Preface - yearbook one - louisgiffordachesandpains



Preface

The physiotherapy and medical professions involved in pain diagnosis and management are facing major challenges. These are exciting times that should reap the rewards of the mature and well controlled research that is now available. Our professional profile can only benefit if we start to show that we are acting on the knowledge and messages coming from this high quality work.

In a very timely editorial to the journal ‘Pain’ Steven Linton (1998) persuasively argues the case for the instigation of early preventative programmes in the management of acute low back pain: .....“we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8-fold as compared to ‘treatment as usual’. The program included a thorough examination by a doctor and physical therapist, information designed to reduce fear, uncertainty and anxiety, self-care recommendations, and the recommendation to remain active and continue everyday routines”(Linton 1998). He also makes a plea for the early instigation of adequate pain control since it is well established that intense pain in the acute phase of a disorder is a significant risk factor for chronicity. He bluntly points out that if ‘medical’ risk factors such as ‘pain intensity’ are being missed by clinicians, then ‘what kind of job is being done with ‘yellow flag’ risk factors?’. ‘Yellow flag’ is the term used to represent the psychosocial factors which have been shown to be powerful and very useful predictors of chronicity and poor outcome for treatment (see Kendall et al 1997). They have been shown to have far greater predictive power for a poor outcome than many biologic/structural/anatomic/biomechanical/pathology based findings. These psychosocial yellow flags need our understanding and attention.

Linton (1998) highlights the work of Indahl and colleagues (1995) whose recent paper title is in itself great food for thought: ‘Good prognosis for low back pain when left untampered. A randomized clinical trial’. What they did was provide a straight-forward and low cost intervention for people off work more than 8 weeks because of back pain. Firstly they provided a ‘classic clinical examination by a physician’, tested physical capacity, and took X-rays. The patients were informed about the findings and advise was provided. Patients were told that ‘light activity would not injure the disc, but instead would speed recovery’. This message was given even where discs had verified herniations where surgery was not recommended. They placed great emphasis on removing fear about the back pain and specific recommendations about movements and lifting were provided. In their randomised clinical trial this ‘minimal’ treatment was shown to significantly reduce sick leave as compared to the control group and the return-to-work rate was more than twice as high in the intervention group.

Linton (1998) notes seven common features of the highly successful programmes for acute or subacute low back pain he reviewed for the editorial:

1. They all appear to take a multidimensional view of the problem. A major emphasis is placed on the psychosocial aspects of the problem e.g. fear and worry involved.

2. A thorough , but ‘low tech’ examination is provided.

3. After the examination, time is taken to communicate the results to the patient. i.e. why it hurts and provision of advice as to how to best manage the problem.

4. There is an emphasis on self-care. ‘that the patients behaviour is an integral part in the recovery process’. But also, the use of effective drug therapy and/or non-drug therapy to help control the pain is seen as vital. Linton notes that reducing pain appears to lessen fear and other psychological factors that may ‘fuel long term problems’.

5. There is an attempt to reduce any unfounded fear or anxiety concerning the pain

6. The programmes provide crystal clear recommendations concerning activities and in some cases help patients regain function by providing graded exercises.

7. The programmes do not medicalise the pain. By this he means for example: the indiscriminant use of high tech exams, referrals as a starting point, sick certificates of more than a few days, providing extensive prescriptions, or advising the patient to ‘take it easy’ or bed rest.

This yearbook is about starting to understand pain and its management using whiplash associated disorders rather than low back pain as a vehicle for discussion. Even so, the practical messages that Steven Linton brings to us are largely the same. This yearbook is about starting to understand some of the neglected but very powerful factors that enhance and maintain physical disability - the patient’s beliefs, their fears and their anxieties about movement, about structure and about pain - and how we may begin to challenge these beliefs and help the patient to restore their physical confidence. It is also about how we must be aware that our interactions can just as easily help as hinder the patients progress and that we need to be fully aware of the delicate nature of the therapeutic relationship.

I believe that pain, in particular chronic pain, is one of the most difficult challenges in medicine. I also believe that physiotherapy has lacked the respect it deserves for its efforts in trying to tackle this vast and complicated area. I hope that this yearbook is a beginning that reflects the hard work and unique clinical awareness of the many physiotherapists who are dedicated to seeing that things change for the better.

Thank you to all the current contributors, I hope your high standard of work serves as a challenging benchmark to the contributors of our future yearbooks.

Louis Gifford

Editor

April 1998

References:

Indahl A, Velund L, Reikeraas O 1995 Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 20(4): 473-477

Kendall N A S, Linton S J, Main C J 1997 Guide to Assessing Psychosocial yellow flags in acute low back pain: Risk factors for long-term disability and work loss. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee, Wellington, NZ

Linton S J 1998 The socioeconomic impact of chronic back pain: is anyone benefiting? Pain 75: 163-168

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