The Problem of Using An Outdated Model For Back Pain
Chronic back pain severely reduces quality of life and is one of the most common reasons people visit their doctor.
Despite this, back pain
is something that is poorly understood. The main reason for this is most people, including doctors and therapists, are still operating on an out-dated model of pain that stems back hundreds years!
The Cartesian model of pain was original proposed by 17th century philosopher Rene Descartes . While revolutionary at the time, modern science and real world evidence, has proven it to be incorrect. Unfortunately most people are still influenced by it. This leads many people to unnecessarily suffer with back pain and other types of musculoskeletal pain.
In the Cartesian model, pain is created as a result of damage to bodily tissue by some type of trauma. The trauma could be from a rolled ankle, heat from touching a hot stove, whiplash from a car accident or any other type. The body then reacts to the damaged body part with pain sensations.
While pain does often occur when there is trauma and tissue damage, this doesn’t mean that one causes the other. This s a correlation rather than a causation. It is entirely possible to have tissue damage without pain and no tissue damage with pain.
In 2015, Brinjikji et al. performed a systematic literature review of imaging features of spinal degeneration in asymptomatic populations. They found that the incidence of spinal degeneration ranged from 36% in 20 year olds up to 96% for those in their 80’s.
What this means is that the older you are the more likely you are to have degeneration or tissue damage. This type of research shows us that the Cartesian model is wrong. If millions of people are walking around with spinal degeneration and no pain, there must at the very least be other contributing factors to back pain.
The reason this is so important is that if the person in pain and the people treating them both work from an incorrect model, there is very little chance that the person will ever become pain free. This is evident from the number of opiod medications that are prescribed each year and the amount of money that is spent on different types of manual therapy. There is literally a whole industry for both, yet the numbers for back pain keep rising.
In a typical scenario a person experiences back pain and goes to visit their doctor. The person visiting the doctor believes that pain is being caused by something in their back that has been damaged, like a bone, ligament or muscle. So they request some type of scan to confirm their suspicions. The doctor, who also believes that the back pain must be the result of tissue damage, orders an X-ray.
In instances where the x-ray comes back with a visible finding like disk degeneration or a bulging disk the conclusion is made that the degeneration is the cause of the pain. This is despite the fact that scientific research proved this to be incorrect years ago.
In 2003, Pearson et al. did a cross-sectional study correlating degeneration of the cervical spine with disability and pain. They found that there was no difference in pain severity between those with and those without cervical degeneration. According to the findings, the number of levels of cervical degeneration and the severity of degeneration in the discs, facets, and uncovertebral joints are not related to the levels of pain.
But what about if the x-ray comes back clear, as it often does? In this instance, the most likely scenario is that the person in pain will request further imaging in the form of an MRI. More often than not the sufferer will be placed on the long waiting list. Once again, despite knowledge that the findings of MRI do little to help the patient outcome.
In their 2011 guidelines the American College of Physicians state “Good evidence indicates that routine back imaging is not associated with clinically meaningful benefits and exposes patients to unnecessary harms, but still remains overused.”
Generally while on the waiting list people are recommended treatments from chiropractors, physiotherapists and massage therapists. While these treatments can provide temporary relief they generally don’t provide a permanent solution.
When a therapist releases a tight muscle, or massages an area, they are still thinking with the Cartesian model of pain. They believe that the tight muscle or mechanical abnormality they have identified is the cause of the pain.
This does not discredit these professions; manual therapy is an extremely useful and valuable tool in the right place. If through trauma, a vertebrae has become displaced a skilled Chiropractic can resolve this issue very quickly. The realignment of the spine will result I a quick resolution to the pain.
Likewise therapy can help to reduce the acute pain associated with an injury to the back. After trauma muscles tend to go into spasm and a skilled massage therapist can help to relax these areas providing relief. The physiotherapist then provides a corrective program to help strengthen the person and get them back to their daily activities.
The problem arises when these treatment modalities are employed for chronic pain. It is not uncommon for people to spend tens of thousands of dollars trying to get relief from their pain. In the above examples were talking about acute injuries. It is important to remember that tissues have healing times. If you damage a ligament, tendon, bone or muscle the tissue only takes so long to heal. Normally all tissues heal within 12 weeks. So it is not reasonable to lay the blame for pain on the tissues after this point.
But what happens after when the person finally gets to the end of the waiting list and has an MRI? There are a couple of ways this could go. The first is that the MRI shows some kind of anomaly. In which case once again the finding is used as confirmation of the cause, contrary to scientific evidence. The back pain sufferer returns to manual therapy medications for short-term relief.
The other way this can go is go is that the MRI can come back clear. Now without any source a physical pain the finger often gets pointed at the patient, for making things up. Or the pain “being all in their head”. This situation is often the most problematic for everyone involved.
Beyond the 12-week mark pain becomes chronic. At which point the cause of the pain lie in the neural and chemical signalling process. All the therapy in the world will do little to help chronic back pain unless it addresses the types of messages that are being sent back to the brain. After all the brain is our bodies control centre and where pain is actually felt.
Fortunately, there are ways to address these signalling issues. If you would like learn more the best thing to do is come in for a free session. Simply click the button below then fill out the free session questionnaire and we will call you to find a time that works.
Brinijkii, W., Luetmer, P.H., Comstock B3, Bresnahan, B.W., Chen, L.E., Deyo, R.A., Halabi, S.,Turner, J.A., Avins, A.L., James, K., Wald, J.T., Kallmes, D.F., Jarvik, J.G.2015, Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, v. 36, p. 811-816
Koes, B. W., van Tulder, M., Lin, C.-W., Macedo, L. G., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific back pain in primary care. European Spine Journal, 19(12), 2075-2094.
Peterson, C. Bolton, J, Wood, A.R., Humphreys, B.K., (2003) A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United kingdom patients. Spine, Jan 15;28(2):129-33.
DesCartes, R. (1633/2003). Treatise of Man. Amherst, NY: Prometheus.