Superdoc - Fighting fear and back pain
I remember my first year out of Superhero School; the pleats of my cape still perfectly creased and vibrantly coloured, I was full of exuberance, confidence, readiness. Until I encountered my first villain. Then this little feeling, subtle like the minutes passing, began to grow inside me...
Fear is debilitating. You learn it on your first day at Superschool: 1) stay away from kryptonite (whoops that's the other guy) and 2) fear gets you nowhere fast. This of course is easy to teach, but difficult to employ.
At the turn of the last century the most common cause for low back pain was tuberculosis of the spine. The only treatment available at that time was rest, and this is how advice to rest for back pain came into being.
Researchers then discovered the disc some decades later. It was about the same time that compensation was first being paid for back injuries for people working on the railways, suffering what was then called ‘railway spine'.
Over the last century we've come a long way, but there are huge gaps in our knowledge and understanding about back problems. We've researched, x-rayed, scanned, tested and tried an enormous range of different treatments. We keep looking for a cure for back pain.
If you go to the doctor with a headache you don't want to know whether you've got ‘tempero-mandibular joint dysfunction' or ‘occipital neuralgia'. You know you've got a headache. You might want to make sure you don't have a brain tumour, or that it's nothing serious; but that's usually it.
Fundamentally you don't go searching for a more definitive diagnosis.
When it comes to back pain it's the opposite. People want to know the cause of their problem. They want to know if it's a facet joint or a disc – they want the doctor to be specific.
Back pain is just as common in Indonesia as it is in Argentina, Germany, the US or Iceland. What differs between countries is the degree of disability. If you have a back problem in Nepal or Malaysia your outcomes are better. There aren't tests and rarely treatment. People have to return to activity quickly – and they don't seem to worry about back problems.
Peter Honeyman, an occupational physician, published a fascinating article in the journal Spine about twenty years ago. He studied the beliefs of the Indigenous Australian population regarding spinal problems. Interestingly, neck pain had significant connotations but nobody worried about back ache.
Yet in the broader community back ache is a level of high concern. People continue to worry about their back problem.
Cultural factors play a significant role in the outcome of back pain. People's level of fear about their back problem is an issue that is poorly recognised. Many believe that a back problem is bad and dangerous, and that it may well stick around forever.
Medical evidence tells us otherwise.
Medical evidence tells us that 25% of back problems will take a year or two to settle, but that for most people the outcome is good. One in six people in the community have a long-term back problem; it's common in doctors, bank managers and even professional writers.
Brick layers are going to have more trouble doing their job if their back's playing up, and a plumber might find that they can't do certain activities when their back is bad. In contrast, however, the bank manager can probably continue to work even with a nasty level of back ache.
One of the best researchers on back pain had a back problem himself. He said he could climb the fence to get to his work place as he'd walk to work, but he couldn't sit. He worked for the next nine months standing up until his back problem settled. But he understood about back problems and he didn't fall victim to unproductive worrying.
Two patients come to mind. The first is a chef who has had back problems now for six months. When I saw him at my practice he was obviously worried. His back problem had been settling and then flared up (as back problems tend to do), and when the flare-up occurred he was fearful that this indicated he was going back to square one. He was highly concerned about the fact treatment wasn't making a difference, and had a significant level of anxiety that he was going to have to give up his job – a job he loved.
In fact, his situation was common, normal and highly likely to settle down over time. But there was considerable pressure to find treatment that would work; he was attending two different practitioners and having treatment three days a week. It was no wonder he was worried his back wasn't improving.
The second person was an anxious lady working as a personal care attendant. She'd been referred to a specialist who suggested that she was not ready to return to work, not even on modified duties. He suggested that she might never be able to return to her normal job in the future, despite her back pain only being present for two months.
Misinformation creates fear. Fear stops progress.
People with back pain need good advice and explanations. Providing this with regards to a back problem takes time. There are not many practitioners who will spend the time advising and educating the patient about their problem. There's a lot of demystifying to be done, and a lot of unravelling of beliefs and misunderstandings. The system doesn't pay practitioners for spending time with patients, and there's no good system in place for referral to centres where clear advice and explanation is the foundation of management. Medical payments support short-term consultations, or interventionist treatments such as injections or surgery.
People with back pain deserve better than they are getting at the moment and there's a crying need for services that give them the advice and explanation that many studies have shown they want and need. These are the things that actually make a significant difference in improving outcomes.
When I do guest lectures at the International Academy of Superhero Super-learnings, the first thing I always say to the kids is, ‘The less you worry about the villains of the world, the less they can worry you'. Then, when they look at me blankly, I remind them of the lion in the Wizard of Oz who thinks he's a coward but – in the fleeting moments in which he forgets his perceived inability – he can actually jump great chasms and fend off ferocious animals… Sometimes the students still look at me blankly, but I like to think that as they're flying home the profundity of the metaphor gives them a lift.