In a past life I worked as an auto-electrician in a local car dealer. I was kept busy, as Australian build-quality ensures a steady flow of cars in need of repair. The process was relatively simple. A car would come in to the workshop, I would diagnose the problem, replace the faulty part and send it on its way. For the most part, it wouldn’t come back – for that problem anyway. Explanation to customers was easy too. This is what was wrong and this is how I fixed it. They didn’t have to do anything (except pay the exorbitant fee charged by my employer).
Unfortunately, in my transition from auto-electrician to physiotherapist I discovered ‘fixing’ patients wasn’t as straight forward as fixing cars. ‘Faults’ can remain elusive, management strategies do not always work and explanations to patients seeking to know exactly what is wrong with them are much harder. Take non-specific low back pain (NSLBP) for example. By definition, it is a case of ‘I am not quite sure what is wrong with you’ and thus ‘I am not entirely sure of how to fix you’.
Chronic NSLBP is renowned for being difficult to treat and despite a plethora of management options, it appears no one treatment works for every patient. In the latest issue of the Lancet, Balagué and colleagues reviewed the recent literature to see what advances we have made in treating this condition. They noted that many of the treatments commonly used to manage chronic NSLBP, including acupuncture, behavioural therapy, exercise therapy and drugs, had only modest effects at best[3,4].
That no one treatment appeared more effective than any other appears somewhat disheartening. However, Balagué and colleagues suggest it can be turned into a positive. Reflecting on the work of two of our regular bloggers, Ben Wand and Neil O’Connell, they reasoned that the similarities in effectiveness between the treatments may occur because they all work through the same mechanism – affecting cortical function. For example, a treatment such as back strengthening exercises may show effectiveness due to changes in beliefs, attitudes and coping mechanisms rather than changes in muscular strength. They suggest that the absence of a notable difference between many evidence-based treatments is an advantage because it allows us to consider patient preferences, access to facilities and the budget of our patients. We know that patient expectations can influence the outcome of treatment and that they are less likely to adhere to treatment plans if their preferences are ignored. We should therefore tailor our therapy to incorporate the patient’s preference whilst delivering it in a manner that encourages changes in pain attitudes and beliefs. Not every chronic pain patient is willing to sit through sessions of pain education, nor will all of them read the material we provide them. As long as we treat using a paradigm that recognises the cortical changes that are contributing to their pain, it is likely we will improve the effects of the chosen therapy.
Balagué’s team finally reiterates the pressing need for our education message to be consistent. That is, we cannot afford the good of one therapist to be undone by another in the multidisciplinary team. They alluded that the chances of altering a patient’s beliefs are greater when the message is consistent, thus all healthcare workers are encouraged to keep up-to-date with current scientific knowledge regarding chronic pain. We also need to ensure we are consistent in our explanations such that our ‘story’ doesn’t appear to blatantly change from peripheral driven mechanisms to centrally driven mechanisms as a patient transitions from acute to chronic.
Unlike fixing a car, it is unlikely one management technique will not work for every chronic NSLBP patient. We need to be flexible and adapt to the individual needs of our patients yet work to foster change in faulty pain beliefs.
Mark Catley is a PhD candidate in the Body in Mind Research Group (at University of South Australia) in Adelaide. When he is not busy researching, Mark works as a physiotherapist in a rehabilitation hospital. He is interested in the brain’s involvement in the transition from acute pain to chronic pain, and is currently investigating the relationship between cognitive variables, mood and sensory function in people with back pain.
He also has a very particular approach to cooking rice. For perfectly cooked rice: 2/3 cup rice, double that in COLD water, and then 8mins in microwave uncovered. Actually, he has a particular approach to many things – including windows. He is the only BiM team member you should ever get to clean a window.
1. Balagué F, Mannion AF, Pellisé F, Cedraschi C: Non-specific low back pain. Lancet 379:482-91.
2. George SZ, Robinson ME: Preference, Expectation, and Satisfaction in a Clinical Trial of Behavioral Interventions for Acute and Sub-Acute Low Back Pain. Journal of Pain 11:1074-82.
3. Keller A, Hayden J, Bombardier C, & van Tulder M (2007). Effect sizes of non-surgical treatments of non-specific low-back pain. European spine journal, 16 (11), 1776-88 PMID: 17619914
4. Machado LA, Kamper SJ, Herbert RD, Maher CG, & McAuley JH (2009). Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology , 48 (5), 520-7 PMID: 19109315
5. Wand BM, & O’Connell NE (2008). Chronic non-specific low back pain – sub-groups or a single mechanism? BMC musculoskeletal disorders, 9 PMID: 18221521