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Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 71-79
Debate: This Society believes that in the last 25 years of back pain research we have failed to see the wood for the trees Chaired by C.G. Greenough* CG. Greenough, A.L. Nachemson, M.I.V. Jayson Department of Orthopaedic Surgery, Middlesbrough General Hospital, Ayrsome Green Lane, Middlesbrough, Cleveland TS5 5AZ, UK Motion proposed by: Professor A.L. Nachemson, Department of Orthopaedic Surgery, University of Gothenburg, Sweden Opposed by: Professor M.l.Y. Jayson, Department of Rheumatology, University of Manchester, UK
Introduction The idea for this debate arose out of an idea from the Aberdeen meeting asking whether back pain and all disabilities related to back pain could be described using a simple universal back pain graph (Fig. 1). This graph represents the inexcorable rise of disability caused by back pain over the years. It represents the number of papers published by the members of this Society over the last 25 years. It represents the weight of EU documentation on manual handling in the work place. It is also very versatile because you can turn it around (Fig 2.). This of course represents the physical element in the manufacturing industry over the last 25 years and possibly it also represents our hopes of ever being able to do anything about back pain. This afternoon we are going to debate this issue. We wondered whether
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the Society, despite all its diligent striving and undoubted success in many fields of research, might possibly be part of the problem rather than the solution, given that the more our knowledge increases, the more disabilities we seem to produce. However, it was pointed out to me that this is slightly nihilistic and so we modified the title for the debate. Our proposer for the motion is the Arthritis and Rheumatism Council Guest Lecturer, which position has been more than adequately filled by Professor Nachemson. His work and his immense contribution to the field of back pain over many years needs no further introduction from me. So I would like to ask Professor Nachemson to propose the motion, 'This house believes that in back pain research we have failed to see the wood for the trees'. Professor A.L. Nachemson The title, of course, was given to me and though
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e.G. Greenough / Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 71-79
Fig. 1. The Universal Back Pain Graph.
I would not have chosen this as a title for a talk it does make a suitable title for debate. Before looking at what we have done over the last 25 years, I would remind you that I have been in the field 50 years, so everything was done before 25 years ago! The many trees of research in the field of biochemistry, mechanics, radiology, psychology, etc. has not allowed us actually to influence the shape of the wood that is the disability and suffering arising from back pain. Indeed, there are a lot of studies showing that this is increasing tremendously all over the world, despite the fact the back pain has the same prevalence all over the world; 30-40% in the last month wherever we are. However, how it is dealt with and how individuals cope with it differs tremendously. In Sweden, we found an enormous increase from 1970 to 1987: from 1% in 1970 who were sicklisted to 8% in 1987, and the number of days they stayed off work was much higher. This was coupled with a tremendous increase of 6000% in permanent disability, which really cut into our gross domestic product. Today, the figures are worse than they were 1 year ago. We now have 480000 on perma-
nent disability pension, which is something like 12% of our working population, and 60% of those are due to back pain. When someone is given permanent disability pension before the age of 55 his chance of getting to 65 is reduced to one-half of what it was if he continued to work. Actually, it is the end of the welfare state - that is how simple it is! We have to cut hospital beds and we have to cut research for Societies like yourselves, because all this disability takes up all the money. Our research for the last 25 years has not reduced that, it has actually increased and helped the permanent disability rate go up because we have not solved the problem, we do not know what causes back pain. We have done many things in epidemiology, biochemistry, physiology and psychology, and it is perhaps in this last area, together with pain research, where our hores are at the present time that we will be able to change the whole picture. I do not think that we will be able to change the chemistry, that is in our genes, and I do not believe, for the time being anyway, that the genetic code for proteoglycans or collagen can be changed that quickly. We have heard in this meeting some of the strides forward that
Fig. 2. The Universal Back Pain Graph, position 2.
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have been taken, but certainly the scientists were not able to give us any clues on how to solve the problem of back pain. It has even been the subject of many conferences, like the National Institute of Health conference on Musculoskeletal Tissue Repair. I, and many other people, have looked at the nutrition of the disc and we know that it has to live by diffusion. However, this was done 30 years ago, not recently! We know that these areas are poorly nourished and that is nothing new. There are a few exceptions, one of which is that we know that motion helps restoration of function. So I will have to concede that perhaps. I started running at the age of 40, 25 years ago, when I found out that it was good for the discs! We also found that immobilisation was bad, when we fused dogs discs they were immediately much worse. Vibration is also known to be bad. My claim to fame goes back 45 years when I made disc pressure measurements and I thought that would be the solution for the whole problem: being able to measure what positions are bad for the back and which are not so bad. Or at least I was measuring loading for the back. I thought that loading and back pain were the same thing. Of course I was entirely wrong and nothing came out of it except that we can now tell patients not to exaggerate certain movements because then you may get more pain. However, we can give one very good piece of advice, you can start jogging tomorrow! The patient may laugh! Well laughing and jogging puts the same load on the spine. If you can laugh, you can jog! The only thing that really came from all my biomechanics studies, that went on for 20 years or so, is the fact that twisting, turning and lifting is very taxing. The only thing that fits scientifically with epidemiological studies is that oblique lifting is a cause of disc herniation. If you look at all the biomechanical papers published in Spine and other journals to date, at least 60% of them talk about the biomechanics of various instruments that they then try to sell. My points are that, firstly, we do not need them at all because they have nothing to do with the earlier back pain, and secondly, the screws break anyway whatever they say in the biomechanical studies because they are done on cadav-
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ers. So, in my view, all the biomechanical endeavours have really not been very fruitful at all. Rather, however, the more recent studies of what is happening around the cells in the spinal cord and in the mid-brain are much more interesting. We know that there are nociceptive impulses that are modulated by how much inflammation there is peripherally. Changes in the cord and in the mid-brain certainly playa role and the responses to psycho-social stimulae are much more important. Today this pain research is centred on, among other things, all the various substances that are involved in tissue medication. In passing, low pH at the periphery induces inflammation and can cause sciatica. But that is not new, we found that in a study that I made in 1968 which showed that there are certain people who have a very high hydrogen ion concentration in the disc. Whether that has anything to do with pain I do not know and I still do not know! At that time however, it was said that it cannot be that because it would immediately be buffered. Now that statement has been retracted so maybe there is something to it. What I wanted to say is that now all pain treatment with drugs is concentrated in the area of NMDA receptors in the cells and how they can be changed. There are people with various types of receptors and there are people who can clearly control the impulses that we interpret as pain. Now we know that when these NMDA receptors are sensitized, minor painful stimulae lead to an occurrence of more severe pain states without further tissue damage in the periphery, which is one of the points made earlier in this meeting. But we still have not solved the problem of which receptors to block in order to feel less pain. So what are the solutions? Well certainly not magnetic resonance imaging (MRI). With MRI we are doing more harm than good. We are operating on 'black discs'; indeed, only last night I heard one prominent surgeon in this Society saying that, 'Well, when you have black discs you have to operate on them'. To me a black disc means 2% less water and has nothing to do with pain and I do not see how you can defend the statement that was made. Abnormal diagnostic behaviour leads to abnormal illness behaviour
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which leads to abnormal treatment behaviour and that is what we all are doing. We all have our hangups and use all different types of terms. Consider the incidence of disc herniation or spinal stenosis found in normal volunteers put through an MR imager or seen in a myelogram or by CT. It was known previously to be high but now we have 76% in the recent paper by Boos presented in the January (1996) issue of Spine. He had matching samples, which no one else has had previously, same work, same smoking, same age, same sex and investigated them in the same way as those operated on. He put them into an MR machine, randomised the pictures and gave them to two radiologists to read: 76% of the normals had disc herniations. What differentiated the normals from those that came to surgery? Two factors: the most prominent psycho-social, the next prominent (fortunately for us Orthopaedic Surgeons!) the location of the disc hernia, lateral rather than medial. So, the facts are now that psycho-social factors at work are more important than mechanical ones for low back disability and also for sciatic disability. Now the other thing is, without question, we all respond to economic incentives and disincentives. Taxes and benefits affect behaviour and affect pain behaviour. Also among doctors, physiotherapists and dentists. I had one thesis in my Department from Holland that used figures from an insurance company and he found that the more compensation given to sickness, the more back pain there was and a greater number of sickness days. So insurance benefits are a significant factor. Look at this experiment: in Sweden before April 1993 you got 95 or 100% of your salary when you were sick from the first day. Then they changed the rules. For just 1 day of absence no money is paid. Then, for the first 2 or 3 days, you get only 75% of your income and only after 4 days can you get more. What happened? I have statistics from the city of Gothenburg from 1987 up to 1994. I looked at the 1 month prevalence of disabling back pain of the 230 000 insured in Sweden: down from 5200 to 2600. Overall, longterm disability diminished by 40%. Who achieved this? The politicians! So my question is, 'who should treat back pain - us or the politicians?'
Of course, politicians are much more effective in reducing the total burden to society. Treatment then, do we do any good? Randomised, controlled trials have demonstrated that the less we do the better! At least studies how demonstrate that if you do a proper examination, give them advice on moving around and getting back to work as quick as possible, this is far better than any other treatment. I am talking about the first 2 or 3 weeks of back pain now. So really we have not gone very far have we? It is like someone here said, in Saudi Arabia they never complain of back pain and certainly they went around doing their business whatever it was and it cleared up. We should put up a warning in all workplaces, 'the Government has determined that work absence may be harmful to your health'. That may help, even though it does not reduce smoking! None of this is new. Even Shakespeare said it in Macbeth, 'Present pain is less threatening than fear of future imaginings'. The imaginings that patients have that, 'Oh my God, I will become chronically disabled'. Does that not gives us a message. We need to spend more time telling them that that is not going to happen. We must take a good 'red flag' history - we know all these things and we are good at it, but we have to convey that to the patient. However, the new thing that has happened, and here I must give you the point Dr Jayson, is that we now have some yellow flags that we can work on, and that, I think, has been the major advance during the last 15-20 years. Poor health belief, never pain free, fear of activity or moving, previous long-term disability, frequent emergency treatment, whole body part numbness, whole extremity giving way. When you have these in patients after 3 or 4 weeks of back pain then we must concentrate more because then we know that these patients are far more likely to become chronic back pain sufferers than if these things are absent. There are a lot of minor points also, but this is the total of the collective research that has come out of the last, lets say 20-25 years. Much of this progress has come from British researchers, and this is what you have taught us to do. Look at the head instead of looking at the spine! There is
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nociception, undoubtedly, but there are also in everyone to a greater or lesser extent, psychological factors. Illness behaviour and social interactions are both important factors, but we have actually influenced the social interactions by saying that it is the bad workplace that gives them back pain, and the Press has taken it on from there and given a lot of information to people. But the whole workplace issue is a little questionable. There are ways of returning the patient to work later on, even after 1 or 2 months. We did a study at Volvo to demonstrate that a behavioural psychology activation programme returned people to work on average 3 months earlier than if they did not receive that, and the number of permanent disabilities later on was reduced by 80%. We also demonstrated that it had nothing to do with the actual demands of the workplace. Finally, I was able to convince the healthcare authorities in the city of Gothenburg that they should pay for a back pain clinic, run in a similar way. Three years later they gave us the same number of people who had not been sent to this back clinic, and the recovery rate differed significantly. Permanent disability was reduced in the back health clinic by something like 75-80%, and the average gain per patient was 159 days compared with those that did not go to this clinic. However, there was one exception. We failed completely in one group of patients. There was no effect in the immigrants, who could not understand what we were saying, which teaches us that we must do things a bit differently. We have to convey our message in a different way to these people or perhaps there are different sociological things. However, this is not biomechanics, this is not biochemistry. Rather it is some type of sociology and psychology. So, we have to distinguish efficacy, which is the result of a prospective, randomised trial intervention under ideal conditions, and effectiveness, the result of an intervention in routine clinical practice which was this back clinic. So, it is possible for us doctors to have some influence! But for the 3-4% in our societies now that become chronically ill, that is for 6 months or more, there is really not much hope. There is not a single good study demonstrating anything. If you look for studies that are presented on well
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defined patient populations with a pre-operative evaluation, a controlled clinical trial followed by an unbiased observer follow-up after 2 years after using all the forms, then they become very, very sparse. For instance, no study of fusion operations has shown better than 60% good or excellent results for primary fusion, this is for chronic low back pain. For repeat surgery it drops to 30%, and the number of patients made worse is 40%. So we are not doing very well with these things, although the spread of fusion operations all over the world is used as a strong marketing tactic. What we need, of course, are more and better controlled, prospective, randomised trials and to stop the fusions for back pain for which we do not know the cause. We know how to do outcome studies, and if you do not know, start reading the supplement in the 1994 volume of Spine. However, the worst thing of all is no one in this room knows what causes back pain. We have so many names, for instance facet syndrome, disproven by 11 scientific studies! Yet we do not know who has it! I am not saying that these things do not exist, I am just saying that we cannot prove that they are there. Degenerative disc disease is probably the worst misnomer I know because we all have degenerative disc disease, unless you are below the age of 18! Isolated disc resorption never properly validated. Segmental instability what is that? You cannot measure it from X-rays, indeed you cannot measure it at all! We do not know what we are talking about. A human being is composed of unstable parts, stabilised only by a healthy mind. Who said that in 1670? His name was Spinosa! So I will end by saying that despite 25 years of back pain research we have failed to diminish the back pain burden for society. Professor M.I.V. Jayson Have we failed to see the wood for the trees? Or, have we identified the issues which are important in our patients? When I looked back to where we were when I first started in back pain research and at the beginning of this Society 25 years ago, I had to acknowledge the fact that there was very little interest in the whole back
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pain problem. I used to start off by saying how back pain was a boring subject and generally regarded with a complete lack of interest in both rheumatology and in orthopaedic clinics and very little was done about it. In the early years of research there was great use of loose diagnostic terms. If we think back to 1971, surgery was commonly performed without a proper anatomical diagnosis, patients had some symptoms of back pain and maybe some pain in the legs and they mayor may not have had a radiculogram or a myelogram. Then they were given operations and some of them got better and some of them got worse, but nobody followed them up anyway so one did not know what was happening. Fortunately things have changed quite considerably over the years. We had this concept, at that time, of non-specific back pain and we still use these words today, but we are beginning to analyse this a lot more carefully. Non-specific back pain is a rather meaningless phrase. It simply means back pain for which we do not know the cause. As we have progressed we have begun to chip away at it and to understand much more clearly exactly what is going on in individual patients and we are now making specific diagnoses within this global entity. I look forward in the next 25 years to being even more specific about what is happening in these particular problems. In 1971, our research interests were very much involved in the structure of the spine and the Society was heavily involved in the biomechanics of the spine and the biochemistry of the spine, the structures of the collagen and how it related to function, we looked at how it moved, the ranges of speed and force of movement. We tried to quantify all these aspects and use these in the assessment of various techniques. For various treatments all sorts of trials were initiated and though most of these did not show anything very much, nevertheless this was the approach that has been present since 1971 and which I think has evolved significantly since that time. The progress that we have made since that time has been quite profound. First of all, we have developed validated methods for assessment of progress and we use a variety of questionnaires which have been proven. They are not just our own individual questionnaires, they have been
subjected to careful intra- and inter-observer. reproducibility studies and they have been related to function; physical tests likewise. Certain tests have become helpful and other tests have become less helpful. Imaging has been subject to critical analysis as well. We have developed a variety of techniques for X-rays and scanning and initially we were overwhelmed by the changes we saw. We looked at the black discs and we looked at the bulges and we thought these were the features of importance. However, we now have clear views about the significance of these changes and we know what we should take seriously and what is meaningful. We know that the radiological changes of spondylosis are common in symptomfree individuals and have a poor relationship to symptoms. We know about the changes that are seen in MRI scans and we know that extruded discs do have a correlation with back problems and sciatica and we know the figures that they may be found in symptom-free individuals. So we have identified exactly the significance of these changes and we are using them in a much more critical fashion. The difficulty, of course, is in delivery of this knowledge and perhaps we are not as successful as we might have been in getting the wider audience of society to appreciate the rate of current scientific advance. We have been interested in identifying and understanding specific syndromes and certain things are now very clear. For instance, the high intensity zone, the herniated intervertebral disc, the instability which may be seen in spondylolisthesis and so on; these are all well defined syndromes. I believe that as we study these patients more clearly, now using a different structure to our approach, we will identify much more clearly these specific syndromes. However, I think our standpoint for this type of analysis is going to have to change. The concept of back disability which we all use is a rather unsatisfactory term. It is an umbrella diagnosis - a global term which can be everything to nobody or nothing to everybody but which does not help the person who is disabled with back pain and is not actually giving a specific diagnosis. As we begin to understand much more clearly we are going to chip away at this vast group of disabled people and we are going to be able to analyse in much more specific
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detail exactly what is going on, but our viewpoint is going to have to change. For example, we have now got clear views on the psychological mechanisms which are present in many patients. There is a lot of evidence that has been presented at this Society and we are all familiar with the importance of these psychological mechanisms. Equally importantly we have the tests which allow us to identify these. They may be improved but, nevertheless, the standard test which we use in Manchester and which is used by many members of the Society is the Distress Risk Assessment Method and this does seem to be a very effective test for identifying depression and distress and also an altered cognitive function. We are looking at the neurophysiology underlying these mechanisms, and this clearly is the way we should be looking at the future. We are also appreciating the importance of altered perception in relation to nociception. In other words, there is a nociceptive influence, albeit relatively minor in some cases and major in others, but it is the perception of that which has become the critical factor in so many of our patients and this is enabling us to begin to identify the true significance of spinal pathology. We are now adopting a better technique for clinical trials. Twenty-five years ago we had all these uncontrolled studies and anecdotal case reports and we now know that we have to have a controlled study, we have to compare what we do with some alternative form of treatment in order to try to determine whether the treatment that we offer is of value or not. There are now well defined structures for constructing these trials and without these structures we know that the information in these studies is not of great value. Outcome parameters have been developed and functional assessments - return to work, use of healthcare resources - are all methods which are being used in terms of outcome. We have already heard from Professor Nachemson that these techniques are mandatory for a proper assessment of the outcome of various forms of treatment. I must draw your attention to the Clinical Standards Advisory Group Report on back pain because this has been a major turning point in this country, not so much because of the information provided to members of this Society but because it has become widely disseminated
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throughout the whole of the UK. Indeed it reflects what is happening in North America and in Europe, and this is providing a logical structure to treatment which helps us to understand what is going on. We have learned to triage the patients into simple back ache, nerve root pain and possible serious spinal pathology. We know about the early management and we know about the importance of physical activation and of early return to work. These are factors that we now know, where they were not known 25 years ago. Maybe the message has not got through to the politicians, but nevertheless, we in the Society are fully aware of them. We have also come to appreciate that psychological pain is real pain, it is not malingering. It is not an abstract non-specific process which is meaningless. However, these patients who have major psychological problems are very distressed and, if anything, they are perceiving their pain as more severe than that of purely organic pain. These distressed patients that we see are in much greater pain and distress than the patients with cancer or with crumbling spines, yet these are the ones that we understand. We have looked at the question of hypochondriacs and we know about neuroses, and about depression and so on and we see all these things and we learn to recognise them. We also know how litigation amplifies and prolongs pain and disability and our chairman has conducted an excellent study in which is shown the importance of this with matched injury patients, some of which are compensatable, others are non-compensatable and the compensatable ones have much more severe pain, distress, longer time off work, failure ever to get better and so on. Many of us have met the scenario where the disappointed patient has actually got better and no longer gets as much in the way of compensation. Epidemiological studies, I think, have helped to highlight these problems. There have been major studies conducted, not only in our unit but also elsewhere, which have highlighted the importance, first of all, of psychology and work dissatisfaction, previous back history, and last, and a long way least, the physical factors associated with a particular work and particular circumstances. These are major advances and are at the cutting
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edge of what is happening at the present time. Cross-sectional surveys and prospective surveys have looked at pain free populations and shown how distress and work dissatisfaction predispose towards the development and chronicity of back problems. So, there is good evidence about these factors which helps us to understand what is going on. These things are generally not for the patient with an extruded disc which is impinging on the nerve, the 1% of cases that the orthopaedic surgeon should be looking after. I am talking about the 99% which should be under the rheumatologist. One of my patients did her own pain drawing which was a fascinating glimpse into what she was feeling. She was a young girl with chronic backache and she came up with a terrible story of pain. Lots of jagged lines everywhere and she has not only drawn pain in her back but also pain in both arms, her throat is sore, she has a rash on the face, blurred vision, headaches, thinning of the hair, soreness in the glands, pain and stiffness in the arms, chest, elbows, fingers, wrists, hips and so on. This is a demonstration of the central pain perception which is occurring in these people and clearly this is very, very different from the herniated discs which we all love to think about. So the central pain is not an abstract process, It is an activation of the pain processing pathways in the brain and in the spinal cord. We are studying the dorsal horn and looking much more specifically at the NMDA receptors in the dorsal horn. There are drugs which are being developed which target these receptors and the trials of these drugs are just beginning and I am optimistic that they will lead to significant improvements in pain control in these patients. We also study the brain, especially the mid-brain, and the anterior cingulate region. There has been a shift in ideas about the understanding of chronic back pain and I believe that altered activity in the dorsal horn and the brain are going to be important in the future. We are beginning to understand what is going to happen in these particular patients. In the past we have had the scientists who go sticking needles into the nuclei of discs and measuring their pressures when they bend and twist and it is like the proverbial blind men examining an elephant! They each look at the various parts
of the beast whereas in fact you need to stand back and look at the whole beast and get a holistic view. Then you can see exactly what is going on and understand its mechanism. It is a new paradigm of approach because our paradigm is not a specific nociception, its the body's response in the altered central nervous system responses in a relation to that nociception which is the new approach to the subject. So, have we failed to see the wood for the trees? The answer is that we were looking the wrong way - all is now being revealed. In the last 25 years we have disentangled many specific syndromes. We have provided clear guidelines for management. We have understood the role of imaging. We have identified functional outcomes and back-to-work as prime importance and we have appreciated the fundamental role of psychological distress and we have identified neurophysiological mechanisms at the interface of peripheral nociception and pain perception. What we have not been very good at is convincing the public and our politicians about these issues but nevertheless, I think this is the way and this is the message that we are going to promulgate and this is the way forward. I think we cannot help but conclude that we are now, at long last, seeing the wood for the trees. Professor A.L. Nachemson -
rebuttal
Well, obviously, you heard that we both sang the same song so there is not much to debate. For the first time in my life I am willing to give in to this proposition. I think that we have made some progress but there is still much more to do. The main question is whether this knowledge is only in this room. I agree with you that we have failed completely to make it public. Of course what we have failed to do is to see what is happening in the disc. Most of us still believe that it is the collagen, or various other substances, that playa role here for nociception; nociception that can be modulated in various ways. However, maybe in the future the Human Genome Project will solve some of these issues when we know the expression of the various collagens that exist and can alter them in one way or another. Another thing that is not yet central is
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that we have to practice evidence based medicine. Evidence from randomised control trials are the only ones admissible. Not even good prospective, controlled trials can be put into something that is called the Cochrane collaboration. Of course, this was all started by a good British General Practitioner, I think he was Mr Archie Cochrane who said that it is surely a great criticism of our profession that we have not organised a critical summary of our care by specialty or sub-specialty, and this is certainly a sub-specialty, that is periodically of all relevance to randomised, controlled trials. I happen to run, together with the rheumatologists, the back subgroup of this Cochrane collaboration. We have reviews going on for all these various syndromes and soon there will be evidence saying that for this diagnosis, for example, traction is completely out. It will not be paid for! That is the only way you will change people's minds. Metaanalysis, as you all know, pools individual randomised, controlled trials together to arrive at an overall estimate of the effect of a specific intervention or a disease syndrome and that is being done now for all these things. This has come out already and saved thousands of lives already in Great Britain, in the 5 years it has been out. I can predict that the back pain study will save millions of dollars for any Government. By the beginning of the next millennium the whole picture will have changed more dramatically than it ever has before. It will not reduce back pain, I think, in the next millennium because back pain is a part of life. What it will do is to produce less back pain disability and less unnecessary treatmnent. Now, how do you change physicians' behaviour? It is very, very difficult. Financial penalties are probably the only way forward. Now, of course, there are already Government organisations that have been looking into this, how to diminish the problem by giving recommendations on treatment and looking at the availability. Certainly these attempts are guidelines but they are not put into law yet. Part of what we have missed is this border crossing thing. We have crossed countries, I am a Swede standing here, and there are international societies. We are certainly crossing specialty and discipline
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borders here in this Society but the failure has been, as Professor Jayson has already said, to Society and industry. We have failed really to bring out this information and influence them in a wider sense. So I want to end up by saying that we have to distinguish what types of support will contribute to our nations' future and which ones will undermine it. We have to tell the politicians that we all react to economic incentives, and that if they want to save some money for treating really sick people they have to make a decisions about how much is given in permanent disability and short-term disability. That is the harsh fact otherwise we will not have any money in the National Health Service or in our Swedish system. Finally, to save the industrial nations for the year 2000 and beyond we must diminish the impact of decreased age-related musculoskeletal flexibility by increased job flexibility. We all know that forestry workers cannot work until they are 60 years of age. It is too hard a job for their musculoskeletal system, induding the spine, so we have to give them something else, and that should be part of society's system. The Unions should also allow some changes with a little more salary for the latter part of life. We have to help society in this regard because these are biological facts and we are the biologists who tell them. Professor M.I.V. Jayson -
rebuttal
I think that what we have heard is that Professor Nachemson and I are both saying that we believe that we have advanced significantly in our understanding of back problems and I think we do have a much more holistic view on the whole problem. It is clear that our difficulty is in how we deliver this information to the public, to doctors at large, to our colleagues in related fields and particularly to Government. I personally would like to take this opportunity of paying a special compliment to Alf for his enormous contribution over the years that he has made towards back pain research and is continuing to make, for example the Cochrane Collaboration at the present time I think is going to be of fundamental importance for the future.
Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 71-79
Debate: This Society believes that in the last 25 years of back pain research we have failed to see the wood for the trees Chaired by C.G. Greenough* CG. Greenough, A.L. Nachemson, M.I.V. Jayson Department of Orthopaedic Surgery, Middlesbrough General Hospital, Ayrsome Green Lane, Middlesbrough, Cleveland TS5 5AZ, UK Motion proposed by: Professor A.L. Nachemson, Department of Orthopaedic Surgery, University of Gothenburg, Sweden Opposed by: Professor M.l.Y. Jayson, Department of Rheumatology, University of Manchester, UK
Introduction The idea for this debate arose out of an idea from the Aberdeen meeting asking whether back pain and all disabilities related to back pain could be described using a simple universal back pain graph (Fig. 1). This graph represents the inexcorable rise of disability caused by back pain over the years. It represents the number of papers published by the members of this Society over the last 25 years. It represents the weight of EU documentation on manual handling in the work place. It is also very versatile because you can turn it around (Fig 2.). This of course represents the physical element in the manufacturing industry over the last 25 years and possibly it also represents our hopes of ever being able to do anything about back pain. This afternoon we are going to debate this issue. We wondered whether
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the Society, despite all its diligent striving and undoubted success in many fields of research, might possibly be part of the problem rather than the solution, given that the more our knowledge increases, the more disabilities we seem to produce. However, it was pointed out to me that this is slightly nihilistic and so we modified the title for the debate. Our proposer for the motion is the Arthritis and Rheumatism Council Guest Lecturer, which position has been more than adequately filled by Professor Nachemson. His work and his immense contribution to the field of back pain over many years needs no further introduction from me. So I would like to ask Professor Nachemson to propose the motion, 'This house believes that in back pain research we have failed to see the wood for the trees'. Professor A.L. Nachemson The title, of course, was given to me and though
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Fig. 1. The Universal Back Pain Graph.
I would not have chosen this as a title for a talk it does make a suitable title for debate. Before looking at what we have done over the last 25 years, I would remind you that I have been in the field 50 years, so everything was done before 25 years ago! The many trees of research in the field of biochemistry, mechanics, radiology, psychology, etc. has not allowed us actually to influence the shape of the wood that is the disability and suffering arising from back pain. Indeed, there are a lot of studies showing that this is increasing tremendously all over the world, despite the fact the back pain has the same prevalence all over the world; 30-40% in the last month wherever we are. However, how it is dealt with and how individuals cope with it differs tremendously. In Sweden, we found an enormous increase from 1970 to 1987: from 1% in 1970 who were sicklisted to 8% in 1987, and the number of days they stayed off work was much higher. This was coupled with a tremendous increase of 6000% in permanent disability, which really cut into our gross domestic product. Today, the figures are worse than they were 1 year ago. We now have 480000 on perma-
nent disability pension, which is something like 12% of our working population, and 60% of those are due to back pain. When someone is given permanent disability pension before the age of 55 his chance of getting to 65 is reduced to one-half of what it was if he continued to work. Actually, it is the end of the welfare state - that is how simple it is! We have to cut hospital beds and we have to cut research for Societies like yourselves, because all this disability takes up all the money. Our research for the last 25 years has not reduced that, it has actually increased and helped the permanent disability rate go up because we have not solved the problem, we do not know what causes back pain. We have done many things in epidemiology, biochemistry, physiology and psychology, and it is perhaps in this last area, together with pain research, where our hores are at the present time that we will be able to change the whole picture. I do not think that we will be able to change the chemistry, that is in our genes, and I do not believe, for the time being anyway, that the genetic code for proteoglycans or collagen can be changed that quickly. We have heard in this meeting some of the strides forward that
Fig. 2. The Universal Back Pain Graph, position 2.
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have been taken, but certainly the scientists were not able to give us any clues on how to solve the problem of back pain. It has even been the subject of many conferences, like the National Institute of Health conference on Musculoskeletal Tissue Repair. I, and many other people, have looked at the nutrition of the disc and we know that it has to live by diffusion. However, this was done 30 years ago, not recently! We know that these areas are poorly nourished and that is nothing new. There are a few exceptions, one of which is that we know that motion helps restoration of function. So I will have to concede that perhaps. I started running at the age of 40, 25 years ago, when I found out that it was good for the discs! We also found that immobilisation was bad, when we fused dogs discs they were immediately much worse. Vibration is also known to be bad. My claim to fame goes back 45 years when I made disc pressure measurements and I thought that would be the solution for the whole problem: being able to measure what positions are bad for the back and which are not so bad. Or at least I was measuring loading for the back. I thought that loading and back pain were the same thing. Of course I was entirely wrong and nothing came out of it except that we can now tell patients not to exaggerate certain movements because then you may get more pain. However, we can give one very good piece of advice, you can start jogging tomorrow! The patient may laugh! Well laughing and jogging puts the same load on the spine. If you can laugh, you can jog! The only thing that really came from all my biomechanics studies, that went on for 20 years or so, is the fact that twisting, turning and lifting is very taxing. The only thing that fits scientifically with epidemiological studies is that oblique lifting is a cause of disc herniation. If you look at all the biomechanical papers published in Spine and other journals to date, at least 60% of them talk about the biomechanics of various instruments that they then try to sell. My points are that, firstly, we do not need them at all because they have nothing to do with the earlier back pain, and secondly, the screws break anyway whatever they say in the biomechanical studies because they are done on cadav-
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ers. So, in my view, all the biomechanical endeavours have really not been very fruitful at all. Rather, however, the more recent studies of what is happening around the cells in the spinal cord and in the mid-brain are much more interesting. We know that there are nociceptive impulses that are modulated by how much inflammation there is peripherally. Changes in the cord and in the mid-brain certainly playa role and the responses to psycho-social stimulae are much more important. Today this pain research is centred on, among other things, all the various substances that are involved in tissue medication. In passing, low pH at the periphery induces inflammation and can cause sciatica. But that is not new, we found that in a study that I made in 1968 which showed that there are certain people who have a very high hydrogen ion concentration in the disc. Whether that has anything to do with pain I do not know and I still do not know! At that time however, it was said that it cannot be that because it would immediately be buffered. Now that statement has been retracted so maybe there is something to it. What I wanted to say is that now all pain treatment with drugs is concentrated in the area of NMDA receptors in the cells and how they can be changed. There are people with various types of receptors and there are people who can clearly control the impulses that we interpret as pain. Now we know that when these NMDA receptors are sensitized, minor painful stimulae lead to an occurrence of more severe pain states without further tissue damage in the periphery, which is one of the points made earlier in this meeting. But we still have not solved the problem of which receptors to block in order to feel less pain. So what are the solutions? Well certainly not magnetic resonance imaging (MRI). With MRI we are doing more harm than good. We are operating on 'black discs'; indeed, only last night I heard one prominent surgeon in this Society saying that, 'Well, when you have black discs you have to operate on them'. To me a black disc means 2% less water and has nothing to do with pain and I do not see how you can defend the statement that was made. Abnormal diagnostic behaviour leads to abnormal illness behaviour
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which leads to abnormal treatment behaviour and that is what we all are doing. We all have our hangups and use all different types of terms. Consider the incidence of disc herniation or spinal stenosis found in normal volunteers put through an MR imager or seen in a myelogram or by CT. It was known previously to be high but now we have 76% in the recent paper by Boos presented in the January (1996) issue of Spine. He had matching samples, which no one else has had previously, same work, same smoking, same age, same sex and investigated them in the same way as those operated on. He put them into an MR machine, randomised the pictures and gave them to two radiologists to read: 76% of the normals had disc herniations. What differentiated the normals from those that came to surgery? Two factors: the most prominent psycho-social, the next prominent (fortunately for us Orthopaedic Surgeons!) the location of the disc hernia, lateral rather than medial. So, the facts are now that psycho-social factors at work are more important than mechanical ones for low back disability and also for sciatic disability. Now the other thing is, without question, we all respond to economic incentives and disincentives. Taxes and benefits affect behaviour and affect pain behaviour. Also among doctors, physiotherapists and dentists. I had one thesis in my Department from Holland that used figures from an insurance company and he found that the more compensation given to sickness, the more back pain there was and a greater number of sickness days. So insurance benefits are a significant factor. Look at this experiment: in Sweden before April 1993 you got 95 or 100% of your salary when you were sick from the first day. Then they changed the rules. For just 1 day of absence no money is paid. Then, for the first 2 or 3 days, you get only 75% of your income and only after 4 days can you get more. What happened? I have statistics from the city of Gothenburg from 1987 up to 1994. I looked at the 1 month prevalence of disabling back pain of the 230 000 insured in Sweden: down from 5200 to 2600. Overall, longterm disability diminished by 40%. Who achieved this? The politicians! So my question is, 'who should treat back pain - us or the politicians?'
Of course, politicians are much more effective in reducing the total burden to society. Treatment then, do we do any good? Randomised, controlled trials have demonstrated that the less we do the better! At least studies how demonstrate that if you do a proper examination, give them advice on moving around and getting back to work as quick as possible, this is far better than any other treatment. I am talking about the first 2 or 3 weeks of back pain now. So really we have not gone very far have we? It is like someone here said, in Saudi Arabia they never complain of back pain and certainly they went around doing their business whatever it was and it cleared up. We should put up a warning in all workplaces, 'the Government has determined that work absence may be harmful to your health'. That may help, even though it does not reduce smoking! None of this is new. Even Shakespeare said it in Macbeth, 'Present pain is less threatening than fear of future imaginings'. The imaginings that patients have that, 'Oh my God, I will become chronically disabled'. Does that not gives us a message. We need to spend more time telling them that that is not going to happen. We must take a good 'red flag' history - we know all these things and we are good at it, but we have to convey that to the patient. However, the new thing that has happened, and here I must give you the point Dr Jayson, is that we now have some yellow flags that we can work on, and that, I think, has been the major advance during the last 15-20 years. Poor health belief, never pain free, fear of activity or moving, previous long-term disability, frequent emergency treatment, whole body part numbness, whole extremity giving way. When you have these in patients after 3 or 4 weeks of back pain then we must concentrate more because then we know that these patients are far more likely to become chronic back pain sufferers than if these things are absent. There are a lot of minor points also, but this is the total of the collective research that has come out of the last, lets say 20-25 years. Much of this progress has come from British researchers, and this is what you have taught us to do. Look at the head instead of looking at the spine! There is
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nociception, undoubtedly, but there are also in everyone to a greater or lesser extent, psychological factors. Illness behaviour and social interactions are both important factors, but we have actually influenced the social interactions by saying that it is the bad workplace that gives them back pain, and the Press has taken it on from there and given a lot of information to people. But the whole workplace issue is a little questionable. There are ways of returning the patient to work later on, even after 1 or 2 months. We did a study at Volvo to demonstrate that a behavioural psychology activation programme returned people to work on average 3 months earlier than if they did not receive that, and the number of permanent disabilities later on was reduced by 80%. We also demonstrated that it had nothing to do with the actual demands of the workplace. Finally, I was able to convince the healthcare authorities in the city of Gothenburg that they should pay for a back pain clinic, run in a similar way. Three years later they gave us the same number of people who had not been sent to this back clinic, and the recovery rate differed significantly. Permanent disability was reduced in the back health clinic by something like 75-80%, and the average gain per patient was 159 days compared with those that did not go to this clinic. However, there was one exception. We failed completely in one group of patients. There was no effect in the immigrants, who could not understand what we were saying, which teaches us that we must do things a bit differently. We have to convey our message in a different way to these people or perhaps there are different sociological things. However, this is not biomechanics, this is not biochemistry. Rather it is some type of sociology and psychology. So, we have to distinguish efficacy, which is the result of a prospective, randomised trial intervention under ideal conditions, and effectiveness, the result of an intervention in routine clinical practice which was this back clinic. So, it is possible for us doctors to have some influence! But for the 3-4% in our societies now that become chronically ill, that is for 6 months or more, there is really not much hope. There is not a single good study demonstrating anything. If you look for studies that are presented on well
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defined patient populations with a pre-operative evaluation, a controlled clinical trial followed by an unbiased observer follow-up after 2 years after using all the forms, then they become very, very sparse. For instance, no study of fusion operations has shown better than 60% good or excellent results for primary fusion, this is for chronic low back pain. For repeat surgery it drops to 30%, and the number of patients made worse is 40%. So we are not doing very well with these things, although the spread of fusion operations all over the world is used as a strong marketing tactic. What we need, of course, are more and better controlled, prospective, randomised trials and to stop the fusions for back pain for which we do not know the cause. We know how to do outcome studies, and if you do not know, start reading the supplement in the 1994 volume of Spine. However, the worst thing of all is no one in this room knows what causes back pain. We have so many names, for instance facet syndrome, disproven by 11 scientific studies! Yet we do not know who has it! I am not saying that these things do not exist, I am just saying that we cannot prove that they are there. Degenerative disc disease is probably the worst misnomer I know because we all have degenerative disc disease, unless you are below the age of 18! Isolated disc resorption never properly validated. Segmental instability what is that? You cannot measure it from X-rays, indeed you cannot measure it at all! We do not know what we are talking about. A human being is composed of unstable parts, stabilised only by a healthy mind. Who said that in 1670? His name was Spinosa! So I will end by saying that despite 25 years of back pain research we have failed to diminish the back pain burden for society. Professor M.I.V. Jayson Have we failed to see the wood for the trees? Or, have we identified the issues which are important in our patients? When I looked back to where we were when I first started in back pain research and at the beginning of this Society 25 years ago, I had to acknowledge the fact that there was very little interest in the whole back
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pain problem. I used to start off by saying how back pain was a boring subject and generally regarded with a complete lack of interest in both rheumatology and in orthopaedic clinics and very little was done about it. In the early years of research there was great use of loose diagnostic terms. If we think back to 1971, surgery was commonly performed without a proper anatomical diagnosis, patients had some symptoms of back pain and maybe some pain in the legs and they mayor may not have had a radiculogram or a myelogram. Then they were given operations and some of them got better and some of them got worse, but nobody followed them up anyway so one did not know what was happening. Fortunately things have changed quite considerably over the years. We had this concept, at that time, of non-specific back pain and we still use these words today, but we are beginning to analyse this a lot more carefully. Non-specific back pain is a rather meaningless phrase. It simply means back pain for which we do not know the cause. As we have progressed we have begun to chip away at it and to understand much more clearly exactly what is going on in individual patients and we are now making specific diagnoses within this global entity. I look forward in the next 25 years to being even more specific about what is happening in these particular problems. In 1971, our research interests were very much involved in the structure of the spine and the Society was heavily involved in the biomechanics of the spine and the biochemistry of the spine, the structures of the collagen and how it related to function, we looked at how it moved, the ranges of speed and force of movement. We tried to quantify all these aspects and use these in the assessment of various techniques. For various treatments all sorts of trials were initiated and though most of these did not show anything very much, nevertheless this was the approach that has been present since 1971 and which I think has evolved significantly since that time. The progress that we have made since that time has been quite profound. First of all, we have developed validated methods for assessment of progress and we use a variety of questionnaires which have been proven. They are not just our own individual questionnaires, they have been
subjected to careful intra- and inter-observer. reproducibility studies and they have been related to function; physical tests likewise. Certain tests have become helpful and other tests have become less helpful. Imaging has been subject to critical analysis as well. We have developed a variety of techniques for X-rays and scanning and initially we were overwhelmed by the changes we saw. We looked at the black discs and we looked at the bulges and we thought these were the features of importance. However, we now have clear views about the significance of these changes and we know what we should take seriously and what is meaningful. We know that the radiological changes of spondylosis are common in symptomfree individuals and have a poor relationship to symptoms. We know about the changes that are seen in MRI scans and we know that extruded discs do have a correlation with back problems and sciatica and we know the figures that they may be found in symptom-free individuals. So we have identified exactly the significance of these changes and we are using them in a much more critical fashion. The difficulty, of course, is in delivery of this knowledge and perhaps we are not as successful as we might have been in getting the wider audience of society to appreciate the rate of current scientific advance. We have been interested in identifying and understanding specific syndromes and certain things are now very clear. For instance, the high intensity zone, the herniated intervertebral disc, the instability which may be seen in spondylolisthesis and so on; these are all well defined syndromes. I believe that as we study these patients more clearly, now using a different structure to our approach, we will identify much more clearly these specific syndromes. However, I think our standpoint for this type of analysis is going to have to change. The concept of back disability which we all use is a rather unsatisfactory term. It is an umbrella diagnosis - a global term which can be everything to nobody or nothing to everybody but which does not help the person who is disabled with back pain and is not actually giving a specific diagnosis. As we begin to understand much more clearly we are going to chip away at this vast group of disabled people and we are going to be able to analyse in much more specific
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detail exactly what is going on, but our viewpoint is going to have to change. For example, we have now got clear views on the psychological mechanisms which are present in many patients. There is a lot of evidence that has been presented at this Society and we are all familiar with the importance of these psychological mechanisms. Equally importantly we have the tests which allow us to identify these. They may be improved but, nevertheless, the standard test which we use in Manchester and which is used by many members of the Society is the Distress Risk Assessment Method and this does seem to be a very effective test for identifying depression and distress and also an altered cognitive function. We are looking at the neurophysiology underlying these mechanisms, and this clearly is the way we should be looking at the future. We are also appreciating the importance of altered perception in relation to nociception. In other words, there is a nociceptive influence, albeit relatively minor in some cases and major in others, but it is the perception of that which has become the critical factor in so many of our patients and this is enabling us to begin to identify the true significance of spinal pathology. We are now adopting a better technique for clinical trials. Twenty-five years ago we had all these uncontrolled studies and anecdotal case reports and we now know that we have to have a controlled study, we have to compare what we do with some alternative form of treatment in order to try to determine whether the treatment that we offer is of value or not. There are now well defined structures for constructing these trials and without these structures we know that the information in these studies is not of great value. Outcome parameters have been developed and functional assessments - return to work, use of healthcare resources - are all methods which are being used in terms of outcome. We have already heard from Professor Nachemson that these techniques are mandatory for a proper assessment of the outcome of various forms of treatment. I must draw your attention to the Clinical Standards Advisory Group Report on back pain because this has been a major turning point in this country, not so much because of the information provided to members of this Society but because it has become widely disseminated
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throughout the whole of the UK. Indeed it reflects what is happening in North America and in Europe, and this is providing a logical structure to treatment which helps us to understand what is going on. We have learned to triage the patients into simple back ache, nerve root pain and possible serious spinal pathology. We know about the early management and we know about the importance of physical activation and of early return to work. These are factors that we now know, where they were not known 25 years ago. Maybe the message has not got through to the politicians, but nevertheless, we in the Society are fully aware of them. We have also come to appreciate that psychological pain is real pain, it is not malingering. It is not an abstract non-specific process which is meaningless. However, these patients who have major psychological problems are very distressed and, if anything, they are perceiving their pain as more severe than that of purely organic pain. These distressed patients that we see are in much greater pain and distress than the patients with cancer or with crumbling spines, yet these are the ones that we understand. We have looked at the question of hypochondriacs and we know about neuroses, and about depression and so on and we see all these things and we learn to recognise them. We also know how litigation amplifies and prolongs pain and disability and our chairman has conducted an excellent study in which is shown the importance of this with matched injury patients, some of which are compensatable, others are non-compensatable and the compensatable ones have much more severe pain, distress, longer time off work, failure ever to get better and so on. Many of us have met the scenario where the disappointed patient has actually got better and no longer gets as much in the way of compensation. Epidemiological studies, I think, have helped to highlight these problems. There have been major studies conducted, not only in our unit but also elsewhere, which have highlighted the importance, first of all, of psychology and work dissatisfaction, previous back history, and last, and a long way least, the physical factors associated with a particular work and particular circumstances. These are major advances and are at the cutting
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edge of what is happening at the present time. Cross-sectional surveys and prospective surveys have looked at pain free populations and shown how distress and work dissatisfaction predispose towards the development and chronicity of back problems. So, there is good evidence about these factors which helps us to understand what is going on. These things are generally not for the patient with an extruded disc which is impinging on the nerve, the 1% of cases that the orthopaedic surgeon should be looking after. I am talking about the 99% which should be under the rheumatologist. One of my patients did her own pain drawing which was a fascinating glimpse into what she was feeling. She was a young girl with chronic backache and she came up with a terrible story of pain. Lots of jagged lines everywhere and she has not only drawn pain in her back but also pain in both arms, her throat is sore, she has a rash on the face, blurred vision, headaches, thinning of the hair, soreness in the glands, pain and stiffness in the arms, chest, elbows, fingers, wrists, hips and so on. This is a demonstration of the central pain perception which is occurring in these people and clearly this is very, very different from the herniated discs which we all love to think about. So the central pain is not an abstract process, It is an activation of the pain processing pathways in the brain and in the spinal cord. We are studying the dorsal horn and looking much more specifically at the NMDA receptors in the dorsal horn. There are drugs which are being developed which target these receptors and the trials of these drugs are just beginning and I am optimistic that they will lead to significant improvements in pain control in these patients. We also study the brain, especially the mid-brain, and the anterior cingulate region. There has been a shift in ideas about the understanding of chronic back pain and I believe that altered activity in the dorsal horn and the brain are going to be important in the future. We are beginning to understand what is going to happen in these particular patients. In the past we have had the scientists who go sticking needles into the nuclei of discs and measuring their pressures when they bend and twist and it is like the proverbial blind men examining an elephant! They each look at the various parts
of the beast whereas in fact you need to stand back and look at the whole beast and get a holistic view. Then you can see exactly what is going on and understand its mechanism. It is a new paradigm of approach because our paradigm is not a specific nociception, its the body's response in the altered central nervous system responses in a relation to that nociception which is the new approach to the subject. So, have we failed to see the wood for the trees? The answer is that we were looking the wrong way - all is now being revealed. In the last 25 years we have disentangled many specific syndromes. We have provided clear guidelines for management. We have understood the role of imaging. We have identified functional outcomes and back-to-work as prime importance and we have appreciated the fundamental role of psychological distress and we have identified neurophysiological mechanisms at the interface of peripheral nociception and pain perception. What we have not been very good at is convincing the public and our politicians about these issues but nevertheless, I think this is the way and this is the message that we are going to promulgate and this is the way forward. I think we cannot help but conclude that we are now, at long last, seeing the wood for the trees. Professor A.L. Nachemson -
rebuttal
Well, obviously, you heard that we both sang the same song so there is not much to debate. For the first time in my life I am willing to give in to this proposition. I think that we have made some progress but there is still much more to do. The main question is whether this knowledge is only in this room. I agree with you that we have failed completely to make it public. Of course what we have failed to do is to see what is happening in the disc. Most of us still believe that it is the collagen, or various other substances, that playa role here for nociception; nociception that can be modulated in various ways. However, maybe in the future the Human Genome Project will solve some of these issues when we know the expression of the various collagens that exist and can alter them in one way or another. Another thing that is not yet central is
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that we have to practice evidence based medicine. Evidence from randomised control trials are the only ones admissible. Not even good prospective, controlled trials can be put into something that is called the Cochrane collaboration. Of course, this was all started by a good British General Practitioner, I think he was Mr Archie Cochrane who said that it is surely a great criticism of our profession that we have not organised a critical summary of our care by specialty or sub-specialty, and this is certainly a sub-specialty, that is periodically of all relevance to randomised, controlled trials. I happen to run, together with the rheumatologists, the back subgroup of this Cochrane collaboration. We have reviews going on for all these various syndromes and soon there will be evidence saying that for this diagnosis, for example, traction is completely out. It will not be paid for! That is the only way you will change people's minds. Metaanalysis, as you all know, pools individual randomised, controlled trials together to arrive at an overall estimate of the effect of a specific intervention or a disease syndrome and that is being done now for all these things. This has come out already and saved thousands of lives already in Great Britain, in the 5 years it has been out. I can predict that the back pain study will save millions of dollars for any Government. By the beginning of the next millennium the whole picture will have changed more dramatically than it ever has before. It will not reduce back pain, I think, in the next millennium because back pain is a part of life. What it will do is to produce less back pain disability and less unnecessary treatmnent. Now, how do you change physicians' behaviour? It is very, very difficult. Financial penalties are probably the only way forward. Now, of course, there are already Government organisations that have been looking into this, how to diminish the problem by giving recommendations on treatment and looking at the availability. Certainly these attempts are guidelines but they are not put into law yet. Part of what we have missed is this border crossing thing. We have crossed countries, I am a Swede standing here, and there are international societies. We are certainly crossing specialty and discipline
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borders here in this Society but the failure has been, as Professor Jayson has already said, to Society and industry. We have failed really to bring out this information and influence them in a wider sense. So I want to end up by saying that we have to distinguish what types of support will contribute to our nations' future and which ones will undermine it. We have to tell the politicians that we all react to economic incentives, and that if they want to save some money for treating really sick people they have to make a decisions about how much is given in permanent disability and short-term disability. That is the harsh fact otherwise we will not have any money in the National Health Service or in our Swedish system. Finally, to save the industrial nations for the year 2000 and beyond we must diminish the impact of decreased age-related musculoskeletal flexibility by increased job flexibility. We all know that forestry workers cannot work until they are 60 years of age. It is too hard a job for their musculoskeletal system, induding the spine, so we have to give them something else, and that should be part of society's system. The Unions should also allow some changes with a little more salary for the latter part of life. We have to help society in this regard because these are biological facts and we are the biologists who tell them. Professor M.I.V. Jayson -
rebuttal
I think that what we have heard is that Professor Nachemson and I are both saying that we believe that we have advanced significantly in our understanding of back problems and I think we do have a much more holistic view on the whole problem. It is clear that our difficulty is in how we deliver this information to the public, to doctors at large, to our colleagues in related fields and particularly to Government. I personally would like to take this opportunity of paying a special compliment to Alf for his enormous contribution over the years that he has made towards back pain research and is continuing to make, for example the Cochrane Collaboration at the present time I think is going to be of fundamental importance for the future.
