By Nortin M Hadler
This article was brilliantly written in 2005 and published in 2006.
It is as true now as it was then.
Regional back pain intrudes into the life of healthy working age people for no particular reason. It is painful, noxious and trying. Regardless of the degree to which it hurts or overwhelms, regional back pain is normal. It is an obligate, frequent, intermittent and remittent predicament of life. It is no more abnormal than cold symptoms, headache, heartache, heartburn, and many other common conditions. Regional back pain has, however, come to hold a special place in the fabric of morbidity; it supports an attributional narrative. No one can blithely describe a headache as ‘I injured my head’. Neither would it be sensible to denote angina as stair-climber’s chest. However, everyone is comfortable with the narrative beginning, ‘I injured my back...’ Every physician is inclined to query what the patient was doing when the back pain started, and every sufferer is comfortable searching for an external cause for the pain. Understanding the contemporary experience of back pain is, therefore, not an exercise in pathoanatomy, but an exercise in semiotics. Society pays a grave price for the contemporary social construction of backache.1 Under the rubric of regional back pain, and despite a concerted reme- dial effort, all resource-advantaged countries are facing escalating disability claims and costs.2
Feeling ‘well’ demands invincibility, the conviction that one can cope with the next morbidity. Being ‘well’ symbolizes the triumph of having coped with the latest morbidity for as long as it took to remission, and to cope so well that the episode is barely memorable, if at all. Being ‘well’ does not symbolize avoiding the challenges, such as regional musculoskeletal disorders, as that is not possible. In coping with back pain one has much to consider. There is the personal impact to process: how and to what degree is function restricted and comfort compromised? What vocational and avocational activities are compromised or precluded? Then there are the patient’s options to consider: is the situation bearable? Need one consume any of myriad pharmaceuticals, unctions and potions
that have always been widely purveyed and forcefully marketed? Need one seek professional assistance? If so, how does one choose among so many sources of aid?
It has long been common sense that a person’s press to recourse is driven by the physical inten- sity of the predicament. The more severe the pain, the more likely it is to be memorable, and the more likely one is to consume analgesics, to experience work incapacity, and to seek profes- sional care. Epidemiology has put this common sense to the test and it is no longer tenable. The common denominator that drives all this choosing is compromise in the wherewithal to cope.3 Community-based cohort studies have probed associations with the recall and reporting of incident back pain.4 Psychological distress, aspects of illness behavior and other somatic symptoms come to the fore.
This insight has strong implications for the act of clinically treating the disorder. The narrative of distress of a patient with a regional backache might well be a surrogate complaint.5 ‘My back hurts’ is likely to mean ‘My back hurts but I’m here because I can’t cope with this episode.’ Yet, treatments for back pain are wont to focus exclusively on the spine. This treatment focus is the patient’s expectation when seeking care, and it is the approach purveyed by most chosen professionals. The clinical contract demands specific treatment for the cause of the pain. Such a treatment act rests on the shakiest of scientific grounds; there is no compelling, consistent scientific evidence to support specific treatments for regional backache in the people who choose to be patients.6 It unsurprisingly follows that the response of these patients to such primary care treatment acts is anything but dramatic.7 Perhaps this response reflects the inability to design specific treatment for discrete disorders, or maybe it’s because a treatment act that focuses on the pathoanatomy of the spine is misguided. Regardless, the standard treatment act instructs the patient as to the clinical hypotheses, which are purveyed as reasonable.
This instruction will irretrievably alter the patient’s conception of health and the patient’s choice of idioms to describe current and future distress, but to what end?
A worker in a resource-advantaged country with incapacitating backache generally has another option for recourse. In most countries, the worker can seek benefits indemnified by workers’ compensation insurance, which indemnifies medical care and wage replacement for any injury that arose out of and in the course of employment and occurred by accident. Does regional backache qualify? By definition, regional musculoskeletal disorders occur in the course of activities that the worker would generally find customary and comfortable. By definition, there is no traumatic violent event. Since the region that hurts is likely to hurt more when used, can we assume that the usage that causes it to hurt more is the usage that caused it to hurt in the first place? For decades society has accepted this ‘injury’ construction for a work-related regional backache.8 The notion assumes that the biomechanical demands of tasks in the workplace are different from the demands of tasks outside of work. This ‘injury’ inference has driven 50 years of ergonomic empiricisms with no discernible impact on the incidence of disabling back pain. By contrast, so-called ‘ergonomic injuries’ now account for the majority of medical and indemnity costs incurred under workers’ compensation. Workers with chronic backache constitute the majority of those in the modern workforce who suffer long-term disability.
This sorry state of affairs has led to an outcry for ergonomic reform and underwrites a vast array of treatment acts and treatment settings. The dialectic barely takes notice of the science that has matured in the past decade regarding the plight of the worker with a disabling regional musculoskeletal ‘injury’. This is a science that, in parallel with the science that informs the treatment of the patient with a regional musculoskeletal illness, should redirect efforts on behalf of workers who find their regional musculoskeletal disorders disabling. The culprit lurks in an adverse psychosocial context of work, not simply, if at all, the physical demands of tasks.9,10 The likely proximal cause of rendering regional backache disabling is an assault on the wherewithal to cope with the predicament by adverse factors in the organization of work, interpersonal relationships, management styles and decisions, and the like. Any innovation in workplace health and safety policy that ignores this science is as futile as its predecessors. And any treatment act afforded the worker with a disabling regional musculoskeletal disorder that ignores this science is sentenced to failure as well.
If workers were provided the opportunity to labor in a context that is comfortable when they are well and accommodating when they are not, a discussion of the socioeconomics of backache would reflect the triumph of an enlightened society. As it stands now, the worker who finds their next backache disabling is faced with a costly and iatrogenic vortex.2,11
1 Hadler NM (2005) Occupational Musculoskeletal Disorders, edn 3. Philadelphia: Lippincott Williams & Wilkins
2 Waddell G et al. (2002) Back Pain, Incapacity for Work and Social Security Benefits: an international literature review and analysis. London: The Royal Society of Medicine Press.
3 Main CJ and Williams AC (2002) Musculoskeletal pain. BMJ 325: 534–537
4 Hoogendoorn WE et al. (2000) Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine 25: 2114–2125
5 Hadler NM (1994) The injured worker and the internist. Ann Intern Med 120: 163–164
6 Hadler NM (2003) MRI for regional back pain. Need for less imaging, better understanding. JAMA 289: 2863–2685
7 Koes BW et al. (2001) Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine 26: 2504–2514
8 Hadler NM (1998) Workers’ Compensation and chronic regional musculoskeletal pain. Brit J Rheum 37: 815–818
9 Torp S et al. (2001) The impact of psychosocial work factors on musculoskeletal pain. J Occup Environ Med 43: 120–126
10 PincusTetal.(2002)Asystematicreviewof psychological factors as predictors of chronicity/ disability in prospective cohorts of low back pain. Spine 27: E109–E20
11 HadlerNM(2001)Rheumatologyandthehealthofthe workforce. Arthritis Rheum 44: 1971–1974
NM Hadler is a Professor of Medicine and Microbiology/ Immunology at the University of North Carolina at Chapel Hill, and an Attending Rheumatologist at the University of North Carolina Hospitals, in Chapel Hill, NC, USA.