Low back pain: Review and Prescription

Part 1

Introduction

Writers, philosophers and surgeons share a common dilemma: in order to be able to begin, they must decide where to put the knife in. The foci of interest must be decided, and the ontology and epistemology that will be brought to bear on the subject defined. In this essay, the reader will be informed of the derivation of the reference sources, and what has been left out of the study and why will be described. The essay will briefly review current medical anthropology, and briefly review the philosophical and epistemological inheritance of the particular ethno-medicine under study.

The focus of this paper is a common illness, low back pain, which will be referred to from now on simply as “back pain”. Back pain has been described as, “A wilderness across whose inhospitable terrain orthopaedic surgeons, neurosurgeons, physiotherapists and, above all, general practitioners are doomed to travel [50].” The medicine under study is biomedicine, called “allopathic,” “cosmopolitan,” “Western” and “modern,” among others; in any case the dominant form of the many forms of medicine available in Australia today.

This paper will attempt an anthropological analysis of the area of study. That is, anthropological as defined by Young, “A viewpoint in which one’s own concepts and ideas are simultaneously privileged and part of a cultural system, and thus also subject to analysis [90:260].” Young also identifies a group of anthropologists whom he identifies with the explanatory model of illness approach, and whose work we will draw upon. Most important among these anthropologists are Good and Good [26], and Kleinman [30, 30a, 42, 43]. Their areas of interest are primarily the clinical encounter and medical efficacy, and their focus is the individual. Other anthropologists important to this paper are Taussig [78] and Moerman [52, 53], the former because of his emphasis on the effects of social structure on medicine and the latter because of his emphasis on the mind’s effect on bodily processes; or as Young so neatly puts it, “The effectiveness of healing on curing [90:266].

Before reviewing the literature on back pain, I will outline a brief history of biomedicine, in an attempt to trace the antecedents that have led to its current development and attitudes. A following section will look at the reference articles and relate them to the work of the anthropologists mentioned above. Hahn and Kleinman have noted that medical anthropology has assisted biomedicine in its search for efficacy in some ways by shedding light on the whys and wherefores of practice [30a], and in similar fashion, the final section includes some suggestions for how general practitioners might improve the clinical efficacy in the treatment of back pain. The essay will conclude with a few suggestions for a preventative medical position.

Reference sources – see the appendix for important notes in regard to selection criteria and methodology for the articles, books and anthropology sources.

A brief history of biomedicine

As has been noted by many writers, Western science (and one of its subsets, biomedicine) can trace its roots back to Plato and Aristotle. In modern times, most historians agree that the writing of Descartes, Newton and Galileo have had the most profound and lasting effect on today’s science.

Descartes is remembered for his “method of doubt,” in which he made it clear that mathematical reasoning would be the basis for his proposed new system of knowledge, and his assertion, “Je pense, donc je suis,” with its proposition that the world is made up of two distinct and incompatible substances. He postulated that the mind or consciousness is unextended and indivisible, and that matter is extended and divisible. His conclusion was that our physical bodies including our brains, being part of the extended divisible world, are not part of our essence as thinking beings. While philosophers argue to this day over the logic used to arrive at this conclusion, this absolute division of the mind and the body, known as “Cartesian Dualism,” has exerted a lasting effect on philosophy and general thought to this day.

Newton’s work on planetary motion and gravity and his assertion that the universe is a vast machine of matter and motion obeying mathematical laws supported the Cartesian worldview. His explanation of gravity in particular, helped the scientific world to focus its attention on the “how” of processes, and not the “why”: that the measurement and quantification of phenomena was to be the paradigm for scientific analysis, and this “positivism’’ is still the “public face” of science.

Galileo’s motion experiments combined reason and experimentation and lifted science to a new level of abstraction. In particular, Galileo postulated ideal conditions such as frictionless planes and zero air resistance for his experiments and in combining rationalism and empiricisms, established the distinction of fact and value. This allowed the scientist to step outside Nature and to reify it: he became the detached observer.

Such detached observers founded various branches of science and medicine and important discoveries were made: blood circulation (Harvey), physiological and cellular processes (Bernard and Virchow), and microorganisms (Pasteur); thus cellular biology and the germ theory of disease were established as the bases of medical science [13:122-25]. Eisenberg echoes this, “Biology has been institutionalised as the fundamental science of biomedicine [17:10].” Engel identifies the Church as a further important influence on the biomedical model, in its permitting dissection. Coupled with the science of the day with its emphasis on “isolable causal chains or units,’’ the study of anatomy via dissection reinforced the premise of the functioning of the whole being able to be understood by an analysis of its parts [18:42].”

Although historically the criteria for the identification of disease have always been behavioural, psychological and social in nature [18:41], it is clear that through the rigorous deployment of the scientific method, these causal agents have been pushed further into the background, or eliminated altogether. To quote Engel:

Biomedicine assumes that disease will be fully accounted for by deviations from measurable biological norms, and as such, there is no room within its philosophical framework for consideration of behavioural, social or psychological dimensions of illness. Implicit in this view is that behavioural aberrations must also be explained in the same terms [18:39].

The successes of the scientific method as it has been applied in Western medicine are numerous, but not without cost. We are left with, “the notion of the body as a machine, of diseases as the consequence of breakdown of the machine, and of the doctor’s task as repair of the machine [Capra quoting Engel, 1977].” Galileo’s legacy of the detached observer has led to what Capra has described as the main problem of the biomedical approach:

…the confusion between disease process and disease origin: instead of asking why a disease occurs (and how it might be prevented) researches focus on the biological mechanisms involved, and how they may be altered [13:150].

In the Western medical model, the body is regarded fundamentally as a machine or a collection of biological processes. Illness may be a breakdown of a part of the machine or something may invade the machine’s external barriers and disrupt the internal processes; in this case, diagnosis involves identifying the invading organism or agent. A specific condition is diagnosed by identifying specific symptoms and a particular instance of a disease is found and labelled. This process uses the cause and effect model, or more precisely, effect and cause. The process of curing uses some means of eliminating or repairing the cause of the condition. Chemical or surgical means are usually applied. It must be remembered however that a model is nothing more than a belief system used to explain natural phenomena, and that scientific models are primarily designed to promote scientific investigation. The tendency to mistake the model for reality can have unfortunate consequences. Two important consequences are described by Engel and Eisenberg, “In the West, the scientific model has become the West’s culturally specific perspective on disease and has acquired the status of dogma [18:40].” and, “The models physicians use have decisive effects on medical behaviour- including what kind of data they collect and what kind of data will be excluded from consideration [17:18].”

There is one further legacy of the reductionist approach: a hierarchy of importance of the various branches of medicine, the effect of which extends across social and financial boundaries. Surgery and internal medicine head the list, with the talking cures (psychiatry) rating much lower. Even organs occupy particular places in the hierarchy, with the heart and brain (and those who work with them) having higher status than the lowly kidney or digestive tract. Both financial remuneration and access to high technology follows these divisions [30:315]. Back pain does not rate a mention on this scale.

Clearly, the prevailing attitude to health care is curative rather than preventative. Western medicine, arising from and bound to the reductionist scientific approach, has its own vocabulary and is usually experienced through and interpreted by another person, deemed by society to be qualified to do so. Medicine and its associated apparatus seems impenetrable and inaccessible to the average person, and many doctors seem to try to preserve this attitude. The common habit of abrogating the responsibility of one’s own health to a doctor, or at least externalising the relationship between one’s self and one’s state of health, can be traced to the mechanisation of the body, the separation of the body and the mind, and the perceived need to seek the services of one who is qualified to mediate between them.

The back pain articles

A review of the 48 articles and the 13 books containing references to back pain allows the making of a number of observations about the changing nature and current state of biomedicine’s attitudes to back pain. These may be summarised:

(i) that back pain is more or less inevitable

(ii) that back pain is one of the most common reasons patients seek a doctor’s services

(iii) that back pain costs the community dearly

(iv) that biomedicine regards vertebral pathology as the cause of the great majority of back pain episodes

(v) that despite (iv) above, biomedicine acknowledges that over 50% of back pain episodes spontaneously remit within one week

(vi) that treatment is reactive, not preventative

(vii) that the biomedical model is expanding to include modalities of treatment once labelled “fringe practices” only a few years ago

Each of these points will be addressed in turn.

The seeming inevitability of the illness has much to do with both the mechanistic and reductionist model of the spine, and the way its individual parts are related to it and how this model is then related to the person as a whole. Anatomists and physiologists claim that the lumbar lordosis (posterior concavity of the lower spine) is a major weakness of the body, due in part to the shearing forces present at the lumbral-sacral interface (L5-S1). Kapandji suggests that during the transition from quadrupedal to bipedal movement, the spine which originally was curved anteriorly, became straight and then curved further to is present state. The normal lumbar lordosis results because the pelvis has not tilted far enough posteriorly. The same changes in curvature from anterior to posterior are observed during the first ten years of life [39:16]. Henderson states that the lumbar spine of most quadrupedal vertebrates is a smooth anterior curve; those animas with lordotic curves (many dogs and horses) also suffer spinal problems. Thus, man is predisposed to spinal pathology [32:1156]. Bedbrook notes that many aboriginal races have a very low incidence of back pain and attributes this to their not assuming the erect position any more than necessary; the squatting position in fact reverses the lordotic curve and stretches the posterior lumbar muscles [84]. Taylor states that disc prolapse is, “decidedly rare in primitive people,” ascribing this to the use of the squatting posture. Littler says that, with the adoption of upright posture, the “axial” skeleton is subject to conservable compression forces for which it was not designed [50:59]. This sort of anatomical determinism illustrates Eisenberg’s notions of the influences of medical models on data collection quite well [17:18].

The above arguments seem somewhat teleological – the lumbar curve can also be seen as a superb adaptation mechanism: without is three curves (cervical, thoracic and lumbar), the spine would have almost no longitudinal shock absorbing capacity and each step would jar the skull [39:87]. Film analysis has shown that while walking or running, the head hardly moves vertically at all, and most pelvic movement is absorbed by the curves of the spine tightening and releasing. The argument of maladaptive evolutionary change does not explain those people who never suffer back pain (by calculation from the figures below, around 20% of the population). A brief description of the physiological support systems of the spine will be made in a later section.

The ubiquity of the problem is quite staggering. Estimates vary, but at least 5% of all patient visits to the doctor are due to back pain [58]; and it affects between 60% and 85% of the population [22, 28, 31]. In different studies, researchers reported that 21% of patients had experienced back pain in the 14 days preceding the study [10], 22% of males and 30% of females had back pain at time of study [31], and 30-40% of the group in another study [28]. More chronic back pain is suffered by women than men [84]. In the sports world, the picture is far from clear: Rovere writes that back pain is relatively uncommon in competitive athletes [66]; five years earlier in the same sports medicine journal, Stanitski writes that back pain is one of the most common complaints of athletes [71].

The cost to the community is immense, even if one considers only the figures that relate to financial costs. For example, more working hours are lost annually from industry through back pain than to industrial action [8], back pain accounts for half the workers’ compensation payments in the U.S and Australia [32], is the single greatest cause of lost work time [22] in both countries, and costs $18 billion annually or 3% of the U.S. national budget [22]. (This “budget” was not defined). The social cost cannot be calculated – back pain is the most frequent cause of inactivity in people under 45 years of age and the 10% of patients who suffer chronic back pain cost 75% of the compensation payments. However, Quintner notes that only 8% of persons with a compensable back injury used any rehabilitation agency.

Vertebral pathology is accepted as the causal agent in the great majority of back pain episodes. Ganora states, “…There is little doubt that most cases are due to derangement of the intervertebral joint in association with ‘degeneration’ of the disc and arthrosis of the facet joints.” However, in his following sentence, Ganora says, “Exactly which structure within this motion segment are the actual sources of pain remains conjectural [22].” “Treatment over the years has been a series of ‘empirical enthusiasms’ [32].” A research paper in 1934 identifying lumbar disc protrusion or “lesion” as the cause of low back pain led to the period during the 40’s and50’s being described as, “the dynasty of the disc” and many “exploratory” laminectomies were performed with “indifferent results” [31]. Taylor describes the “mammoth surgical exercise” of the same period as inevitable, because the solution appeared simple – removal of the disc would cure the problem [84]. Conrad reminds us about the controversy surrounding tonsils and tonsillectomies: that the well-functioning of organs is a problematic concept, and that changes to organs or systems may be due to environmental adaptations [14:104]. No studies placed any emphasis on lifestyle as an environmental mechanism that causes adaptations – some of which can be good and some not.

Murtagh notes that the most common cause is “soft tissue injury”, but that such patients do not come to the doctor’s surgery; and of those that do, vertebral dysfunction accounts for 67% of their problems [58]. Disc degeneration is the most common cause according to Littler, although vertebral collapse or displacement may also present [50]. In another article, Murtagh states that there is considerable debate as to the causes, opinions being divided between disc prolapse and “overriding” (subluxation) of the pain-sensitive apophyseal joints; he described back pain as the “Achilles heel” of the medical profession and that, “we do not enjoy a good reputation for its management [55].” Patkin ponders the cause: is it discs, ligaments, or muscles [60]? The only doctor who speculated on the role of muscles and muscle spasm in back pain wrote that he had been impressed with the amount of improvement in low back pain using treatment aimed at producing muscle relaxation.

In comparison to general practise, most instances of back pain in sports are attributed to strains or partial ruptures to the extensor muscles, mechanical distortions to the intervertebral joints, or chronic over-use [31].

In a number of biomechanical studies, professor Hirsh showed that there were no striking differences in mechanical response between normal and degenerative discs: therefore, morphological changes to the disc may well be asymptomatic and not necessarily a cause of pain [84]. Littler notes that most patients over 35 years of age show discographic evidence of disc degeneration [50]. Other surveys suggest that in over 80% of cases, no definite diagnosis can be reached [10]. For the last word on causes, Professor Taylor wrote:

Often, even after the most careful clinical and radiological assessments, one has to be content with a decision that the patient has a mechanical disorder of the lumbar spine, the cardinal features of which are pain worsened by movement and relieved by rest. This non-specific, rather inelegant diagnosis satisfies neither the physician nor the patient…The medical profession has a penchant for inventing disease processes on the flimsiest of evidence…Catch phrases such as low back strain, lumbago, lumbo-sacral strain, myofascial syndromes and so on have appeared in the most prestigious journals and text books as medical entities and for some inexplicable reason remain there, unsupported by a scintilla of scientific evidence and notably, clear documentation of the hypothesised pathology [84].

The figures on spontaneous remission of the problem are extremely interesting and can be interpreted in different ways. In one Australian five year study, 82% of patients suffering a back pain episode returned to work in less than five days [10, 61], although 48% of these same patients suffered up to three reoccurrences of back pain during the study period [61]. In the same study group, only 2% had undergone surgery. The vast majority of back pain is “self limiting”, regardless of underlying causes [10]. Littler points out that 44% of patients consulting a GP recover within one week, 86% within a month, and only 8% are still in pain after two months [50]. Littler goes further, “It is fortunate that so many of them tend to recover spontaneously as we have little specific therapy to offer [50].” Brooks, reviewing wide-scale studies of various treatments, states that a patient’s return to work did not seem to be related to treatment and notes that the response to a “no treatment” regimen would have been interesting to observe [10].

(vi) Biomedicine reacts to problems rather than prescribes how to avoid them. In the articles surveyed, no preventative medical position could be found. The doctors whose speciality is rehabilitation come closest, but their efforts are aimed at restoring a “pre-back pain-episode” level of function only and therefore cannot be construed as preventative. This attitude of reaction is fundamental to biomedicine: the notion of repair of the machine. Capra offers a moderating observation on this point however, “Many people obstinately adhere to the biomedical model because they are afraid to have their lifestyles examined and to be confronted with their unhealthy behaviour [13:165].”

Lifting is the most common cause of injury at 61%, with failing (15%) and bending (11%) much less common [61]. For this reason, rehabilitation tends to focus on teaching people how to lift correctly [22, 60], and gentle stretching and strengthening exercises [22, 56, 57]. Somewhat problematic is the illustration of correct lifting technique in Australian Safety News: the arms of the wooden model are significantly longer than its legs. This device, described as “scientifically designed”, is advertised by the National Safety Council as an aid to teaching correct lifting techniques. One can only speculate as to its efficacy.

As might be expected, the sports medicine journals go further in identifying muscle weakness and stiffness as causal agents in back pain and offer a variety of methods to overcome such problems. Based on the preceding material and the author’s clinical experience, the following comments are offered. Some of the exercise programs suggested were comprehensive, but seemed to neglect the area of the body most vulnerable to injury, the trunk [19, 20, 21, 46]. The trunk muscles support the lumbar spine, and it should be noted that increasing the strength of the arm and leg muscles in relation to the trunk muscles can lead to an increased imbalance, which may predispose towards injury. The recommendation against the use of an object to elevate the heels in the squat exercises seemed biomechanically unsound [82]. Some programs suggested incomplete range of movement exercises [36, 37]. Most articles on stretching used illustrations which, (like the wooden model mentioned previously) can be made to assume any position and therefore are less convincing than photographs; the one article which used photographs lacked any written explanations, which is potentially dangerous [86].

The inclusion of those practices once labelled as “fringe” in the biomedical model is a continuing trend. The survey of only the biomedical literature (I am excluding the chiropractic references here) suggests that Eisenberg’s remark, “We ignore, at peril to our understanding, the extent to which American patients seek out marginal practitioners (Firman and Goldstein, 1975) and obtain as much (or as little) relief as orthodoxy is able to provide for such chronic disorders as low back pain (Kane et al, 1974) [17:14].” may be even more appropriate now, as more patients seem to be availing themselves of such practitioner’s services. Hay in his concluding remarks at the W.A.I.T conference, left his audience with this admonishment:

This (the success of forcible manipulation) has seriously undermined the public confidence…If we honestly face the facts this attitude (open hostility) should cause no surprise. No excuse will avail us when a stiff joint, which has been treated for many months by surgeons and general practitioners without effect, rapidly regains its mobility and function at the hands of an irregular practitioner [84].

The only article on chiropractic to appear in a biomedical journal appeared with the note, “prepared by request”, suggesting that the article had been requested of the writer. The focus of the article was anatomical, with an emphasis on the sort of tests that should be performed by the chiropractor before manipulation, particularly in reference to a syndrome known as “vertebrobasilar accident”, the fatal severing of the cervical artery during a neck rotation. The tone was both scientific and reassuring [47].

There were two references to acupuncture. One mentions acupuncture in a range of treatments and notes that the, “skills of acupuncture can be acquired by most general practitioners with a short training course [77].” The other, written by a GP who teaches acupuncture, mixed a large number of esoteric terms, Chinese names of acupuncture points and biomedical anatomy. Subtle acupuncture techniques with which no GP would be familiar were named using traditional nomenclature, yet the article was not part of a series. No outline of acupuncture theory was attempted and the overall impression was confusing [74].

The review of hypnotic pain control and low back pain was interesting. Spinhoven [70] states that traditional biomedical treatments for back pain were developed on the basis of a “somatosensory” model, which assumed a direct relationship between pain and pathology. The absence of clear organ pathology has led to the development of a “multidisciplinary’’ approach, which considers psychological and social factors as well. Spinhoven notes that many authors consider that the absence of pathology and positive indications of psychosocial problems is a contraindication for hypo-analgesia, whereas patients presenting with psychogenic back pain may demonstrate symptom replacement (termed ‘displacement’ later in the paper), and only temporary or no pain relief. Spinhoven states that, “amazingly little is known that no researchers have demonstrated a clear relationship between pathogenic factors and back pain [70:120-121].”

Reviewing the use of a diverse range of psychometric instruments, he states that the tests produce “little useful information”, and he doubts whether this line of research is worth pursuing. He writes, “From a biopsychosocial perspective…organic and functional pain are conceptualised as forming a continuum [70:121].” He concludes that the “lively discussions” regarding the relative importance of psychosocial factors, their exact nature and whether they should be regarded as the cause of the result of back pain, are largely futile and he suggests that the emphasis should be which combination of procedures best suits the particular signs and symptoms [70:119-128].

Engel [18], three years before Spinhoven’s report was prepared, said that consideration of the patient (in social and psychological terms) must be made as well as any biological indices in the search for causes of illness; he termed this wider approach the “bio-psycho-social model”. He argued that this approach would tend to alleviate the current paradox wherein some patients who feel well are told that they are sick and others who are experiencing illness are told that they have no “disease” and hence are well [18:47]. Spinhoven does not cite Engle among his references.

An interesting result of one of the studies mentioned was that patients who claimed to have never suffered from back pain and who scored high on a depression scale proved four times more likely to develop back pain in the 1.5 years of the study than those with a low depression score and no history of back pain. This relationship was independent of presence or absence of disc degeneration [70:125]. The effectiveness of hypnosis and relaxation training appeared comparable [70:125].

Spinhoven [70] identifies a factor common to all hypnotic interventions: that pain experience can be influenced by means of a psychological procedure. This means that patients trapped in the dilemma of organic versus psychological pain require a translation process. He goes on:

Moreover, an approach aimed at modifying the experience of pain facilitates the establishment of a therapeutic relationship, because pain is the patient’s main complaint and is thus taken seriously. A therapeutic relationship centred around pain and its psychological consequences also seems to be a condition for allowing patients to discover for themselves that psychological factors can also give rise to pain [70:126].

Achterberg [1] also describes the efficacy of using imagery for pain control and cites a number of studies, including her own work in burn units [1:108-11, 138-9, 140, 151]. Moerman goes further and suggests that the construction of a symbolic image does not need to be reconstructed in another dimension of reality to be effective in healing; he says, in other words, that, “the construction of healing symbols is healing [52:66].

The only difficulty in a wider acceptance of these ideas would seem to lie in the promulgation of these techniques in a large and diverse industry whose, “Crisis stems from the logical inference that since ‘disease’ is defined in terms of somatic parameters, physicians need not be concerned with psychosocial issues which lie outside medicine’s responsibility and authority [18:37].” The underlying problem is the Cartesian paradigm and its mind/body division: so much research energy is spent in defining the difference between organic and psychogenic pain and not enough spent on how the various techniques could best be employed in the clinical situation.

One aspect of the therapeutic relationship that has been receiving considerable attention in the biomedical journals is the ‘sick role’. The fullest description of this role comes from Conrad:

The sick role has four components. First the sick person is exempted from normal responsibilities, at least to the extent necessary to ‘get well’. Second, the individual is not held responsible for his or her condition and cannot be expected to recover by an act of will. Third, the person must recognise that being ill is an inherently undesirable state and must want to recover. Fourth, the sick person is obligated to seek and cooperate with a competent treatment agent (usually a physician) [14:107].

The main concern of the biomedical writers is the problem of back pain becoming chronic and some feel that the various compensation schemes are counterproductive to the goal of resolving the problem. Currently, Conrad’s second and third conditions (that the individual is not held responsible for the condition and must want to recover) are being questioned. Bedbrook, talking about the difficulty in rehabilitating people with chronic back pain:

The most important and powerful method of stimulating motivation is that the patient should not be paid too much money for being off work…Man is a mercenary creature and as such, will accept most things for nothing if he is able to do so…there must be a stimulus towards recovery and towards employment and this stimulation, unfortunately, in many cases can only be of a financial nature [84].

Conrad reminds us that, “as legitimater of the sick role and as healer returning the sick to conventional social roles, the physician functions as a social control agent [14:108].” and this role is clear in rehabilitation and compensation. Quintner observes that, since the introduction of weekly payments at the 100% level, the actual amounts paid for any period off work has more than doubled. He added that, “41% of the 193 back injured persons remained unemployed and at least 28% of this population had not attempted or been able to attempt any employment at all.” Brook councils against the early use of radiological and laboratory testing, both because it is of little value in the acute situation and because it may encourage the adoption of the sick role. In addition he notes that the slower rehabilitation noticed in some groups in the community was related to fluency in English and not to country of origin, refuting the notion of “Mediterranean back [10]”. The results of the five-year study previously mentioned also supports the assertion that the popular stereotype of back pain sufferers as “litigious and hypochondriacal persons”, was completely unfounded and the respondents “not only generally continued to work in spite of the pain but they also ceased to receive medical or other treatment [61].” It is not clear whether the wider medical community shares this change in perspective.

Part 2

Medical anthropology and back pain

The main challenges to medical care have been described as the new morbidity – functional disorders and chronic illness [17:10]. These are good general descriptions of back pain. As we have seen in the words of the biomedical writers themselves, biomedicine is not very effective in treating back pain. Hahn and Kleinman remind us that medical anthropology has developed various concepts that have had practical significance in clinical settings [30:327]; and that insight into one’s own fiend can arise from without it. In the following pages, I will argue that biomedicine’s lack of efficacy in treating back pain stems from its inherited epistemology and its continuing adherence to a rigid notion of the scientific model. I will try to show that in many cases, in adhering to narrow views of pathology and disease, biomedicine unwittingly creates many back pain episodes and the social conditions for its continuation.

Good and Good describe the predominant theoretical framework of biomedicine as the empiricist model of clinical reasoning; that is, that symptoms as described by the patient must be interpreted as the indicators or reflections of underlying somatic states and hence (for the doctor), achieve their meaning in relation to these states [26:170]. Such symptoms, although loaded with meaning from the patient’s point of view, are reduced to somatic variables in the search for pathology. In its simplest form, Good and Good’s principle is, “symptoms are irreducibly meaningful [26:191].” The clinical reality, as Hahn and Kleinman write, is somewhat different: It should be realised that in taking a “patient history’’, most doctors are not interested in the patient’s life world but in “diagnostic evidence”. This “interested distance” is described as “detached concern [30:316].” As Eisenberg states, patients suffer illness; doctors treat disease [17:11].

In consideration of back pain as a clinical phenomenon, it must be remembered that different cultures invest illness with entirely different significance and that this tendency is visible within a culture too. Good and Good offer the example of obesity in contemporary America, which is associated with a unique network of meanings in that culture – among them shame, embarrassment, implications of low status and lack of self control [26:176]. In contrast, Conrad speaks of the Pagopago Indians of the American Southwest, who bring their babies to the doctor for treatment if they are skinny, believing them to be sick [14:104]. Culture shapes disease first by shaping our perceptions and explanations of disease. Kleinman observes that psychiatrists in Chinese cultural areas have noted for some time that many Chinese patients present somatic complaints in place of psychological complaints [42:3-5]. This “somatisation” avoids the social stigma of mental disease (which can affect marriage prospects for generations) and allows the patient to assume a legitimated sick role. In writing about the sick role in general, the medical historian Sigerist observes:

Illness releases. It releases from many of the obligations of society, first from school attendance and generally from work duties. The sick person is relieved from many important concerns with which society demands the healthy busy themselves…(Sickness) also lessens the degree of responsibility or removes it entirely [48:43].

Thus, to paraphrase Good and Good – sickness is irreducibly meaningful, and a sore back can be a great deal more than just back pain.

Good and Good describe the back pain episode of a 28 year-old black American, wherein the patient and the doctor had quite different explanatory models: the doctor saw the problem as a muscle spasm, and the patient saw his problem in terms of a network of stressful experiences, including an over-stretched muscle in his back, being regarded as a malingerer, difficulties with his girlfriend, the stress of his mother’s current illness, financial problems, his being on probation and the status of not being able to work [26:183-4].

In the ubiquity and ambiguity of back pain as an illness experience, we can see the same processes at work: the patient is often seeking an explanation that considers as much of his world experiences as possible and an explanation that gives some meaning to the patient’s personal disorder; meanwhile the doctor is looking for pathology. Writing about therapy in general, Kovel describes a model that could help the general practitioner towards a better understanding of the chronic back pain sufferer:

The model for therapy is not the cure of a disease but the growth – more specifically, the education – of a person. In contrast to education as it is usually conceived, therapy takes into account the emotional and subjective needs and assumes an imbalance that has to be righted [45:46].

This process of education is implicit in Kleinman’s writing of the need for the doctor to translate across both the patient’s and doctor’s explanatory models [43]. What I am suggesting here is that doctors tend to ignore the significance of the existence of the back pain itself and its meaning for the patient in the search for pathology. The all-important question should be, “What is the patient trying to tell me?” As Moerman put it, a wide range of psychological and sociological phenomena has been shown to correlate with a variety of physiological symptoms [52:61].

Taussig speaks of “reification”, a term employed to convey the process in which the patient’s symptoms (and eventually the patient) becomes “reified” or objectified. The human and social aspects of illness are stripped away, initially through the diagnostic and then the treatment processes and power over one’s body is abrogated to those in society whose responsibility it is to treat disease. I would like to extend this notion to include the process wherein a patient treats his own body as though it is an object completely separate from him; and where the patient is not responsible for its fallibility and capriciousness. This process is summed up in the phrase, “I’ve got a bad back.” Implicit in reification is the diminution and abrogation of responsibility for the condition. Taussig again, “Don’t contemplate rebellion against the facts of life for these…are locked in the realm of physical matter…To the degree that matter can be manipulated, leave that to ‘science’ and your doctor [78:6].”

Capra writes that the doctor’s role should be to make the patient aware of the context from which the illness arose. The recognition of the complex web of interrelated patterns which give rise to the condition is highly therapeutic, relieving anxiety and giving hope and confidence and initiating the healing process. Awareness of what past patterns helped give rise to illness gives the patient new insight and can lead to a change of those patterns. Capra notes that the fundamental role of the doctor is to teach; the word doctor comes from the Latin “docere” which means, “to teach” [13:335].

As medicine has advanced and become more scientific, it has lost its “unscientific” parts; some of this has been good and some bad. Kleinman writes:

Symptoms relief under medical care is the commonest outcome for most episodes of illness. Historically, this bonus to medicine as craft has been plague to medicine as science. The benefits patients have obtained have been attributed to the procedures in fashion rather than to the social dynamics of the medical encounter…such benefits have been labelled “placebo” effects [17:19].

The estimates of the effectiveness of the “placebo effect’’ vary from 30% to 60% [52:62]. According to Achterberg, the placebo is actually nothing more than granting (yourself) permission to heal; “it is a symbol the imagination can incorporate and translate into wondrous biochemical changes that are as yet beyond the comprehension of the finest scientific minds [1:85].” Moerman describes the same processes and states that the form of treatment as well as its content can be effective medical treatment; thus, medical treatment must be understood bimodally, in terms of its specific and its general dimensions [53:157]. Moerman here refers to a double-blind study of the effectiveness of the bilateral internal mammary ligation operation (BIMAL): both groups (those who had ligation surgery and those who had the operation but not the ligation) showed “substantial” relief from angina and reduced need for medication (actual operation, 66%; sham operation, 88%) [52:159-60]. Moerman ascribes the effects to placebo effect, following a “cosmic drama, following a most potent metaphorical path [52:161].” Other writers have described similar experiments and have ascribed the healing power to the placebo effect. Fundamental to an understanding of this effect is the notion of imagery.

“Imagery is the thought process that invokes and uses the senses: vision, audition, smell, taste, the senses of movement, position and touch. It is the communication mechanism between perception, emotion and bodily change [1:3].” In healing, imagery can work for or against the patient, “Belief kills; belief heals. The beliefs held by persons in a society play a significant part in both disease causation and its remedy [30a:16].” The interaction of belief and culture is an explanation offered for various phenomenon, from the extremes of the “voodoo death syndrome”, to faith healing. Achterberg continues, “Diagnoses are whimsical names, culturally determined and have very little absolute meaning or power in and of themselves. It is not the diagnosis that kills (or cures) but the expectations and images accompanying it [1:81].” The effects of a name are therefore difficult to separate from the name itself.

Torrey speaks specifically of the clinical effect of the naming process, termed the principle of Rumpelstiltskin, “The very act of naming (it) has a therapeutic effect…It says to the patient that someone understands, that he is not alone with his illness, and implicitly that there is a way to get well [81:16].” The reverse can also be true and the act of naming or diagnosing can have beneficial or harmful effects. The effects themselves have been named, “placebo” (from the Latin meaning, “I shall please”), and, “nocebo” (“I hurt”) [30a:17]. In the case of back pain and biomedicine, the author contends that the nocebo effect is far the more common and the more influential of the course of the illness, precisely because of the biomedical context, which says that any degenerative change to the vertebral structure of the back is irreversible. As we have seen, such somatic change is looked for, and most often is found. Thus the act of naming – “degenerating” or “extruded disc,” ”scoliosis,” “apophyseal joint dysfunction,” “spondylolysis” – and the like, are sentences of doom for most patients, because everyone knows that these are names of irreversible, harmful changes to the body; this is how our culture constructs this illness. Brooks suggests that, “Many patients regard pain as a manifestation of serious damage and this concept needs to be redefined [10].” When back pain is interpreted by the doctor as evidence of serious somatic change, what the author has termed the “reverse Rumpelstiltskin” principle is activated and the stage is set for the adoption of the sick role. Some never recover.

In dealing with back pain, medicine has painted itself into a corner: by insisting on pathology as the basis for most back pain and finding it, it can offer no course other than surgery (to change the pathology) or drugs (to cover the effects). Biomedicine admits that marginal practitioners are successful in treating back pain. One possible reason for this success can be found in the way they use positive imagery in their practise. Chiropractic will serve as an example. A brief description of the basic chiropractic theory requires an understanding of the biomedical concept, “dermatomes.”

In biomedical theory, nerves branch off from the spinal cord predictably and specific muscles and internal organs are innervated by specific branches of the nerves; the patterns of innervations are called dermatomes. The main significance of dermatomes for biomedicine is the prediction of the probable site of injury to the spinal cord following trauma. The term “neurological deficits” is used to describe such signs as a loss of feeling in a body part, or an inability to use a particular muscle, or a loss of bladder control and the like. Using the dermatome pattern, the physical location and severity of a deficit tells the surgeon which vertebral junction is likely to be involved.

Borrowing from the biomedical model, chiropractors have built an entire theory of medicine around “subluxations” and their relation to dermatomes, to treat illnesses of almost every kind. “Subluxations,” defined by Webster’s as a partial dislocation of a joint, are employed as an explanatory model of illness. A subluxation of a vertebra in relation to its neighbour is said to affect the segment of the spinal cord associated with it and hence the muscles or organ associated with that segment. For example, a stomach problem may be explained in terms of a subluxation of a particular pair of vertebrae, the manipulation of which will cure the problem.

In practice, the chiropractor runs his hand or a machine down the spine to locate any “subluxated” vertebra. He will always find one or two. The spine is then forcibly manipulated. A loud cracking sound results, which is audible evidence of the treatment in action. The chiropractor will again palpate the spine to determine whether the manipulation was successful. The patient will be told that the subluxation was the root cause of the problem. The patient is pronounced cured.

All of the healing elements mentioned in preceding paragraphs accompany such treatment: the cultural construction that says that chiropractors help people with back problems, the naming of the problem, the powerful accompanying image of a partially dislocated bone in the spine (which so appeals to our mechanistic minds), the sound that results from the manipulation which tells you that some physical aspect of your body has been changed, and so on. The sound of the manipulation (often called an “adjustment”) is a powerful metaphor for the healing process. If the cure is not immediately successful, you are assured that continuing treatment will fix the problem, in time. As the figures for remission of back pain suggest, this prognosis is most likely. Chiropractic is also practised preventatively.

Doctors too still rely on hope, faith and belief on the part of the patient [59:190]. If doctors are losing their charisma and becoming more prosaic figures like Myerhoff and Larson suggest, it would seem reasonable to expect to see a reduction in the efficacy of the placebo effect, in which, as Capra writes, the only active ingredient is the power of the patient’s positive expectations.

Worsley suggests, “It is now increasingly believed that they (doctors) know no more, often less, about the ‘non-medical’ dimensions of illness other than others…and invoke the authority of ‘science’ often only in order to cover up their own uncertainties and shield themselves against the demands and criticism of the layman [89:32].”

The placebo – that useful, “marginal” effect that has so long played a major role in healing and so long discredited –is however becoming the focus of medical researchers around the world in various fields: investigation into the clinical use of altered states, relaxation therapy, the field of psychoneuroimmunology, the use of images by athletes to aid performance and by the sick to help reduce pain and speed the healing process, and many others. In time through this work, the “unscientific’’ parts of medicine will be rejoined with the “scientific” ones. Capra sums up the process:

To reincorporate the notion of healing into the theory and practice of medicine, medical science will have to transcend its narrow view of health and illness. This does not mean that it will have to be less scientific. On the contrary, by broadening its conceptual basis it will become more consistent with recent developments in modern science.

Conclusion

“Essential to all therapies and counselling is the effect of the relationship with the therapist [45:48].” This fundamental aspect of health care will be found to be lacking in any medicine that focuses on pathology as the main cause of disease and in any medicine that focuses on disease rather than illness. Broadly speaking, these are the main problems of biomedicine today. Hahn and Kleinman, writing in 1983, have noted that, “The practitioners (and often patients) of biomedicine hold that medicine is separate from art, economics, religion, politics and morality [30:312].” It is no longer; there is an increasing awareness in the community of the shortfalls of biomedicine, especially in the way it deals with common illness episodes. With back pain, in the absence of serious neurological deficits, care should be taken to ensure that all non-invasive techniques are tried for its successful cure. This is as much the responsibility of the patient as the practitioner.

Surgery for back pain is one area where the placebo effect seems conspicuously to be lacking: only 30% or so of operations cure the symptoms. The author has suggested that this may be due to the “routinisation of charisma”, mentioned above, coupled with the nocebo effect (through the “reverse Rumpelstiltskin” process) and both added to the high probability that the original symptoms had other root causes.

It is suggested most strongly that, in the absence of neurological deficits, episodes of back pain should not be attributed to such powerfully negative images as “prolapsed disc” and similar, because, as the evidence suggests, a great many people with quite serious vertebral degeneration of various kinds are symptom free and with good back function. Instead, the doctor should say simply that the evidence is that most back pain episodes are self-limiting (the episode will have a finite course), and likely to be healed within a week or so. The doctor should advise a day or two of rest, followed by some gentle mobilisation exercises, perhaps under the guidance of a physiotherapist. The patient should not be encouraged to adopt the sick role. Medium and long-term strategies for rehabilitation should follow, with counselling and lifestyle advice given as appropriate.

Apart from surgery’s ineffectiveness as a means of curing back pain, the patient should make every effort to stay out of hospitals in any case, as they are potentially dangerous places: accidents in hospitals now outnumber all other industries except mining and high-rise construction and one in five patients hospitalised will develop an iatrogenic illness – fifty percent of these episodes resulting from drug therapy and ten percent from diagnostic procedures [13:149].

A preventative position

If back pain has its root in postural problems as some researchers have suggested, early screening of students while in primary and high school could prove extremely cost effective in the long term. This could be done in the same way that preventative dentistry is performed currently. Researchers have specifically cited such problems as “short leg” syndrome [22, 24, 25, 64], Scheuermann’s disease [31, 72], juvenile functional or structural scoliosis [31], and other back problems that are amenable to conservative treatment such as exercise, if detected sufficiently early. Techniques for detection of these problems need not be invasive.

Many anatomists, physiologists and surgeons have pointed out the vital role that the trunk muscles play in the support of the spine. Kapandji and others have shown that, if correctly recruited when lifting heavy objects, the abdominal muscles reduce the load of the spine by up to 50%, by turning the thoraco-abdominal cavity into a closed, pressurised cavity [39:108]. The abdominal muscles also flatten the lumbar curve, which as described above, has been implicated in many degenerative processes [39:107]. The paravertebral muscles play a powerful support role to the spine itself, also. All of these muscles may be strengthened by appropriate exercise. This is even more important in athletes involved in body contact sport [2,19-21, 28, 31, 35-40, 46, 54-56, 66-68, 82-83].

It was mentioned above that the lumbar curve arose through the transition from quadrupedal to bipedal movement and the lumbar curve resulted partially due to incomplete backward tilting of the pelvis on the spine. From clinical observation and experience, the author offers an alternative interpretation. Excessive lordosis (lumbar curve) can result from simple chronic tightness of psoas and iliacus muscles. These muscles, arising from the lumbar vertebrae and iliac fossa respectively, join and cross the hip joint anteriorly to join the femur; together they are powerful hip flexors. Of all the trunk/hip muscles, these have had to lengthen by far the most during evolution, and are often extremely inflexible. If this is so, and this inflexibility coincides with weak abdominal muscles, the lumbar vertebrae will be pulled anteriorly and lordosis will result.

As noted by Burnell, spasm in the hamstring muscle group can be misinterpreted as a positive Lasegue’s sign, or evidence of pressure on the sciatic nerve roots. He describes clinical experience where a few minutes of hamstring relaxation exercise shows an improvement of 20 degrees or more of hip flexion and, on retesting, no apparent Lasegue’s sign [84]. The author can report many instances of a similar reduction in “sciatic nerve pain” in the clinical situation.

The author’s prescription for the majority of chronic back pain, then, is three-fold: strengthening of the abdominal muscles and a stretching of psoas/iliacus and hamstring muscles. Such a routine would take five minutes to do. It is also recommended that gentle stretching exercise be added to the curriculum of primary and high schools, along with the early screening described above.

The final suggestion in the management of back pain, whether acute or chronic, is the inclusion of stress-reduction techniques in one’s daily life. This will both reduce the incidence of chronic back pain and aid speedy recovery from an acute attack. Of all suggestions, this is the easiest to adopt into one’s normal routine: simply lie on the floor in front of the stereo covered by a blanket or the like and listen to soothing music for twenty minutes, everyday. This position is well supported in the literature [5, 22, 23, 69, 70].

Worsley quotes from the conclusion of the Mozambican statement of policy on health, “The creation of the system of primary health care is the top necessity in any country in the world…It is a rational and effective system of health under any conditions [89:345].” Capra writes, “Many reasons are given for the widespread dissatisfaction with medical institutions – inaccessibility of services, lack of sympathy and care, malpractice – but the central theme of all criticism is the striking disproportion between the cost and effectiveness of modern medicine [3:131].” Finally, the time may have come when the economic forces that helped to create biomedicine three centuries ago will push it in the direction of preventative medicine.

Capra ought to have the final word:

The first step in…self-healing will be the patient’s recognition that they have participated consciously or unconsciously in the origin and development of their illness and hence will be able to participate in the healing process. In practice, this notion of patient participation, which implies the idea of patient responsibility, is extremely problematic and is vigorously denied by most patients…they refuse to consider the possibility that they may have participated in their illness, associating the idea with blame and moral judgement. It will be important to clarify exactly what is meant by patient participation and responsibility [13:329].

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APPENDIX

For the anthropology references I have relied mainly on the Medical Anthropology B26 reader, and a number of books. For references to back pain in biomedicine, I approached the National Library, and made my initial search through the microfiche index. I was looking for sportsmedicine references, as I have found that the latest developments in biomedicine tend to be used by sportsmedicine practitioners ahead of others. This may reflect the relatively young age of its practitioners. Some ten years’ worth of Physician and Sportsmedicine and American Journal of Sportsmedicine were searched, yielding 16 references to back pain. I then approached the Australian Medlars Service, and asked for a search of the Ozline database, some 39,000 books and journals, under the rubrics of back pain: (a)etiology, treatment, and rehabilitation. This yielded 81 references, of which I selected 17. I realised that the serach had not made any reference to either Australian Family Physician or Australian Journal of Medicine – a check with Ozline revealed that these two publications are indexed under the Medlars system (US sources). A further search of these two sources provided 12 relevant articles. Twenty-five books are listed in the references; some are secondary sources and some are quoted explicitly; they include works on anatomy and physiology, stress, kinesiology, and the clinical use of altered states. The articles retrieved by Medline and Ozline are grouped functionally below.

I have excluded analysis of the surgical techniques for the relief of back pain that form a large part of many of the articles, and have concentrated instead on the attitudes and assumptions of surgeons and others as revealed in their writing. Apart from a brief analysis of chiropractic in contrast with biomedicine, I have not included any reference to ‘alternative medicine’ and what it can offer to back pain sufferers. I have not attempted any analysis of the rationale behind stretching and strengthening exercise as either prevention or cure of back pain either.

In order to be able to recognise trends among the articles surveyed, I have grouped them by approach and content, from those that adhere most closely to a strict interpretation of the biomedical model to those that embrace a wider range of methodologies.

Anatomical studies of mechanisms of back pain: [16, 24, 60, 49]. Additional references not cited in the bibliography are found in [84], the low back pain conference in W.A.
Back pain in general and surgical practice: [9, 22, 32, 33, 41, 50, 55, 56, 58, 70, 72, 77, 81].
Postural aspects of back pain: [2, 11, 24, 64]. The reader will notice that three of the four references cited appear in the Journal of Australian Chiropractor’s Association; this form of medicine is by no means universally accepted as part of biomedicine.
Back pain in the workplace: [10, 61].
Back pain in athletes: [7, 27, 28, 31, 66, 71].
Stretching techniques for muscles and joints related to back pain: [4, 57, 75, 86].
Strengthening techniques for muscles related to back pain: [19, 20, 21, 35, 36, 37, 40, 82, 83]. Articles [67] and [68] have an emphasis on rehabilitation, and some of the techniques included are not accepted as part of biomedicine by most reserachers.

The reader will notice that, of the articles retrieved by Medline/Ozline, none predates 1980. Of the other relevant articles, none was written before 1974, as I have endeavoured to make my focus historically broad, rather than deep. However, in this modern literature there are a number of interesting references to previous eras in biomedicine.

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