The rehabilitation of persons with low back pain.
Rehabilitation of the Person
with Low Back Pain
There has been an enormous growth of interest in disabling back pain in recent years. This interest has led to the involvement of medical, allied health and rehabilitation professions in its management, and has been responsible for the initiation of many new treatment strategies, therapy regimens and rehabilitation approaches designed to counter the increasing costs, both financial and personal, of disability associated with back conditions. The purpose of this article is to provide the rehabilitation counselor with a broad overview of the many and complex issues which will most likely affect the vocational planning process, and to provide a practical perspective from which to counsel clients on how best to return to gainful activity.
Perhaps the most vexing issue in addressing the rehabilitation needs of an individual with complaints of back pain is how best to define the problem. Historically, the treatment of any condition involving significant pain symptomatology has been viewed exclusively as a medical problem. Thus in the case of persons with low back pain (LBP), a diagnosis is developed, (e.g., disc herniation at L4/5 with radiculopathy), treatment is rendered (e.g., surgical decompression at L4/5) and recovery is projected (e.g., 3-6 months for surgical recovery, physical therapy and return to work). However, in the case of LBP the medical model breaks down for two major reasons: 1) the vast majority of persons complaining of LBP do not require surgical intervention (McCorwin et al., 1991), and 2) the majority of persons with clear patho-physiologic abnormalities do not achieve complete pain resolution even after surgical intervention (Frymoyer & Cats-Baril, 1991). Consequently, the problem of LBP has become increasingly frustrating for physicians, since the prospects of a "cure" for this condition have proven to be exceedingly slim (Mayer & Gatchel, 1988).
Re-defining the Back Problem
Chronic back pain is the summation of physical lesions, lifestyle (esp. lack of exercise, diet etc.),age, hereditary factors, secondary gain incentives and psychological needs. AR must be addressed in determining both treatment plans and rehabilitation goals.
Acute back pain may be the result of an injury to the muscles, ligaments, fascia and/or disc or its coverings, i.e. capsule. It is important to identify a probable medical cause but at the same time remember that a disc bulge seen on a CT or MRI scan does not necessarily suggest an acute injury. A bulging disc may very well have been pre-existent - and non-symptomatic - and may be the result of normal aging processes. Weisel et al. (1984), perform blind study in which 52 CT scans of persons with no history of back trouble were evaluated by three different neuroradiologists. They found that over 35% of these asymptomatic CT scans were interpreted as "abnormal," with the most likely diagnoses being "herniated nucleus pulposus" (i.e., disc herniation), followed by "facet degeneration" (i.e., arthritis of the bony joints adjacent to discs) and "spinal stenosis" (i.e., narrowing of the spinal canal). Awaad et al. (1991), retrospectively examined the myelograms of 433 patients with herniated thoracic discs in order to determine the relationship between morphological features on the myelograms and actual physical symptoms. They concluded that there were "no identifiable imaging features that could reliably classify a disc as an asymptomatic thoracic herniated disc or a symptomatic herniated disc" (p. 180). Weisel et al. (1984) conclude that the credibility of such diagnostic tools is dependent on their correlation with the overall clinical picture.
Many people have inappropriate fear reactions associated with the terms "disc bulge" or "herniation" and once mentioned it often becomes a subject of discussion with other laypersons. This often leads to misunderstanding of the condition and/or outright distrust of the treating physician, and typically results in multiple visits with different physicians. Different physicians give different opinions or similar opinions in different manners and then the patient becomes more confused. At this point, the patient often seeks legal help, especially in cases where workers' compensation is involved. Thus disc injuries can often result in secondary gains associated with financially rewarding workers' compensation claims although physically, they may not be more disabling than soft tissue injuries.
Frymoyer (1984, 1988, 1991), an orthopedic surgeon, has written extensively on the incidence, nature and costs of treating persons with LBP. He estimates that only 2-3% of all individuals reporting an incident of LBP within a particular year may be surgical candidates, while the annual incidence of lumbar spinal surgery in the U.S. is approximately 100 operations per 100,000 population (.1%). However, when examining local, regional and even international lumbar surgical data, he reports wide discrepancies between surgical rates. He concludes that "The preference for operative versus
nonoperative treatment seems to be largely a result of local, regional, and national preferences, rather than any inherent differences in the incidence or prevalence of symptoms that night serve as surgical indications." Indeed, this orthopedist makes a very convincing argument that it is not the incidence of back pain that has changed recently, but rather a complex psychosocial transformation which is responsible for the almost epidemic increase in disability resulting from LBP. Put another way, the population's overall frequency of LBP hasn't changed with time, but the response to the phenomenon of back pain has changed dramatically.
The observed increase in the level of surgical response to the phenomenon of LBP has increased the cost of treatment but has curiously not impacted significantly on the overall recovery rate or resolution of back complaints. This cost-effectiveness issue has been examined empirically by Norton (1986), who studied the costs of surgical disc removal by both excision and use of chymopapain (an enzymatic lytic agent) in workers' compensation claimants in Oregon. He concluded that the costs for surgical interventions were extremely high when compared to non-invasive approaches, principally due to an unacceptably high rate of surgical failures. Hence, although surgery may be indicated in specially selected cases, the widespead use of a surgical approach to the treatment of LBP does not appear to be as cost-effective as more conservative measures which often achieve comparable results.
International research examining the prevalence and incidence of low back pain seems to indicate that there are very strong cultural factors involved in the identification, treatment and residual disability associated with low back pain (Mayer & Gatchel, 1988). Waddell (1987) describes how treatment services for LBP were practically non-existent in a Near Eastern country where this condition was not frequently diagnosed, yet citizens flocked to a new treatment center when they learned that treatment was available. This and other reports have led Frymoyer & Cats-Baril (1991) to question whether medical professionals have contributed to the emergence of LBP as an epidemic disease, both by validating its identification as a "medical" condition, and by attempting a variety of medical solutions.
Waddell (1987) observes that while nearly all adults have experienced some degree of LBP at sometime in their lives, the vast majority never seek medical care nor have any significant functional impairments. Deyo & Tsui-Wu (1987) found in examining the National Health and Nutrition Examination Survey data, that only 13.7% of the U.S. population had experienced LBP of two-weeks or more duration, thus supporting Waddell's contention that most people recover rapidly from incidents of LBP, requiring minimal bed rest and no specific (medical) treatment. In addition, Hazzard et al. (1989) and Weber (1983), in their prospective studies of recovery from LBP, found that of persons reporting significant sciatica with neurologic dysfunction, a significant number recovered to the point of returning to work without back surgery.
Concerning the relationship of age and LBP, one might suspect an increased incidence of this condition as time progresses, especially when we consider the effects of degenerative disc disease and osteoarthritis over time. Indeed Heliovaara (1988), reports that there is a very strong correlation between age and LBP, with peak prevalence and incidence occurring in the fifth decade of life. Lastly, Heliovaara reports that men with sciatica are more likely to be hospitalized and have surgery than women, although there appears to be no significant difference in incidence between the sexes.
The growth in the phenomenon of disability due to LBP has been in large part derived from the population of injured workers. Indeed, Battie & Bigos (1991) report that for the twenty-year period ending in 1976, awards for back disability from the Social Security Administration increased an astounding 2700%! As the rate of disability related to LBP has continued to climb, researchers have taken a much closer look at the sociology of disability in the workers' compensation structure as well as medical factors associated with this condition.
In a study of low-back injuries in the petroleum drilling industry, Clemmer & Mohr, (1990) examined the relationship between economic factors and the incidence of lost-time low back claims for injured workers. They found that during periods of recession and possible lay-offs, there was an increased incidence of reports of low-back strains. They concluded that "it is likely that the increase in lost-time low-back strain injuries was a worker response to possible layoff (p.831)." Although the authors stop short of any type of direct malingering or overt manipulation theory for this phenomenon, their work underscores the interplay of economic, psychological and medical variables in the complex process of disability development.
Battie & Bigos (1991) have identified two major factors that support the argument that the dynamics of LBP differ significantly between populations with work-related versus non-work related conditions. Reporting on a major study by the Boeing Company which involved over 3000 workers and examined over 56 variables, Bigos & Battie found that only the variables of job satisfaction and emotional distress were significantly correlated with initial reports of back pain. In contrast, physical factors which were thought to be predictive for non-work related LBP were not found to be significantly correlated with reports of worker LBP.
The second major factor that these authors report as differing between the compensable versus non-compensable LBP patients is a lowered success rate from surgical intervention (as measured by return-to-work outcomes) for patients with compensation-related back pain than with non-compensation related back disorders. In fact, in a study of the results of lumbar anterior interbody fusion for patients with degenerative disc disease, Flynn and Joque (1979) found that only one fourth of the compensation-related cases were able to return to work as compared to private insurance cases. Both of these factors serve to underscore the apparently strong involvement of non-medical issues in both the onset and outcome of complaints of LBP.
The Clinical Examination
Thorough clinical examination of a patient who has had back pain for more than three months is extremely important to identify the problem (McCorwin, et al., 1991). The patient may have an underlying neurological disease, e.g., amyotrophic lateral sclerosis which may cause "hyper-reflexia" (increased reflexes) and muscular weakness and may have very similar findings as in a patient with "cervical spondylosis" (arthritis of the neck). Hypothyroidism may cause back pain. The patient may have "fibromyalgia syndrome" (musculo-ligamentous disease) or somatization disorder or bizarre hysteric findings. It is equally important to determine whether there are any bladder or bowel problems or "dysesthesia" (numbness) that can be matched to any particular nerve or group of nerves. Patients with spinal cord tumors have been diagnosed after a back injury because the back injury led to the appropriate investigations.
Diabetes mellitus and herpes may present with a radicular pattern of pain. A rash may be visible in cases of herpes. Thoracoabdominal radiculopathy has been diagnosed in cases unrelated to any injury (Sellman & Mayer, 1988).
It is important to present the findings in a manner that is comprehensible to the patient. Discussions regarding body habtitus underlying degenerative disease, and personal habits, (e.g., smoking) have to be done in a sensitive manner. The value of exercise has to be explained and the negative effect of prolonged bedrest should be emphasized (Bigos & Battie, 1987). Occasionally the symptoms and the illness become a way of life and the physician has to recognize this phenomenon and, if necessary, refer the patient to a psychiatrist or psychologist who is knowledgeable in this area (Lichstein, 1986). Sometimes multiple tests lead to findings that are totally unrelated to the back condition. It is true that occasionally serious illnesses such as cancer and renal stones and gall stones, etc., have been diagnosed during investigation for back pain. However, it should be the physician's responsibility to make it clear to the patient as to what is related and what is unrelated to the back injury. Many patients have been mistakenly off work on a work-related injury for a prolonged period while they are receiving treatment for conditions that were not caused by a work injury. Sensitivity to the patient's needs while at the same time being sincere will often reduce confusion and hostility. Health consciousness should be urged, i.e., the value of being in shape, as well as the hazards of smoking upon possible surgical non-union in cases of fusion.
Highly skilled physicians sometimes fail to recognize their limitations. This often leads to multiple surgeries' and disappointments on the part of the physician as well as the patient (Sternbach, 1974). Once the back condition has been stabilized and the patient has reached a plateau, admonitions such as "do not do too much," "if it hurts lie down" etc., often lead to poor muscle tone and the patient's belief that being more active would be harmful
Treatment options should be clearly discussed with the patient. Most patients do not recognize that they themselves have to play a significant role in their recovery. LaCroix et al. (1990), in examining factors of value in predicting outcome from LBP, found that the patient's understanding of his/her condition was the single most important factor in successful treatment. Using a standardized instrument to assess a patient's understanding of the medical aspects of LBP, LaCoix et al. examined two groups of 50 workers' compensation patients on a variety of potential predictive variables. They found that 94% of those patients with a good understanding of their condition return to work, compared to only 33% of those with a poor understanding of their condition. Other variables examined by these researchers which were not effective predictors were severity of condition, prognosis, age, education, non-organic physical signs and MMPI scales 1-3. This research shows the strong link between the patient's understanding, and presumable participation in the recovery process.
Sternbach (1974) has used concepts of transactional analysis to describe "games" of chronic pain patients and physicians. He describes three different "Pain roles" that patients have adopted in his clinical practice. These include the "professional patient," who receives financial payment for his/her disability; the "addict," who is adept at manipulating the physician for drugs; and the "confounder," who seems to enjoy the process of stumping the professionals. Sternbach also notes that in his experience working with chronic pain patients, the cause of the pain - whether organic or functional - seemed to play no role in the subsequent pain dynamics; an interesting observation which would raise further questions on the efficacy of surgery for persons with reported chronic pain.
Oftentimes patients continue to have subjective reports of pain, despite the best efforts of multiple physicians to identify a specific cause (Catalano, 1987). The goals of treatment may have to be scaled down at times because symptom-free life may not be possible. Too much medical intervention sometimes leads to chasing an elusive cure that does not exist or reinforcing a pseudo-illness for which there may be no cure (Lichstein, 1986). Assuming that all of the appropriate investigations have been done to rule out a missed disc fragment, recurrent dish herniation lateral stenosis, instability etc., the physicians may not have an answer for all the symptoms and should only investigate objective findings. Thus at this stage in treatment, a clear contract that negotiates expectations and limitations is critical, as well as the identification of one treating physician to coordinate drug therapy, consultations, etc. The patient must begin to accept his condition and learn plan his life around his functional abilities, utilizing the guidance of his physician and rehabilitation coordinator to manage pain, develop a realistic vocational plan and begin a return to typical living routines.
Blumer (1977), a psychiatrist, examined and tested 234 patients with chronic pain complaints in an attempt to identify specific personality variables that might explain their continued difficulties. He found and described a prevalent personality type, termed "ergomanic," which correlated highly with the pain patient's pre-injury personality. This type is characterized by a very active work lifestyle, an inability to utilize or enjoy leisure activities, strong dependency needs and neurotic repressive mechanisms. Conversely, after an injury, these individuals displayed an "ergasthenic" personality; essentially an extremely passive and inactive lifestyle focussed upon pain as validation of their inactivity. Although beyond the purview of this article, it is important for the rehabilitation practitioner to recognize the complexity and subtlety of chronic pain behavior, and consequently the absolute necessity to develop an informed team approach to managing the individual who may be exhibiting psychological as well as physical pain characteristics.
It is also imperative to discuss narcotics and the ill effects they can induce when used for prolonged periods. Bigos & Battie (1987) report that strong narcotics are no more effective at controlling LBP than milder analgesics, especially after the first few days of symptoms. Their experience indicates that, in fact, narcotics can delay the recovery process. Physicians should establish long term relationships with patients so that they can help patients better deal with their problems over time, and should they develop any future objective findings that can then be addressed.
The rehabilitation counselor can occupy a central role in assisting the person with LBP through the oftentimes confusing medical system and ultimately returning to work. The counselor can significantly assist patients in understanding their condition and treatment options by insuring that appropriate questions are asked and answered by the treating physician, and that patient education is not neglected. Choices in treatment options should be developed and discussed with the physician and patient, and long-term vocational goals should be weighed by all parties against the likely outcomes of surgery, conservative treatment and/or the natural progression of the condition. For example, a 40-year-old construction laborer with significant degenerative disc disease who is facing surgery for a bulging disc may select a more conservative approach if the likelihood of both a cure or returning his former work is remote or non-existent.
The following concepts and issues should guide the rehabilitation counselor as s/he endeavors to develop a realistic rehabilitation plan for the back patient:
1. The vast majority of persons with acute episodes of low back pain will recover rapidly (i.e., within three months). Education about the condition, active exercise (vs. extended bedrest) and return to work as early as possible are strongly indicated to minimize both prolongation of recovery and avoidance of the development of permanent disability (Frymoyer, 1991; Bigos & Battie, 1987).
2. LBP has evolved from primarily a medical problem to primarily a psychosocial phenomenon (Waddell, 1987). Consequently, treatment strategies must also evolve from a medical-only model, to an interdisciplinary team structure with clear psychosocial goals. Vocational goals should be discussed at the outset of medical treatment, since many physicians may alter treatment approaches depending upon the likelihood of treatment success.
3. Given the strong correlation between age and LBP (Heliovaara), it seems reasonable to conclude that LBP in older persons should be treated as more of a social-lifestyle problem than a medical condition. Persistent low back pain in older persons requires thorough investigations to rule out inflammatory and neoplastic causes. However, degenerative changes are often part of the aging process. Thus the worker on the assembly line who is 50 years of age and encounters severe, chronic LBP may be simply too old to perform this constant, repetitive type of work. Although job modification or job change may be extremely undesirable at this stage of life, it may be the wisest alternative to "trial" surgery or temporary medical solutions which may further decrease functional capacities in the long run.
4. Degenerative changes (e.g., degenerative disc disease, disc space narrowing, facet hypertrophy etc.), are a normal part of the aging process. Whether they produce any pain symptoms at all depends upon a host of risk factors, (e.g., individual physiology, hereditary factors, level of physical activity during play as well as work, overall physical condition, exposure to unusual physical exertions, tolerance of pain/discomfort etc.) Blaser et al., 1988. Consequently, the rehabilitation of persons with LBP necessarily must involve a "lifestyle analysis" to determine those activities in a person's routine which may increase the risk of pain development or exacerbation.
5. Given the spiral of deconditioning that often occurs as time from onset of LBP increases, the importance of exercise and physical activity (especially walking) in maintaining muscle tone and limiting the increase of disability due to LBP cannot be overemphasized (Bigos & Battie, 1987).
6. Although an exercise program may not prevent the onset of LBP, it can certainly minimize the likelihood of pain emerging as a major disabling element in both vocational and personal activities. Appropriate exercise and proper instruction on correct body mechanics while lifting can be the most effective prevention of disabling LBP (Bigos & Battie, 1987).
7. Counseling strategies, while acknowledging subjective reports of pain, should focus on specific outcomes, timelines and functional/behavioral criteria. The counselor should avoid reinforcing pain behavior and attempts by the client - either conscious or unconscious - to validate the "disability" role.
8. Psychological variables which can significantly impede successful rehabilitation planning include: 1) secondary gain factors, especially monetary; 2) poor understanding of the condition and its natural course; 3) chronic pain dynamics, which should be examined when typical medical and/or rehabilitation interventions have proven ineffectual.
The medical literature abounds with articles on the limitations of treating LBP with a strictly medical model paradigm. However, its management as a single modality model often continues to dominate. The pychosocial or "biopsychosocial" model of illness for treatment of low-back disorders (Waddell, 1987), needs to be further emphasized and researched. Certainly long-term follow-up studies would help address the critical question of which treatment appoach(es) made a lasting difference, if any. Similarly, correlational research should examine the relationships between recovery variables (e.g., rate, degree of functional disability, recurrent episodes, etc.) and socioeconomic variables (source of insurance benefits, education, sex, age, industrial classification, etc.) to determine significant non-medical recovery factors.
Rehabilitation counselors should prepare themselves to be more pro-active in the coordination and management of the rehabilitation of persons with LBP by familiarizing themselves with the complex dynamics involved with this population, as well as by adopting a leadership role in return to work planning. Critical to this role is accurate knowledge about the complexities of LBP etiology and treatment, and the fact that no one discipline alone holds the key to resolution of this condition.
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|Publication:||The Journal of Rehabilitation|
|Date:||Apr 1, 1993|
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