Belief reinforcement: one reason why costs for low back pain have not decreased.

Recent figures show that there has been no change in the upward trend of direct and indirect costs for the largely benign symptom of low back pain in Western societies. This is despite greater understanding and the recommendation of a much more conservative and independent approach to its management. Moreover, in recent years, several large-scale education programs that aim to bring knowledge of the public (including general practitioners) more in line with evidence-based best practice were carried out in different countries. The hope was that the information imparted would change beliefs, ie, dysfunctional patient behavior and biomedical practice on the part of clinicians. However, these programs had no influence on behavior or costs in three out of the four countries in which they were implemented. It is argued that one reason for the overall lack of success is that it is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of "hands-on" providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.

A note to the musculoskeletal physiotherapist.

Musculoskeletal (formerly manipulative) physiotherapy is widely used for the rehabilitation of patients with common musculoskeletal pain and related disability. As part of its progress from largely empirical beginnings to becoming basic sciences informed this sub-specialty of the physiotherapy profession has developed a profound interest in pain mechanisms, causal and therapeutic. It is of some concern, however, that the use of pain terminology and classification among the fraternity has tended to be typically idiosyncratic and at times inaccurate. This is not only confusing to followers of the wider medical science literature. It also compromises clear communication between the physiotherapist and fellow orthodox health care professionals. This 'note' restates the acknowledged pain terminology and its applicability to recognised pain categories.

There's something about passive movement...

The recognised (funded) stand-alone clinical status for therapeutic methods of passive movement has become increasingly threatened in recent times as the preference for active treatment (specific exercise) gains hold. This is in part due to the equivocal results for clinical trials of passive movement, queries regarding its cost-benefit and negative findings for many of the fundamental claims and recommendations of its clinical process. Linked to these issues has been the profession's difficulty in demonstrating plausible science-based mechanisms for anything more than transient effects. The present proposal is that the manual application of graduated oscillatory tensile loading to healing (or unhealed) soft tissues in the form of passive movement could facilitate optimal repair and tissue integrity (and so protection against subsequent 'stress'). The mechanism depends on the intrinsic ability for non-excitable connective tissue cells to 'sense' mechanical stimuli and to transduce mechanical into chemical signals. This leads to gene transcription and subsequent adaptive remodelling of the extracellular matrix (ECM). An outline of these events is given, emphasising their dependence on the effective interplay between internally (cellular) and externally (matrix) generated mechanical forces. In principle, it ought to be possible to investigate the proposal and other clinical passive movement issues using modern soft tissue imaging and biological techniques with suitable human subjects and animal models.

The late whiplash syndrome: a psychophysical study.

Some patients who have sustained whiplash injuries present with chronic widespread pain and mechanical allodynia. This single-blind, case control matched study of 43 chronic whiplash patients sought to examine psychophysical responses to non-noxious stimuli and their relationship to psychological profiles. Symptom Check List 90-R (SCL-90-R), Neck Disability Index and Shortform McGill Questionnaire were completed prior to testing. Qualitative stimuli comprised light touch, punctate pressure, moderate heat and cold. Additionally, sustained vibration was administered using a vibrameter which allowed ramping of either frequency or amplitude. Twenty-eight patients reported vibration-induced pain. No control subject experienced pain in response to vibration. No significant differences in perception threshold to vibration were noted between patients and control group. Twenty-three patients and ten control subjects reported painful responses to cold. Eleven patients and nine control subjects experienced pain in response to moderate heat. Four patients rated punctate pressure and one patient rated light touch as painful. SCL-90-R profiles revealed an overall elevated level of distress in the whiplash group. No significant difference was found between patients with and without vibration-induced pain for any dimension of the SCL-90-R. Pain in response to non-noxious stimulation over presumably healthy tissues suggests that central mechanisms are responsible for ongoing pain in at least some whiplash patients. The additional findings of pain on punctate pressure and hyperalgesic responses to heat and cold stimuli are consistent with enhanced central responsiveness to nociceptor input. These results have important therapeutic and prognostic implications.

Structure-oriented beliefs and disability due to back pain.

The modern costly epidemic of disability due to back pain is considered to be effectively the result of various beliefs as to the cause, and therefore appropriate management, of this commonplace, generally benign and self-limiting symptom. Prominent is the belief that spontaneous or provoked pain is evidence of some problem with the structure of the spine. As such, along with therapeutic rest, the logical means of relieving pain would be with interventions which actually or purportedly influence structure. Evidence is discussed endorsing the existence, likely origins, potency, fallacy and dysfunctional consequences of this view in the context of the unique 20th Century phenomenon, chronic disability following non-specific back pain.