“Exponential increases in magnetic resonance imaging (MRI) scanning to identify these damaged structures (believed to be causing low back pain) have led to escalating rates of spinal fusions and disc replacements.”
There is a trend towards increased surgery rates in the US for low back pain. We see upwards of a 777% increase in spine surgery for low back pain. The sad part is that the your chance of having surgery is more dependent on your geographic location than other variables. It has been said that if you are trying to avoid a surgery that you should also avoid an MRI…which takes us to the next fact.
“…evidence that abnormal MRI findings are prevalent in asymptomatic populations and are poor predictors of future LBP (low back pain) and disability”
In other words, if you go looking for a problem…you’re likely to find one. The “problem” on the MRI may not actually be causing your symptoms though, as we see “problems” with people that have no symptoms. To put it another way, if a “herniated disc” was always a cause of pain, then everyone with a herniated disc will have pain. We know that this isn’t true. This indicates that the structure/tissue that is a “problem” on the MRI may not be causing any problems at all during your day.
“…providing a patient with a pathoanatomical diagnosis can result in increased fear and iatrogenic disability”
Lots of big words there, so let’s work through this together.
Anatomical: body parts
Therefore: pathoanatomical = bad body parts
This is typically what you hear when you have imaging (MRI, X-ray, CT scan) performed. Herniated disc, degenerative joint, arthritis, stenosis. All of these words mean that something abnormal was seen on the image.
Iatro: means relating to medical treatment
Genic: means coming from
This means that the “iatrogenic disability” could be disability coming from medical treatment.
I know what you’re asking: “How can the medical interaction with a doctor/therapist/medical professional be causing the disability?”
This is a great question that the authors of the article will go into in a short while. More to come.
“It is increasingly clear that persistent and disabling LBP is not an accurate measure of local tissue pathology or damage alone…it is best seen as a protective mechanism produced by the neuro-immune-endocrine systems in response to the individual’s perceived level of danger, threat or disruption to homeostasis.”
This means that the tissue that was previously damaged may not be the culprit for prolonged pain. For instance, your body can have a protective mechanism produced by the brain when it feels threatened. The brain is powerful in creating change. For instance, watch this video to see how quickly it can start to change.
“…pain and behavioral responses may fluctuate based on a person’s perception of threat, levels of attention to pain, mood, contextual social stressors, sleep, and activity levels.”
If you feel threatened, your pain levels may increase. Removing threat through distraction has been shown to be helpful in multiple studies. Tetris seems to be one of the most studied games. Also, math is more painful to some than others. In the clinic, I have used math as a distraction and watched how pain rapidly resolves and some patients are able to perform movements that they wouldn’t consider performing if they weren’t distracted. There is some thoughts that the more often we ask you about pain…the worse it actually gets because we force the patient to emphasize the feelings of pain compared to their current function. Finally, we know that a lack of sleep can cause a myriad of problems from difficulty concentrating to an increase in pain due to increased nerve sensitivity. These are all factors that play a role when a patient comes to the clinic experiencing pain.
“This contemporary understanding demands a shift away from providing a simplistic structural and/or biomechanical diagnosis and treatment for LBP…enables the patient to become a partner in a therapeutic journey”
For some patients, we can correlate a “problem” on the MRI with their symptoms, but in a subgroup of patients, we are unable to do this. For that subgroup, we need to look past the pathoanatomical model and therapeutic alliance (the teamwork between the therapist and patient) becomes very important in order to empower the patient with regards to symptom response and education.
“Growing evidence suggests that current practice is discordant with contemporary evidence, and is in fact often exacerbating the problem.”
We may not need to abandon the patho model completely, but we as practitioners need to have more than just the patho model. In order to prevent iatrogenic pain beliefs, we need to grow our skills in order to better help you…the patient. If you are going to therapy and are not seeing relief within 6 visits and don’t feel that your therapist has a strong understanding of your pain…seek a second opinion. Not all Medical Doctors are the same, and the same can be said for physical therapists.
Excerpts taken from
O’Sullivan P, Caneiro JP, O’Keefe M, O’Sullivan K. Viewpoint: Unraveling the complexity of low back pain. J Orthop Sports Phys Ther. 2016;46(11):932-937.