Below, a guest-post by Dr. Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America and , more recently, Stabbed in the Back: Confronting Back Pain in an Overtreated Society. I admire both books because they are so well-written and richly referenced..
Hadler is Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and Attending Rheumatologist at the University of North Carolina Hospitals.
His commentary on “The Predicament of Backache” is adapted from, Stabbed in the Back. It puts my posts on spinal surgery in a larger context, illustrating how “cutting” is not always a cure for life’s problems
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To live a year without a backache is abnormal. Here, I am speaking of the commonest form of low back pain: the backache that bedevils working-age adults who are otherwise totally well. This is a pain that does not involve the legs, and that comes on suddenly, seemingly without cause.
Low back pain is one of many recurring predicaments of life, like heartburn and heartache. To be well is not to be spared. To be well is to have the wherewithal to cope till the pain goes away, cope so well that the episode is not even memorable.
Low back pain relates to posture and movement. It hurts less recumbent. It hurts more slouched forward in a chair or propped up on pillows, let alone bending over. One is forced to choose between less pain and less invalidity. Compelling science says less pain is not worth it. Feeling useless just enhances the suffering without enhancing the rate of healing. Take an over-the-counter analgesic and get on with life as best you can.
Low back pain will go away, but seldom overnight. Weeks are more like it, and months for a few. One should never despair. Nor should one feel so desperate that one grasps at straws. And there are many offering straws, many who would gird your loins, empty your pockets, push pull and poke you, offer you potions and pills, and attempt to excise the evil.
This response to back pain serves as an object lesson. We live in a time when science seems to be bursting with promise. Details of the very latest for diagnosis and treatment find their way into the headlines of print media and the features of broadcast media. We are told to expect cures. All of us respond with baited breath, some with speculative investing. Yet if we give way to the promise of cure, we risk compromising our sense of well being, our belief that we can cope. We succumb to what some call the medicalization of life, brought to us by an industry dedicated to the proposition that none of us are well.
Realize that despite all the jargon, there is no one who can reliably pin point the cause of the common backache. Realize that despite all their theories and all you hear on the street, no one has a “modality” they can apply to you that can be shown to benefit you. All these helpful people are engulfing you and your pain in their frame of reference, in their belief system. You will no longer suffer alone. But your narrative of illness will change, as will your self-image, permanently. Despite these ministrations, you will not return to your prior state of well-being any more rapidly. If you return at all, you will greet any recurrence of the back pain with idioms that were taught to you. If all this is a pleasing prospect, go for it. But do so informed.
Granted, for some of us, coping becomes impossible. Certainly, that could reflect the severity of the pain. But science informs us that another explanation is far more likely. It is not the pain, but other aspects of life that blunt our coping skills. Leading the list of confounders are adverse aspects of life at home or at work. If you can not cope any longer, find someone trustworthy to discuss the possibility that the pain is surrogate for some assault on your coping skills. In all likelihood, you coped with similar predicaments in the past. If you are unwilling to countenance the possibility that something in life is more a pain than the pain in the back, you run the risk of feeling so desperate that you submit to pills, potions, magical thinking or ineffective surgery before you come to grips with your psychosocial adversity. Surgery can not excise an intolerable job, nor can an intolerable home situation yield to manual therapy. Don’t let the pain cloud your thinking. Don’t let preconceived notions lead you astray.
That’s low back pain, 2011.
I’m not much of a post-modernist, but I agree that, in some instances, disease is more a social construct than a pathological entity. Typical low back pain is one of those instances.
Chris–
Good to hear from you.
And yes, I agree that back pain is a “social construct.”
I also think that many of our aches and pains are compounded by stress–if not caused by stress. And the only cure is to remove oneself from the cause of streas.
(In my case that means close the lap top, go out on the terrace and begin gardening. Just the act of going out on the terrace, sometimes makes me feel that someone has just taken a load of bricks off my chest.)
great post
I think the cause of back pain is our having had to stand up as a species evolved from going about on all fours. I once read the length of our thighs, from hip to knee, is what forced us to stand up. But our skeletal structure, particularly the spine, didn’t evolve with that and so standing up, and gravity, does its dirty do. I profess absolutely no claim to any medical or scientific support for this.
Thanks Maggie – from a “Charter Hadlerian”
I hope Nortin Hadler gets appointed to advise Don Berwick but Nortin may be too far ahead of the mainstream pack?
Dr. Rick Lippin
Southampton,Pa
Years ago I supervised a woman who had a lot of aches and pains that often prevented her from arriving at work.
In a bit of youthful foolishness I took the tact of suggesting that she an over-the-counter analgesic and get on with it.
She raised this issue a level, and instead of me appearing to me commited to work and the productivity of my team I appeared insensitive and inaapropriate. I took a new job and got on with it and she remained, if you can can call her sorry state of attendance remaining.
That experience left me convinced that telling other people that their aches and pains are “normal” and they should get on with it is not a winning strategy. I didn’t hesitate to continue to do this with my own children, but that’s a different type of relationship.
My feeling is that people make better choices when something objective, like their pocketbooks, bears the stress. If people want to pursue “cures” of dubious quality it’s fine with me, but I think they have to pay themselves.
seo company,Tom, Dr.
Rick, Ginger$
seo company– thank you.
Tom
Very glad to hear from you.
I, too, have no idea why humans are so prone to back pain.
Your explanation is at least ss good as others that I have heard.
But whatever the reason, it does seeme to me that, as Hadler says, backache,like heart burn of heart ache is simpliy part of the human condition.
Ginger R.
I think that your attempt to help that patient was admirable, and I’m very sorry that your institution didn’t support you.
As you have become more experienced, don’t you find that some patients would be more open to counseling than others?
Of course some people just don’t want to hear what you were trying to tell your patient. They will just become incensed.
In my experience, people who are terribly obssessed about their health will pour money into treatment that they don’t need–even if this means doing without other things that would be good for them . . .
They just can’t accept the fact that everything can’t be cured (particularly the aches and pains that come with aging–which is no fun– but inevitable.)
So I’m not convinced that requiring that they pay higher co–pays or deductibles for unnecesary treatments would solve the problem. (And higher co-pays will mean that some less affluent people won’t get care that they do need.)
Perhaps we should charge higher co-pays for clearly ineffective care. ..But I think we should simply refuse to pay for ineffective care all together. (If somone wants to pay the whole bill out of pocket, fine.)
My guess is that doctors are the key to thsi problem. If doctors beocme more conservatie about the treatments they recommend (bassing their advice on the best clinicaxl evidence available) most patients will follow their lead.
In those many “gtey areas” of medicine where a doctor can’t be sure whether the more aggressive treatment makes sense, “shared decision making” seems to me the best answer.
The doctor should outline what we know about teh potentiall benfits and risks of the treatment in question, and encourage the patient to express his own priotities. What does he hope for? What is his greatest fear? How woUuld he deal with the possible side efects?
Ideally, the patient and the doctor woudl make the decision, together, based on what the doctor knows about the medical evidence, and what the patient knows about himself.
Bach pain or backache is something which is causing a lot of difficulties to those who are working on chair by sitting at one place for a longer period of time
Low back pain related to the position and movement. It hurts less recumbent. This is hurting more slouched forward in a chair or supported on pillows, let alone bending and more. One is forced to choose between less and less pain of invalidity.