Psychosocial Aspects and Work-Related Issues Regarding Lumbar Degenerative Disc Disease

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Chapter 190 Psychosocial Aspects and Work-Related Issues Regarding Lumbar Degenerative Disc Disease

There are few diseases that are so pervasive, yet so difficult to treat satisfactorily, as low back pain. Physicians are scientists first. Therefore, they look to treat diseases by making logical assumptions based on a group of clinical signs and symptoms combined with clinical tools such as imaging and laboratory tests. This is called the disease model of illness: the progression from signs and symptoms, to diagnosis, to treatment, to cure. Why then, is the diagnosis and treatment of low back pain so difficult? Few other disease processes have provided as much clinical material to the biopsychosocial model of disease as low back pain.

Over previous centuries, back pain was poorly understood, and the affected, unfortunate patients were left to go about life and deal with their pain. More recently, it was proposed that pain was a direct indication of tissue injury and that repair of the injuring mechanism would relieve the pain. It is now understood that some components of low back disability may be a manifestation of actual physical pain, but the vast majority of this may be due to the psychological reaction to pain. In his review in 1991, Waddell1 considered the history of low back pain and disability. Interestingly, the first reported case of low back pain was from the Edwin Smith papyrus in 1500 bce, and not much has changed about back pain since then. The first idea that back pain came from spine and nervous system dysfunction came from Brown in 1828.2 After the industrial revolution, the concept of back pain due to injury became quite popular.3 Changes in the law allowed individuals to benefit from compensation due to work injuries. By 1915, King4 declared that “pain in the back as a result of injury is the most frequent affection for which compensation is demanded from the casualty company.” This has certainly been expanded since that time, and low back pain continues to be one of the most common reasons for loss of work today.

The history of the development of various specialties in the medical profession also tells an interesting story with regard to low back pain. Development of the fields of orthopaedics and neurosurgery in the early 20th century has had a great impact on the role of back pain as a disease process today. As orthopaedics advanced as a specialty, the concept of rest for treatment of back pain came about. Prior to this, patients who had pain remained at work, and the concept of pain as a disability was unheard of. This was followed by the discovery of the ruptured disc by Mixter and Barr5 in 1934, which led to the revolutionary treatment of low back pain and sciatica with surgery. This trend has remained today with much controversy surrounding the treatment of back pain and discogenic disease by surgical means.

Epidemiology and Risk Factors

Studies regarding the epidemiology of low back pain are highly variable. This is not surprising—it is a condition that is highly specific to each individual patient. Survey studies are difficult because one patient’s perception of pain may be quite different than that of another. The incidence of developing a new episode of back pain has been estimated as low as 4% and as high as 93%.69 On the basis of larger longitudinal studies, this incidence has been estimated to be much lower, between 3% and 5% for episodes where patients sought medical attention. The incidence of back pain that did not require professional medical care was much higher, at 30%.7 Prevalence is difficult to study due to variance among study populations and the different factors that may affect the development of low back pain. Studies estimate that 15% to 20% of adults experience memorable low back pain within 1 year and up to 80% experience such pain over a lifetime.1013

In terms of age, back problems do not necessarily occur more frequently during the third to fifth decades. When they do, however, they are certainly more often related to claimed disability during this period. These are the prime working years, where low back pain leads to the greatest disability and days off work. Interestingly, the symptoms of low back pain do not become worse with age-related degeneration of intervertebral discs.1,1417 Back pain in the elderly is thought to be one of the most important factors to affect the individual state of health.18 Similar to younger adults, the prevalence of back pain in patients older than 65 years of age is 13% to 49%,19 but this pain seems to be more episodic and intermittent with a lesser occurrence of chronic pain.20 Despite the relatively high prevalence of abnormal curvature of the spine in adolescents, the chance of these children presenting with low back pain is quite low. Some studies suggest that the peak age for development of back pain in children is 13 to 14 years and that beyond this age, the risk factors for developing back pain in adults also apply in children.2123

Risk factors for the development of low back pain are demographic, physical, socioeconomic, psychological, and occupational factors. Many studies of these risk factors are small and include only self-reports of the variables. A review by Hildebrandt discusses 55 personal factors and 24 occupational factors that have been linked to low back pain.24 Many studies have looked at the relationship between socioeconomic status and level of education and the development of back pain. The association seems to be not so much with the incidence of pain but with the ability to adjust to pain. The incidence of disability from back pain appears to be 22 to 25 times higher in patients with less than 7 years of education compared with those with college degrees.25

Observations Regarding Low Back Pain and Disability

First, it is important to differentiate between pain and disability. Both are related in that they are generally subjectively relayed by the patient and are not viewed the same in any two patients. There is no objective measure for either of these disorders. Disability is related to the patient’s perceptions and attitudes about pain26,27 and may be based on avoidance based on previous painful experiences.1,28,29 Many people live with low back pain, and few patients view this condition as a disability.

It is also useful to discuss the difference between acute and chronic pain. Acute pain often bears a close relationship to an inciting event and may be thought to stem directly from tissue injury. Chronic pain, on the other hand, is often a behavioral adaptation of an individual who may or may not have had an initial injury. This bears very little relationship to physical injury and is very difficult to treat by medical and surgical means. The failed back syndrome is indeed closely related to this concept. Chronic pain becomes a syndrome of emotional distress, depression, and disease conviction.1 If these patients are taken to surgery under the misconception that their pain is actually related to tissue injury, they are virtually never cured and are often made worse. Surgery in these patients also plays into the “sick role” and gives them further reason to take time off work and to claim that they are disabled. These patients often clog pain clinics and spine clinics and place a heavy burden on the health-care system.

Despite low back pain and sciatica taking center stage in many medical circles today, there is no evidence that the biology of the problem has changed at all over the years. Back pain is the same as it always has been. It is low back disability that is a new concept. Ninety percent of patients with low back pain become better within 6 weeks in spite of technologically advanced medical and surgical care, or interestingly, no care at all.1,15,30,31 This is likely a product of the explosion in the size and complexity of the health-care systems of Western countries and individuals’ perceptions that the abilities of modern health care should be able to end pain. Physicians bear some responsibility in this regard because it is they who certify patients with pain to be excused from work, thereby feeding into the concept of low back disability.

Perhaps the most referenced expert to publish on low back pain and disability is Gordon Waddell. In his book The Back Pain Revolution,32 he discusses his time spent in Oman. At the time of his writing, Oman was an emerging, primarily developing country. In the mid-1980s, new oil money soon brought modern medical treatments to this country. At the time, patients with back pain flooded into the newly established clinics seeking treatment for their pain. These patients had very similar problems with similar etiology to patients in developed Western countries. The interesting part is that nearly none of them were off work or “disabled” as a result of their pain. Waddell’s observation was that the patients who were able to escape the confines of their country to have “modern” medical procedures in other countries became disabled after surgery at a much higher rate than those who did not have access to modern medical care. This is another illustration that suggests that low back pain is nothing new but that low back disability is largely a product of modern Western medicine.