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A Paper Presented At The
American Back Society Conference In Los Angeles, California on December 3, 1994
At the August 1994 Meeting of the International Society for the
Study of The Lumbar Spine, a presentation was given by Drs. Tom and Ane Bendix
of Denmark's Copenhagen Back Center. They reported that "higher low back
pain impact is achieved by an intensive multidisciplinary program that included
physical training, psychological pain management, work hardening, stretching,
education and leisure time activities." This observation has been made in
a number of papers in recent years and it is shared by many clinicians in the
field.
The
intention of this paper is to present a model for understanding multidisciplinary
programs and to suggest a reason why they are often more effective in the
treatment of chronic back pain than single disciplinary interventions.
First,
we must clarify some definitions. Healing is a process whereby damage is
repaired so that the structure is able to respond appropriately to both normal
and abnormal demands. When healed, a normal demand (such as leaning over to
pick a paper off the floor) will not result in damage. An abnormal demand (such
as inefficient lifting of a heavy object) may result in damage to the healed
back but the damage will not be out of proportion to the stress which has been
placed on the involved structures.
Healing
is achieved by two methods. The first, curing, is practitioner directed. The
patient is essentially passive and needs only "the will to live." If
the correct remedy is administered, improvement will occur. In curing the
number of interventions as well as the time needed for the process to be
completed is predictable. When cured, the patient is usually "good as
new." Many diseases and most infections respond to cure.
Mending,
the second method, is a process which is patient active with the practitioner
often (but not always) part of a team. The number of interventions and the time
necessary to complete the process is much less predictable. When mended the
patient is restored to sound functioning, he or she may not be
"perfect."
There
is a fundamental misunderstanding on the part of most of the public and,
unfortunately, many of the practitioners about chronic back pain and the
methods needed to fully heal it. This misunderstanding has created enormous
frustrations for both the sufferer and the practitioner. Many clinicians are
unwilling to treat back patients - whom they find difficult, noncompliant, incurable.
At the same time, many back patients feel disappointed - more, deceived - by
those they believed would end their pain.
The
chronically dysfunctional back is rarely responsive to cure. There are two
reasons why this is so. Much of the tissue involved in back pain has a
relatively limited blood supply. Because of the physiology of these soft
tissues, they do not heal easily. The structural material at risk, the
ligaments, discs, joint capsules, do not heal well and once injured tend to
stay injured.
The
second reason has to do with adaptation. Chronic pain can create
musculoskeletal, neurological and emotional changes which can perpetuate a
dysfunction. Unless these adaptations are dealt with, the pain will likely
recur.
While a
cure is usually not possible, mending often is. Painful backs may never be the
same as they were but they have the potential to be better than they are. As
long as the tissue is viable, if it is not diseased or compromised by age to
the point that the body no longer has the energy to repair itself, that
structure has the potential to be mended.
There
are six components in the process of mending. In an appropriate evaluation we
understand the location, tissues involved and mechanism of an injury. We
understand the predisposing factors - physical, emotional and spiritual - which
led to or exacerbated the injury and are aware of any compensatory responses.
Communication
and Commitment refers to the necessity of explaining to our patient our
diagnosis and suggested treatment in terms that they can understand. It is
essential that we explain what is happening and what must happen next in ways
that are meaningful to that particular patient. Once explained (it may take
more than once), the patient must commit to doing whatever is necessary for
repair to occur. The patient who is unwilling to do any part of the prescribed
treatment is a cause for concern.
The
third component in the process is the Correction of Mechanical Issues. In
chronic back pain, it is the author's contention that there is almost always a
mechanical dysfunction. Whether by surgery, manipulation, pharmaceutical or
other reduction, any mechanical inhibitions to healing must be removed.
The
fourth components are Strengthening what has Weakened and Expanding what has
Contracted. Through physical training, work hardening and other programs,
stabilization of weakened structures is accomplished. With stretching expansion
of contracted structures is achieved. (While stretching is the most commonly
prescribed expansion technique for back pain, any intervention which creates
expansion in the structure - relaxation techniques, biofeedback, psychotherapy,
among others - are included in this component.)
The
fifth component in mending is Learning Appropriate Movement. This component
concerns how to use the body appropriately and is accomplished through
"back schools" and various movement re-education techniques such as
the Feldenkrais Method, the Alexander Technique, yoga or Rolfing. The sixth
component has to do with a certain amount of good fortune. No matter how hard
patients strive to heal damaged structures, if they are reinjured by another
fall, car accident or mis-step off a curb, they must begin the process again.
The final component is therefore labeled Avoiding Re-Injury.
The
healing process is often non linear. One does not go from Totally Dysfunctional
to Complete Resolution. There are many intermediate stages along the path. But
as long as the patient continues to make progress, he is healing. The job of
the patient and practitioner is to remove any barriers which are preventing
that process from moving forward.
The
components involved in mending will not be the same for every patient. Some
will need emphasis on component one or three, others two, three, five and six.
Whether a practice is single practitioner or multi-disciplinary, if a patient
is not improving, an examination of the various components may help us
understand what is needed.
The
theme of this conference has been the new health care environment.
Multidisciplinary centers are becoming the norm in a time of managed care. One
of the intentions of this paper was to present a model for understanding how
the various disciplines fit together into a comprehensible totality. Every
treatment currently prescribed fits into these components. It is suggested that
the reason multidisciplinary practices (as opposed to practices which have a
number of practitioners sharing space but who are not interacting in patient
care) may be more effective than single discipline interventions is that
different practitioners will emphasize and supply different components to the
overall process. By working together we may significantly increase the chance
for success.
®1994 Paul
Gordon
Paul Gordon, M.A.
17 Mast Cove Road, Eliot, ME 03903 207-439-8522
875 Massachusetts Avenue, Suite 83, Cambridge, MA 02139 617-628-6661
http://www.paulgordonrolfer.com/