Book Review

The Back Pain Revolution

N Engl J Med 1999; 341:545-546August 12, 1999

Article

The Back Pain Revolution
By Gordon Waddell. 438 pp. New York, Churchill Livingstone, 1999. (Distributed by W.B. Saunders, Philadelphia.) $60. ISBN: 0-443-06039-8

If we are ever to make substantial progress in reducing the burden of disability from back pain in developed countries, credit will be due Gordon Waddell and a small group of persons who, through their insight and research, have helped forge a new paradigm for the care of patients with back pain. Waddell is an orthopedic surgeon from Scotland who came to the realization during his clinical training that the medical model of back pain was inadequate for evaluating and treating many patients. Over the next two decades, through clinical observation, his own research, and the research of others, Waddell developed a new model for treating patients with back pain. The Back Pain Revolution is the culmination of 20 years of effort.

This is not a typical book about the back. There is, of course, one chapter on the clinical course of back pain, another chapter on the physical basis of back pain, and a chapter that reviews the scientific basis for various treatments. The book contains all of the usual descriptions of the various physical findings in patients with back pain and the maneuvers one would consider using for them. Most of the book, however, is devoted to an explanation of the social and psychological nature of back pain. The message of the book is as follows. Humans have always had back pain, and it is no more common or severe now than it was in earlier times. What has changed is the way in which we understand and manage back pain. Three key ideas developed in the 19th century — back pain comes from the spine and involves the nervous system, is due to injury, and should be treated by rest — laid the foundation for the current approach to treatment. This approach has not solved the problem of chronic disability attributed to simple backache in Western countries and may even have contributed to it. Waddell devotes much effort to supporting these statements and laying out ways to rectify the situation.

It was Waddell who first pointed out to me the differences among back pain, disability due to back pain, and lost work as a result of back pain. These three concepts are frequently used interchangeably, yet the correlation among them is actually not large. Waddell convincingly argues, on the basis of both the scientific literature and his own clinical experience, that it is primarily the social and psychological milieu that defines disability and lost work as a result of back pain. He also argues that much of recent medical therapy has helped contribute to the increase in reports of disability resulting from back pain. He cites several specific examples. One of them is the now discredited concept that the proper treatment for acute back pain is complete bed rest. A second example is the overreliance on surgery in an attempt to treat back pain that lacks a clear anatomical cause. A third, more subtle influence of modern medical care is the way in which we communicate with patients who have back pain. All too often we tell patients that their back pain is most likely the result of an injury or degeneration of the spine, that the pain is a sign that there is something wrong with the spine, and that activities that cause pain are to be avoided. All these statements contribute to patients' perception that back pain is a serious problem caused by misuse or injury and that any activities that cause pain may both prolong the problem and contribute to the development of crippling disability. No wonder our patients are becoming increasingly disabled by back pain.

Waddell's central message is that we need to stop over-medicalizing back pain. Through a careful history taking and physical examination, and the use of certain imaging procedures when needed, clinicians can safely distinguish patients with simple backache who are best treated by primary care physicians with minimal intervention from patients with more serious conditions that need the attention of specialists. When patients with a simple backache are not recovering as quickly as expected, careful attention must be paid to their social and psychological environment in order to help determine who is likely to need more aggressive intervention. For such patients, therapy that aims to keep them as active as possible and get them back to work as quickly as possible is the goal, even in the presence of continued pain.

As Waddell states, once back pain becomes chronic, the therapeutic options are extremely limited. In a chapter entitled “Approaches to Chronic Low Back Pain,” he describes several therapeutic options but acknowledges that although these approaches seem reasonable, there is not yet proof of a very effective treatment for chronic, intractable low back pain and disability. Prevention is better than treatment in the case of chronic disability due to back pain.

It is at the level of primary care that the effort needs to be made in order to reduce the risk of disability from back pain. This book, or at least chapters 1 and 14, should be mandatory reading for all clinicians who deal with the primary care of patients with back pain. If we all practiced as Waddell suggests, perhaps the 20th-century epidemic of disability from low back pain would be consigned to medical history, rather than continue to plague us into the next century.

Paul G. Shekelle, M.D., Ph.D.
West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA 90073