, illus, ISBN: 044307227-2, $79.95.

The purpose of the long-awaited second edition of Gordon Waddell's The Back Pain Revolution is to challenge the medical practitioner to re-examine the current manner in which patients with low back pain are examined and treated. This text is geared toward physicians, physical therapists, chiropractors, and any other health care professionals involved with this patient population.

There are 22 chapters in this book. The first chapter explains how low back pain has been treated in the past. The second chapter, "Diagnostic Triage," discusses how to determine whether a patient has "ordinary" backache, a possible serious spinal pathology, or a nerve root problem. Red flags, which represent signs and symptoms that in turn may represent serious pathology, are introduced. The author emphasizes that the majority of patients have "ordinary" back pain and can be managed in a primary care setting. Current information regarding the appropriate use of diagnostic imaging is presented. A flowchart clearly summarizes the diagnostic triage that Waddell proposes.

Pain and disability are the focus of the third chapter. These 2 subjects are contrasted and explained in depth. Acute pain and chronic pain are differentiated as well. Various tests that help measure disability are described. The fourth chapter presents a historical perspective on low back pain and disability. (Interestingly, the first "case study" about back pain dates back to around 1500 BC.) Manual therapy, chiropractic, osteopathy, and physical therapy also are looked at historically. The fifth chapter, "The Epidemiology of Back Pain," presents several studies regarding the prevalence of low back pain, along with its frequency. Chapter 6 explores research on the risk factors for back pain, such as genetics, sex, age, body build, physical fitness, smoking, social class, emotional distress, and physical and psychosocial environmental risk factors.

The next chapter, "The Clinical Course of Back Pain," summarizes various studies, along with clinical tips that practitioners can tell their patients. The rate at which patients return to work is examined along with the risk factors that affect return to work. The risk factors for developing chronic pain and disability are discussed along with screening tools. These psychosocial risk factors have been coined "yellow flags."

The eighth chapter, "Physical Impairment," discusses the different impairment ratings currently in use. The clinical examination is demonstrated using both pictures and text. The physical basis for back pain is explained in chapter 9. Waddell states that back pain is a physical problem. The psychosocial factors affect how patients respond to back pain, he argues, but they are not the cause for the pain itself. Waddell scrutinized multiple radiographic and magnetic resonance imaging studies to see what influence structural changes had in back pain and patient management. The evidence presented, in Waddell's opinion, indicates that patients who demonstrate radiological changes are not at any higher risk for future back pain than others. The evidence surrounding the role of the vertebrae, the disks, facet joints, ligaments, muscles, and the sacroiliac joints is presented. The notion of dysfunction also is presented.

The next 4 chapters explore the roles of illness behaviors, emotions, and social interactions. The biopsychosocial model is introduced. Behavioral signs and symptoms are discussed at length along with clear pictures of various tests. Waddell emphasizes that the presence of nonorganic signs does not mean that the patient is faking or that the pain is psychological in nature. He discusses how stress and distress are related to the way in which patients deal with their pain, and the effect that stress and distress have on their lives. The primary emotions that are associated with back pain include anxiety, depression, increased body awareness, fear, and anger. The presence of these emotional reactions to back pain is well recognized. The author provides methods for clinicians to assess these emotions. It is emphasized that patient-provider communication should be genuine and non-judgmental. The patient's beliefs about back pain influence his or her emotions. Different patients cope differently, and these differences, according to Waddell, must be considered during clinical management. Peer-reviewed research is presented clearly to substantiate this. Chapter 13, "Social Interactions," deals with the influence of a patient's culture, family, and socioeconomic class on his or her pain. Issues of job satisfaction, worker's compensation, and litigation are discussed at length.

Chapter 14 explains the biopsychosocial model. This model integrates the influence of physical dysfunction, beliefs and coping, distress, illness behavior, and social interactions on back pain and disability. Once again, the author provides methods to improve clinical management. Rehabilitation also is discussed utilizing this biopsychosocial model.

The next chapter covers clinical guidelines. Waddell emphasizes that guidelines are not rigid protocols and that clinicians need to individualize the clinical management for each patient. Several guidelines from different countries are presented along with various algorithms. The guidelines developed for Working Backs Scotland includes specific educational sheets with evidence-based recommendations for general practitioners, physical therapists, and pharmacists. The New Zealand Guide for Assessing Psychosocial Yellow Flags in Acute Low Back Pain is an excellent reference for the identification and management of patients who are at risk for developing long-term disability due to their back pain. Occupational health guidelines for low back pain from the United Kingdom, Europe, New Zealand, and Working Backs Scotland can be found 2 chapters later.

Chapter 16 provides information and advice for patients. This chapter discusses methods that will help educate the patient in what to expect from their condition and how they can avoid adding to the problem. Reassurance and positive encouragement are emphasized along with being honest with the patient that symptoms can reoccur. Staying at work and continuing normal activities also are emphasized. An evidence-based educational booklet, The Back Book, and patient education from Working Backs Scotland are included in the appendix.

Rehabilitation is the topic of the 18th chapter. Waddell's stated goal for rehabilitation is to get the patient to return to normal activities. Issues such as obstacles to recovery, exercise, and exercise and beliefs are discussed. The evidence for using behavioral management and the cognitive-behavioral approach for pain management is reviewed. Principles of rehabilitation are summarized concisely.

Chapters 19 and 20 look at how the United Kingdom and the United States care for patients with back pain. The 2 systems are compared by patient profiles, by who provides the treatment, and by what sorts of treatments and diagnostic studies are performed. The author points out that despite the differences in the 2 health care systems, there is little difference in social impact or clinical outcomes. "The Future of Health Care for Back Pain" is the title of the next chapter. This chapter, along with the epilogue, explores various ways that the current system does not meet the needs of patients with back pain and offers some solutions, especially in dealing with and reducing disability created by back pain.

Waddell has written a book that provides a comprehensive investigation of back pain from a medical, societal, and humanistic point of view. One of the key features is the summaries at the beginning of each chapter, which provide a brief overview and key points. Key points, which highlight important facts, research, and ideas, also can be found throughout the text. The research that is presented in the text is summarized nicely and is current. The second edition of The Back Pain Revolution should be in the library of any clinician, employer, or health care administrator who is involved with this patient population.

Jeff Yaver, PT

Groveland, Calif

Mr Yaver is a clinical specialist whose practice focuses primarily on patients with a variety of musculoskeletal dysfunctions.